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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.
Betsy Lee, RN, BSN, MSPH
InAHQ Spring Conference
May 9, 2014
The speaker has nothing to disclose.
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
Inaugural Indiana Patient Safety Summit - March 2010
Source: National and State Healthcare Acquired Infections: Progress Report
Centers for Disease Control and Prevention, March 2014
Source: Hospital Compare Release manipulated by WhyNotTheBest.org, , Measure Start – End Dates:7/1/08- 6/30/11
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
34 states / 1,622 hospitals
Culture of Safety
Teamwork and Communications
Innovation and Transformation
Preventing Harm Across the Board
Health Care Disparities
Expansion to other topics:
- Clostridium difficile
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
Improvement Leader Fellowship (HRET)
National Collaborative (HRET HEN Week)
National and Indiana webinars
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
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.
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.
Hospital: ________________ State: ______ Month: _________
Not Competing on Safety
Culture of Learning
Skilled workforce – technical/safety competencies; coaching
Joy in Work, Give
it Meaning, Make it Personal, Board Engagement
Patients and families involved in improving care and reducing harm
“[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.
Teamwork and communication
Leadership engagement in safety strategies
High reliability principles
Effective handovers and transitions
“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
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
What to Watch For
Source: Seton Southwest Hospital, Austin, TX
Prof. Patrick Hudson, Leiden University, the Netherlands (From Shell E & P)
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
Preoccupation with failure
Reluctance to simplify interpretations
Sensitivity to operations
Commitment to resilience
Deference to expertise
“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
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
The Leadership Challenge
Kouzes and Posner, 2002