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Transforming Patient Safety From the Front Line to the leaders

Monday, November 9th, 2009 Glasgow Scotland Uma Kotagal, MBBS, MSc. Senior Vice President, Quality and Transformation Director, Division of Health Policy and Clinical Effectiveness Cincinnati Children’s Hospital Uma.kotagal@gmail>com.

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Transforming Patient Safety From the Front Line to the leaders

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  1. Monday, November 9th, 2009 Glasgow Scotland Uma Kotagal, MBBS, MSc. Senior Vice President, Quality and Transformation Director, Division of Health Policy and Clinical Effectiveness Cincinnati Children’s Hospital Uma.kotagal@gmail>com Transforming Patient SafetyFrom the Front Line to the leaders

  2. Acknowledgements Core faculty team for transformation: Steve Muething, Maria Britto, Fred Ryckman, Keith Mandel Core team for Pursuing Perfection: Bill Kent , Gerry Kaminski, Gerry Pandzik Leaders of Clinical System Improvement teams Senior Leadership and Board Quality Improvement Infrastructure leaders: Gerry Kaminski, Marta Clark, Terri Byczkowski Faculty and Staff of the Division of Health Policy and Clinical Effectiveness: Peter Margolis, Lisa Simpson, Carole Lannon and their staff Staff of the Department of Quality and Transformation All members of the over 35 improvement teams especially leaders of microsystems and frontline staff Patients and families on Improvement teams

  3. It’s all about the kids

  4. Core Goals And Priorities For Health System Performance Improvement • QUALITY • Getting the right care • Coordinated care • Safe care • Patient-centered care • ACCESS • Universal participation • Affordable • Equitable LONG, HEALTHY, AND PRODUCTIVE LIVES EFFICIENCY SYSTEM CAPACITY TO IMPROVE Source: Commonwealth Fund Commission on a High Performance Health System.

  5. Stages of Translational Research Validation in Humans Application in Medicine Discovery and Model Development How to get discoveries and evidence into practice? What works to improve outcomes for patients? Robert Califf, MD Duke Translational Research Institute

  6. Many necessary stages between research and practice Are doctors/clinicians aware of the evidence? Do they accept it? Is it targeted correctly at their patients? Is the necessary change in practice doable? Is the information recalled at the right moment? (does the doctor remember what to do?) Does the patient agree with the doctor’s recommendation? Does it actually happen?

  7. Many “Leaks” from research & practice Aware Accept Target Doable Recall Agree Done Valid Research Even if 80% is achieved at each stage then0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21 Glasziou, Haynes, ACP Journal Club 2005

  8. Khoury et al. “no more than 3% of research focuses on T2 and beyond”

  9. CCHMC Mission Cincinnati Children’s will improve child health and transform delivery of care through fully integrated, globally recognized research, education and innovation. For patients from the community, the nation and the world, the care we provide will achieve the best: Medical and quality of life outcomes; Patient and family experiences; and Value Today and in the future.

  10. Cincinnati Children’s will be the safest children’s hospital in the world

  11. Why did we embark on This Journey? Patients and families deserve it Have sufficient patient volume for research and education Provide a competent environment for learners Successfully compete nationally for more complex patients Recruitment of world class providers

  12. Conceptual Framework: Pursuing Perfection Patient/Family Experience Top Down • Improvement projects • Patients on teams • Promises, measures • Leadership • Resources • Transparency • Measures Microsystems • Business Units/Clinical Divisions • Cooperation across boundaries Organizational Supports • Leadership, resources • Alignment • Business Case for Quality • Interdisciplinary Teams • Frontline Priorities • Parent priorities • Locally -Contracting for Quality • National Partners to transform pediatric care Environmental Context Bottom Up

  13. Leadership’s Role in Transformation Sharing the vision Transparency Resources Modifying the structure Alignment Enrolling families as change agents Understanding the science Keeping the focus Being steadfast Cheerleading

  14. Sharing the Vision Clear statement of where we are headed Discipline of annual and quarterly goals

  15. Health Care Delivery System Transformation Strategic Improvement Priorities and System Level Measures FAMILY CENTERED CARE ACCESS FLOW PATIENT SAFETY CLINICAL EXCELLENCE REDUCE HASSLES TEAMWELLBEING System Level Measures Risk Adjusted Cost per Discharge

  16. Transparency It has been “x” days since the last SSE Posting data on the intranet Parents stopping the line Parents as teachers Parents on improvement teams

  17. Resources Infrastructure Time for improvement Time for training leaders of tomorrow

  18. Alignment Alignment: Align measurement Align strategy and accountability Build improvement capability Integrate into daily work All strategic goals are part of each component of the organization with specific assignments

  19. Organizing For Transformation System-Wide Priorities CSI Priorities Division-BasedPriorities

  20. IHI Framework For Execution Provide Day-to-Day Leaders for Microsystems Achieve Strategic Goals Provide Leaders for Large System projects Spread and Sustain Manage Local Improvement (Microsystem) Develop Human Resources

  21. Families as Drivers of Change

  22. Families as drivers Families on improvement teams Families on committees Families as teachers Families as innovators

  23. Understanding the Science Treating the improvement effort seriously Holding people to the discipline Expecting logical frameworks and interventions

  24. Deming’s System of Profound Knowledge Appreciation of a system Theory of Knowledge Psychology Understanding Variation Values

  25. Knowledge for Improvement Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Subject Matter Knowledge Profound Knowledge Improvement

  26. Adopter Categorization: Speed Of Adoption Innovators Early Majority Late Majority Early Adopters Tradition-alists 2% 13% 35% 35% 15%

  27. Role of Innovation

  28. Sites for innovation, development and testing Prototype units Chronic Illness Clinical Innovation Lab High Reliability Unit Disease-specific improvement and outcomes programs e.g., Cystic Fibrosis, Inflammatory Bowel Disease Networks of clinical sites improvement and research Populations for community-based improvement large system re-design

  29. Accelerating Transformation Learning From Each Other

  30. Accelerating transformation • Networks of improvement • Multiple simultaneous testing • Link to research • Shared learning • Comparative outcomes data- Registries • Standardization

  31. Business Case for Quality Us as a global referral site_ linked to our research mission Better standing in public finance reports- US Moody’s US report-Clinical Quality have long term impact on Not for Profit Hospital Bond rating Quality as a way to get the maximum of our fixed assets Quality as a cost effective risk mitigation strategy

  32. Results

  33. Results Some examples Access to care- 12% to 60% of Divisions SSI- 1.2 to 0.4 /100 proc. Days (All Class 1 and 2) BSI – 3.5 to 1.4 /1000 line days ( All patients) VAP -7- <1 /1000 vent days (All ICU’s) MRT preventable codes to 0 for the last 4 quarters Adverse drug events 3.5/1000 doses to 0.3 Preventable ADE’s to 0 SSE’s from 1.0/10,000adjusted patient days to 0.3 %Receiving Evidence based care 95% for common conditions in ED and inpatient settings

  34. Additional results Significant improvement in outcomes in CF, diabetes, autism , ADHD and IBD, asthma Good examples of reducing disparities through customizing and standardizing care 90% achievement of perfect care for asthma in 15,000 patients in Cincinnati with significant improvements in parent confidence, functional outcomes and a reduction in ED visits and hospitalization

  35. Patient Safety – One Example of Alignment

  36. System Of Patient Safety Focus on outcomes of harm Detection and Measurement of harm Improvement Capability Reliability Science Culture of Safety High Functioning Microsystems

  37. Harm At Cincinnati Children’s Catheter-Associated Bloodstream Infections Ventilator-Associated Infections Surgical Site Infections Adverse Drug Events(Opiate related and insulin-related) Serious Safety Events Codes outside the PICU Other Adverse Events(IV infiltrates, unrecognized deterioration) Failure of Safe Practices(Hand washing, Handoffs, etc.)

  38. Hospital Acquired infection

  39. Getting started on Safety We started on safety in year 3 of our Transformation journey Opportunity on AHRQ funded adult group partnership Worried about engaging clinicians Began with Ventilator Pneumonia reduction and the 3 ICU’s Internal collaborative Initially led by Director of PICU but quickly became role of the RT’s

  40. Ventilator Acquired Pneumonia Learned about reliability Daily failures- review and fix Honest acknowledgement Holding each other accountable Immediate root cause analysis at the bed side if infection Watching closely- Obsessed with failures

  41. CA BSI reduction We agreed to take on the next infection Tougher because the work was well beyond the ICU’s- BMT, Hem Onc, Anesthesia, OR,ED, Home Care Also involved trainees More ubiquitous- every time you opened a line Often rationalized as urgency trumped good care Measurement of process was a challenge

  42. Adverse Drug Events

  43. Stage 1: Reducing errors in system Reduce inadvertent switch by moving patient’s meds to patient room Develop and implement CPOE and electronic MAR Standard concentrations Decision support in CPOE “Smart” pump software

  44. Stage 2: Standardizing orders to reduce preventable errors Order sets developed for most common conditions including drugs Use of corollary orders built into order sets as appropriate Use of trigger tool ADE measurement to drive ADE reduction strategy

  45. Stage 3: Increased detection and specific ADE reduction Development of automated trigger methodology to increased ADE detection Analyze ADE characteristics to identify causal trends Improvement teams to reduce specific ADE type’s informed by automated trigger data

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