Designing for Patient Safety: Building Capacity for Statewide Change

1. Designing for Patient Safety: Building Capacity for Statewide Change Betsy Lee, BSN, MSPH Director, Indiana Patient Safety Center April 16, 2012

2. Indiana Patient Safety Center Mission To facilitate the development of safe and reliable health care systems that prevent harm to patients. Launched July 1, 2006

3. Indiana Facts: • 6.1 million people • 134 short term acute hospitals • Aim: • To facilitate the development of safe and reliable systems to prevent harm to patients • Strategies: • Regional “safety coalitions” • Dynamic alliances and partnerships • Multi-dimensional educational plan • Balance clinical safety topics with tools and methods • Embed capacity for systems redesign • Engage front line staff and patients www.indianapatientsafety.org

4. Indiana’s Bold Aim: To make Indiana the safest place to receive health care in the United States, if not the world Inaugural Indiana Patient Safety Summit - March 2010

5. Transformational Design Principles • Focus on patients and families • Align statewide efforts and energy • Leverage regional coalitions and natural groups • Distribute leadership • Encourage “boundarylessness” • Embrace both the personal and collective nature of change • Emphasize outcomes and transparency

6. The Leadership Challenge • Model the Way • Inspire a Shared Vision • Challenge the Process • Enable Others to Act • Encourage the Heart The Leadership Challenge Kouzes and Posner, 2002

7. Partnership for PatientsLaunched April 12, 2011 The 40/20 Goal • Keep patients from getting injured or sicker. Reduce preventable hospital-acquired conditions by 40%. 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years. • Help patients heal without complication. Reduce all hospital readmissions by 20% . 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

8. Hospital Engagement Network Overview • Support the Partnership for Patients campaign • Assist hospitals implement best practices to reduce harm & readmissions • Provide education and build improvement capacity • Ten Clinical Topics, Leadership, & Safety Culture

9. HRET/AHA HEN 34 states / 1,621 hospitals

10. Preventing Harm – Categories • Reduce Readmissions • Adverse Drug Events • Catheter Associated Urinary Tract Infections (CAUTI) • Central Line Associated Blood Stream Infections (CLABSI) • Surgical Site Infections (SSI) • Ventilator-Associated Pneumonia (VAP) • Harm from Falls and Immobility • Obstetrical Adverse Events • Pressure Ulcers • Venous Thromboembolism (VTE)

11. Additional Topics • Leadership Systems • Culture of Safety • Teamwork and Communications • Lean Training • Innovation and Transformation • Preventing All-Cause Harm

12. Indiana/HRET HEN Summary • 120 Indiana hospitals aligned with IHA/HRET • Includes: • 26 critical access hospitals • 8 psychiatric hospitals • 5 rehabilitation hospitals • 4 long term acute hospitals • Other HENs in Indiana include: Ascension (18), VHA (3), NAPH (1), UHC (1), Ohio Children’s Hospital collaborative (1), Joint Commission Resources (1)

13. Needs Assessment HRET Survey – Indiana (February 2012): • 111 of 120 hospitals responded • Top requests for support include: • Readmissions - 88 • Falls - 60 • CAUTI 54 • Pressure Ulcers/SSI – 45 each • ADE - 42 • Indiana hospitals report making good progress in VAP, CLABSI, SSI, Pressure Ulcers

14. IHA’s Plan Design HRET (Prime Contractor) IHA (Subcontractor) • HRET National Education: • Access to National Programs • 4 groupings of 10 topics • Plus HCAHPS,TeamSTEPPS • (AHRQ funded activities) • Fellowship Programs • Stand-alone programs (Webinars • educational sessions, etc) • Learning networks • Direct and Shared Services Support: • Regional coalitions and affinity groups • Administrative/organizational support • Local support and facilitation • Technical Assistance: • Purdue Healthcare TAP and CMSA • Individual hospital plans/assessments • Statewide coaching network • Communities of Practice (Lean, Med Safety) • HRET Support: • Measurement warehouse • Best practice clearing house • Access to national experts • Partially defray data collection costs • Indiana Education: • State and regional education: • Key topics from needs assessment • Tools training (Lean certification, • medication safety, etc) • Leadership for cultural improvement

15. HRET Resources • HRET State Contacts • Improvement Advisors • AHA/HRET HEN Website • Topic Specific Change Packages • Data Collection System • Fellowship – 4 Regional Offerings • Topic Specific Collaboratives • Only offered in Chicago for 2012 (May, Aug, Nov)

16. HRET HEN Improvement Leader Fellowship Program Aim: Develop a cadre of front-line hospital improvement leaders in 1,500+ hospitals by 2013 Delivery Model: At least 4 series of three 2-day training sessions across the country Projected Outcome: Increase leadership capacity across the 34 states to lead ongoing improvement efforts

17. HRET Collaborative Design Aim: Provide an integrated approach for hospitals to work together on improving performance in topic specific collaboratives with structured & peer-to-peer exchange of ideas.

18. Ten regional coalitions cover Indiana: only state in the country with this model • Members agree not to compete on patient safety • Create layered model of regional coalitions and affinity groups – Indiana’s “transformation grid” to support dissemination • Benefits: • Innovate at the front lines • Align with state and national efforts, and standardize when beneficial • Model builds local and hospital-specific capacity for improvement and innovation • Encourages safety leadership at all levels across multiple professions

19. Indiana HEN Activities • Statewide improvement activities around the highest level of need as defined by the needs assessment • Development of a statewide “coaching” network to support mentoring and sharing best practices as well as support innovation and implementation, and to link high performers to other hospitals in the state • Regional and statewide support of culture, teamwork, and communications improvement as well as leadership for safety

20. Purdue University Resources • Purdue University HealthcareTAP: • Regional Lean/Six Sigma green belt (2 per hospital) and black belt (1 per hospital) certification and training • Readmission computerized simulation • Lean Community of Practice • Purdue Center for Medication Safety Advancement • Web-based medication safety continuing education (10 per hospital – RN, PharmD, MD) • Medication Safety Community of Practice • The Role of ADEs in Readmissions

21. Escalating Connections • HRET: • Measurement • National experts • Education • Fellowships • Resources Mentor/Coaching Network • IHA HEN • Building knowledge and collaboration • Technical assistance • Support regional coalition initiatives • Lean/Six Sigma training (Purdue) • Developing leaders to promote safe cultures • Expanding medication safety competencies (Purdue) • Peer-to-peer coaching Affiliated Societies Regional Patient Safety Coalitions Affinity Groups Communities Of Practice

22. Why is Data Needed? • To demonstrate hospitals have reduced their Hospital Acquired Conditions and Readmissions over the 2 year period • To monitor that interventions are working • Part of the PDSA cycle • Measures are used to assess the impact of changes

23. What Data is Needed? • At a minimum, 1 process measure and 1 outcome measure • Process: measures how well the practice was followed • Outcome: measures the result of the intervention • Both types may be linked and need to be monitored

24. Indiana Sepsis Mortality Rates

25. Key Elements of Enhancing Cultures • Teamwork and communication • Leadership engagement in safety strategies • High reliability principles • Eliminating fear • Effective handovers and transitions

26. Successful Strategies • Patient Safety Executive Rounds • Patient Safety Ambassadors (front-line staff on each unit) • Implement “Just Culture” program • Emphasis on patient handoffs • Daily nursing huddles • Storytelling • Regular event review sessions with staff • Bedside change of shift report

27. AHRQ Culture of Safety Survey • Of the 12 dimensions of culture measured in the Hospital Survey on Patient Safety, Handoffs and Transitions is the lowest average percent positive • Subscale questions measure these perceptions: • Things “fall between the cracks” • Important information is lost at the change of shifts • Problems occur with the exchange of information across hospital units • Shift changes are problematic for patients

28. How do hand-offs fail? Omissions of content are a major cause of failed communication during handoffs. Arora, 2006

29. Key Principles from the Literature • Face-to-face, verbal, and interactive • Providers come together and stay in a “zone of readiness and attention” during information sharing • Limit interruptions • Limit initiation of actions • Not just about information exchange, but some type of written, structured tool is employed • Includes time for anticipation and foresight • Receiver does read-back to verify content • Good teamwork as foundation

30. Common Components • Introduction and brief patient history • Overview of current situation • Safety concerns or potential problems • Plan (what’s next?) • Anticipation, reflection, and foresight (what might go wrong?) - provide context • Questions and verification

31. Clear and Complete Communication SBAR - a tool to communicate a situation requiring immediate attention, a decision, or action. Diagnosis Recent changes Anticipated changes What to watch for DRAWis a tool to communicate hand-off information Seton Family of Hospitals Austin, TX 2010 Situation Background Assessment Recommendation

32. DRAW DRAW is a tool to communicate hand-off information and includes the items outlined by Joint Commission D – Diagnosis R – Recent Changes A – Anticipated Changes W – What to Watch for

33. Adapted DRAW • Dr. James Buchanan – Ft. Wayne Medical Residency program • Adapted the DRAW tool to incorporate: • Interaction between residents (could apply to nurses, too) • Defined role for sender and receiver for each step of the tool • Anticipatory critical thinking • Resident evaluation

34. Adapted DRAW - Roles D – Diagnosis – by SENDER R – Recent Changes – by SENDER A – Anticipated Changes – by SENDER (what lab results, tests, etc. can be expected on the next shift) AND RECEIVER (what might be expected to occur in the course of this patient’s illness during the coming shift?) W – What to Watch for? and What might Harm this Patient? RECEIVER

35. “Flexible Standardization” • Incorporate the principles • Test different models and roles before you implement • Both flexibility and standardization are essential • Customize/adapt to meet the needs of the local clinical setting. Jorm, et al. Clinical handover: critical communications. Medical Journal of Australia. 190:11, June 2009

36. IHA’s Aim: To build workforce capacities and cultures of safety in all Indiana hospitals … the rising tide will “raise all boats”

37. “We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win…” • President John F. Kennedy Address at Rice University September 12, 1962

39. Contacts Betsy Lee, RN, MSPH Director, Indiana Patient Safety Coalition Indiana Hospital Association blee@IHAconnect.org 317-423-7795