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Making Indiana the Safest State: The Challenge and the Opportunity. Betsy Lee, RN, BSN, MSPH InAHQ Spring Conference May 9, 2014. Conflicts of Interest Disclosures. The speaker has nothing to disclose. Session Objectives.

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Making Indiana the Safest State: The Challenge and the Opportunity

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Making indiana the safest state the challenge and the opportunity

Making Indiana the Safest State: The Challenge and the Opportunity

Betsy Lee, RN, BSN, MSPH

InAHQ Spring Conference

May 9, 2014

Conflicts of interest disclosures

Conflicts of Interest Disclosures

The speaker has nothing to disclose.

Session objectives

Session Objectives

Discuss the status of statewide patient safety improvement in Indiana compared to national benchmarks

Evaluate potential impact of the Partnership for Patients initiative on patient safety at the local level

Outline leadership strategies for engaging front line staff in addressing harm across the board

Indiana s bold aim

To make Indiana the safest place to receive health care in the United States, if not the world

Indiana’s Bold Aim

Inaugural Indiana Patient Safety Summit - March 2010

The challenge indiana performance

The Challenge: Indiana Performance

  • How will we know we are the safest state?

  • Challenge to find comparative data for many safety measures

  • No publicly available comparative data for ADE’s, Falls, Pressure Ulcers, VTE, VAP, birth-related injuries, early elective deliveries

  • Infections: CDC HAI Progress report

    • Nationally, CLABSI dropped 44% from 2008 to 2012

    • The reduction in Indiana was only 34%

    • CLABSI SIR increased from 2011 to 2012

Indiana 2012 healthcare acquired infections

Indiana 2012 Healthcare Acquired Infections

Source: National and State Healthcare Acquired Infections: Progress Report

Centers for Disease Control and Prevention, March 2014

Sepsis mortality reductions are promising

Sepsis Mortality Reductions are Promising

Began sharing

coalition reports

Heart failure 30 day readmission rate

Heart Failure 30 Day Readmission Rate




















































Source: Hospital Compare Release manipulated by, , Measure Start – End Dates:7/1/08- 6/30/11

Partnership for patients aims

Partnership for Patients Aims

  • 40% Reduction in Preventable Hospital Acquired Conditions

    • 1.8 Million Fewer Injuries

    • 60,000 Lives Saved

  • 20% Reduction in 30-Day Readmissions

    • 1.6 Million Patients Recover Without Readmission

  • Projection: up to $35 Billion dollars will be saved

Impact of partnership for patients

Impact of Partnership for Patients

Large scale funded national initiative

Aims aligned with Indiana priorities

Takes statewide and regional improvement efforts to scale

Encourages local adaptation with the discipline of organized effort and measurement

Aha hret hospital engagement network

AHA/HRET Hospital Engagement Network

34 states / 1,622 hospitals


Coalition for care

Coalition for Care

Partnership for patients

Partnership for Patients

National hen targeted harm categories

National HEN Targeted Harm Categories

  • Adverse drug events

  • Birth-related injuries

    • Elimination of Early Elective Deliveries

  • Central line-associated blood stream infections

  • Catheter-acquired urinary tract infections

  • Falls with injury

  • Surgical infections and complications

  • Venous thromboembolism

  • Pressure ulcers

  • Readmissions

  • Ventilator-associated pneumonia

Additional priorities

Additional Priorities

Leadership Systems

Culture of Safety

Teamwork and Communications

Lean Training

Innovation and Transformation

Preventing Harm Across the Board

Health Care Disparities

2014 cms topic expansion

2014 CMS Topic Expansion

Expansion to other topics:

  • Sepsis

  • MRSA

  • Acute Renal Failure

    - Clostridium difficile

  • Procedural Harm

How might we achieve our aim

How Might We Achieve Our Aim?

Focus on initiatives to improve all eleven Partnership for Patients topics

Emphasize measurement, data submission and transparency

Statewide alignment and energy

Engage front-line teams in patient safety efforts

Embrace personal and collective nature of change

National content development

National Content Development

  • Change packages for all 10 topic areas are now available at

  • National HRET conference calls and webinars to share evidence-based practice solutions

  • National CMS calls sharing ideas for change from hospitals around the country

  • Indiana learning opportunities for many topics

Hret hen resources

HRET HEN Resources

Hret hpoe resources

HRET/HPOE Resources

Education and technical assistance

Education and Technical Assistance

Improvement Leader Fellowship (HRET)

National Collaborative (HRET HEN Week)

National and Indiana webinars

Regional “Roadshows”

Indiana Patient Safety Summits

IHA Annual Meetings

Lean Six Sigma training Medication Safety Essentials courses (MSE 1.0 and advanced course MSE 2.0) - on-line, on-demand continuing education

Readmissions computerized simulation model

Communities of practice

Site visits and coaching

Special focus adverse drug events

Special Focus: Adverse Drug Events


  • About 1/3 of all hospital adverse events are related to ADEs

  • LOS is prolonged by 1.7-4.6 days

  • ADEs affect 1.9 million hospital stays annually

  • Cost $4.2 billion annually

  • Responsible for about 100,000 emergent hospitalizations in older Americans, annually4

  • 2/3 result from just four medication classes:

    • Warfarin, insulin, oral hypoglycemics, and oral antiplatelet agents

    • 2/3 result from unintentional overdoses

      1. ClassenDC et al. Health Aff (Millwood) 2011;30:581–9.

      2. Agency for Healthcare Research and Quality, Rockville, MD, 2011 April. HCUP Statistical Brief #109.

      3. ClassenDC et al. JAMA 997;277:301–6. Bates DW et al. JAMA 1997;277:307–11.

      4. Budnitz, DS et al. N Engl J Med 2011:365:2002-12.

Ade resources

ADE Resources

Elimination of eed

Elimination of EED


Scheduling Form


Cms four calls to action

CMS: Four Calls to Action

Reduce harm across the board. It is a call for hospitals to produce reductions in every type of harm.

Take a systemic approach. It is a call to transform the organization and its practices to eliminate all the causes of harm. “Using every means at our disposal.”

Make your safety transparent to all. It is a call for hospitals to define themselves by their safety performance; define themselves to their employees, doctors, patients and the community.

Make safety personal & compelling. Make every incident of harm a personal patient story that propels the institution to higher levels of performance.

Making indiana the safest state the challenge and the opportunity

Harm Across the Board (HAB):

Monthly Update

Hospital: ________________ State: ______ Month: _________

Making indiana the safest state the challenge and the opportunity

  • Eleven regional safety coalitions

  • Members agree not to compete on patient safety

  • Layered model of regional coalitions and affinity groups supports transformation, learning and spread

  • Benefits:

  • Innovate at the front lines

  • Align with state and national efforts, and standardize when beneficial

  • Builds local and hospital-specific capacity for improvement and innovation

  • Encourages safety leadership at all levels across multiple professions

Why regional efforts are important

Why Regional Efforts Are Important

  • Focus on improving patient safety and decreasing harm

  • Identify patient safety issues through data/events

    • Transparency

  • Share expertise, resources, and tools

  • Develop solutions in coalition and collaborative learning

  • We do not compete on patient safety

Making indiana the safest state the challenge and the opportunity

Regional Patient Safety Coalitions: Scope and Focus

Not Competing on Safety

Culture of Learning


Trusting Relationships

Skilled workforce – technical/safety competencies; coaching

Joy in Work, Give

it Meaning, Make it Personal, Board Engagement


State in

the Nation

Patients and families involved in improving care and reducing harm

R egional coalition transparency

Regional Coalition Transparency

Partnership for patients1

Partnership for Patients

Making indiana the safest state the challenge and the opportunity

Patient Engagement and Adverse Events

“[T]here was an inverse relationship between [patient] participation [in their care] and adverse events . . . [P]atients with high participation were half as likely to have at least one adverse event during the admission. ”

Source: Weingart SN et al., Hospitalized patients’ participation and its impact on quality of care and patient safety, International Journal for Quality in Health Care 2011; 1-9.

Partnership for patients2

Partnership for Patients

Hsops agency for healthcare research and quality

HSOPS: Agency for Healthcare Research and Quality

Indiana hsops results

Indiana HSOPS Results

Key elements of enhancing cultures

Key Elements of Enhancing Cultures

Teamwork and communication

Leadership engagement in safety strategies

High reliability principles

Eliminating fear

Effective handovers and transitions

Ahrq culture of safety survey

AHRQ Culture of Safety Survey

  • Of the 12 dimensions of culture measured in the Hospital Survey on Patient Safety, Handoffs and Transitions has 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

What are hand offs handovers

What are hand-offs/handovers?

“The process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver.”

Patterson & Wears, 2010

Characteristics of effective handovers

Characteristics of Effective Handovers

  • 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

Handover components

Handover 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

Example draw

Example: DRAW


Recent Changes

Anticipated Changes

What to Watch For

Source: Seton Southwest Hospital, Austin, TX

Making indiana the safest state the challenge and the opportunity

Evolution of Culture

Prof. Patrick Hudson, Leiden University, the Netherlands (From Shell E & P)

Managing the unexpected weick sutcliffe

Managing the Unexpected (Weick & Sutcliffe)

  • “Mindfulness”:

    • Ability to see the significance of early and weak signals and to take strong decisive action to prevent harm

  • “Sensemaking”:

    • Process of transforming experiences into updated views of the system by “taking the time to make sense out of new and changing circumstances”

    • “Trust is a product of sensemaking.” – J. Morath

Tools for sensemaking weick and battles

Tools for Sensemaking (Weick and Battles)

Literally “making sense of events”

Building a systems understanding to eliminate and mitigate risks to patients

True sensemaking is reactive and proactive

Focus of learning organizations – systematically increasing reliability

Provides data-driven framework for sensemaking through tools and joint reflection

Importance of staff engagement and curiosity

Characteristics of mindfulness in high reliability organizations weick sutcliffe

Characteristics of Mindfulness in High Reliability Organizations (Weick & Sutcliffe)

Preoccupation with failure

Reluctance to simplify interpretations

Sensitivity to operations

Commitment to resilience

Deference to expertise

Mindfulness weick sutcliffe

Mindfulness (Weick & Sutcliffe)

“Struggle for alertness”

Trouble starts small and is signaled by weak symptoms that are easy to miss

Small discrepancies can accumulate, enlarge and have disproportionately large consequences

Engaging front line staff in safety

Engaging Front-Line Staff in Safety

  • Focus on the systems of care and on redesigning work processes

  • Must involve “sharp end” caregivers

  • Education and training alone will not work – requires increased “mindfulness”

  • Cultural change requires strong leadership

  • Must improve reliability through new approaches

Leadership for results

Leadership for Results

Leverage energy and effort at the front line

Regionalize technical assistance and education

Align measures to mark progress

Concentrate on 11 topic areas

Build capabilities for future challenges

Focus on patients and families

Make it personal

Engaging front line teams

Engaging Front Line Teams

The leadership challenge

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



Betsy Lee, RN, BSN, MSPH

Director, Indiana Patient Safety Center

Indiana Hospital Association

(317) 423-7795

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