The Indianapolis Coalition for Patient Safety

1. The Indianapolis Coalition For Patient Safety The Indianapolis Coalition for Patient Safety It Takes a City Opportunities for Research and Partnership

2. Glenn Bingle, MD, PhD Chair, Indianapolis Coalition for Patient Safety Chief Medical Officer Community Health Network Kathy Rapala, JD, RN, DNP (c) Executive Director, Indianapolis Coalition for Patient Safety Visiting Associate Professor Purdue School of Nursing

3. Objectives • Introduction to the Indianapolis Coalition for Patient Safety • Overview of Coalition interests and projects • Opportunities for research and partnership

4. www.indypatientsafety.org

5. Indianapolis Coalition for Patient Safety Marion County Dept of Health Department of Public Health Indiana State Board of Health Anthem WellPoint Deans of Medical RN, Pharm Schools IHIE Health Care Excel Regenstrief Institutes Health Care Advantage Eli Lilly Est. 2003

6. SHAREDVision & Challenge WORKING TOGETHER COLLECTIVE ACHIEVEMENT >> Shared Resources >> Shared Performance Targets >> Shared Accountability >> Shared Funding >> Shared Learning Do not compete on safety! >>Make Indianapolis safest For health care >> Outcomes: Accelerated Improvement “The Indianapolis Coalition for Patient Safety is a prime example of how collaboration is accelerating change…among very competitive organizations (and) is a national model for community-based process improvement…” --Don Berwick, IHI President and CEO

7. USA Safety Collaborative View: Where do we fit? NATIONAL=12 REGIONAL=8 INSTITUTE FOR HEALTH CARE QUALITY IMPROVEMENT JOINT COMMISSION ON HOSPITAL ACREDITATION INSTITUTE FOR SAFE MEDICAL PRACTICE NATIONAL PATIENT SAFETY FOUNDATION CALIFORNIA (4) ILLINOIS PITTSBURGH WISCONSIN TRI CITY (WASHINGTON STATE) Improved Safety INDIANAPOLIS et al SAN DIEGO INDIANA MINNESSOTA STATEWIDE=31 CITY WIDE=2 Google Search Maryland Coalition Survey 7

8. National Collaborators on Safety PSOs Data Collection HCUP Institute for Safe Medication Practices Sentinel Event Reporting National Patient Safety Foundation 100K Campaign AHRQ Safety Goals Joint Commission Institute for Healthcare Improvement Nursing Sensitive Collaboratives Hospital Core HCAHPS Safe Practices SCIP National Patient Safety Efforts National Quality Forum Serious Reportable Events ACE CMS Thoracic Surgery 8th Scope of Work Cancer Care National Committee for Quality Assurance Ambulatory Quality Alliance Leapfrog Group Consumer Groups Partnership for Patient Safety Rewards Program Safe practices Safe Practices L Gelinas VHA 07 modified Bingle

9. Std.& Improve Reliability Delivery to Admin of Anticoagulants & Insulin Safety Rounds & Survey Std. Surgical Safety site; ID; Time out 2003 2004 2005 2006 2007 Std single Plan for Emergency Preparedness/ Avian Flu Response Accelerate & Implement All 100K Lives Strategies Std. Unsafe Abbreviation MRSA collaborative With Regenstrief, VA

12. What activities do city & state collaborations engage in? • Professional, public, media education • Standardization and implementation of best practice around safety issues of mutual concern • Coaching; supporting; encouraging best safety practice • Awarding by recognizing excellence • Sharing best practices • Research • Report safety performance • Guideline developing for best practice • Sharing unique resources like simulation labs

13. Key milestones include: High Alert Drugs anticoagulants Insulin Surgical Areas Root Cause Analysis Patient Safety Rounds Standardized Abbreviations Institute for Healthcare Improvement 100,000 Lives Campaign

14. Indianapolis Coalition for Patient Safety

15. Indianapolis Coalition for Patient Safety History • Officially formed in 2003 • 6 Indianapolis healthcare systems—Clarian, Community, St. Francis, St. Vincent, VA and Wishard--decided to collaborate and not compete on the basis of patient safety. • Held an first executive session facilitated by the National Patient Safety Foundation in 2003.

17. Indianapolis Coalition for Patient Safety: Mission & Vision • Improve the safety of patients receiving healthcare in Indianapolis • Make Indianapolis (Indiana) the safest city (state) to receive healthcare in the United States.

18. Initiative Highlights Anticoagulation Lilly/Wishard 6 Sigma Collaboration High Risk IV Standardization

19. Anticoagulation Initiative 2 babies at Methodist die of overdose 4 others also get wrong dosage of anti-clotting drug September 18, 2006 Methodist may speed up safety updates Bar-code system is in place at Clarian North September 20, 2006 Hospital errors to go public in 2007 Indiana identifies 27 mistakes that hospitals will have to report September 21, 2006

20. Indianapolis Coalition for Patient Safety Recognition – Anticoagulant Workgroup Dan Degnan, PharmD, MS, CPHQ Jim Fuller, PharmD Jen Reddan, PharmD Leann McGinley-Wright, PharmD Bill Malloy, PharmD Chris Scott, PharmD Divya Abraham, PharmD Mechelle Peck, RN Tamra Arnold, PharmD Scott Freeland, PharmD Jim Eskew, RPh, MBA Steve Hultgren, RPh, MBA Susan Brown, RPh, MBA

21. Anticoagulant Workgroup Goal: Make the use of anticoagulant medications in Indianapolis Health-Systems safer Partnership identified with the Institute for Safe Medication Practices (ISMP) Initial model: Collaborative (FMEA, Guided process) Final model: Best practice (Self assessment, commitment to data sharing and comparison)

22. Core Safe Practice Challenges Functional drug interaction warnings for CPOE and pharmacy systems Medication reconciliation for anticoagulants across the continuum Majority were “green” across the board Target Safe Practice Challenges Pharmacy dispensing for all anticoagulant doses Independent double checks Clinical pharmacy monitoring services for anticoagulants Anticoagulant Workgroup – Self Assessment

23. Universal Metric Identification Pre-requisite – Minimize chart review, automated data, meaningful from a safety standpoint, comparable ISMP and IHI were starting points Trial and Error Heparin and PTT measures Protocol (yes or no) PTT %s in four distinct ranges Selection rationale Protocol effectiveness Electronic data Sub therapeutic measurement Anticoagulant Workgroup – Universal Metric

24. Anticoagulant Workgroup – Library

25. Anticoagulant Workgroup – Computer Script

26. Anticoagulant Workgroup – Computer Script

27. Research wishes • Study of the PTTs • Process/computer studies • Validation of best practices • Process measure refinement

28. Lean Six SigmaWishard-Lilly Insulin Safety Project Coalition for Patient Safety Executive Leadership Update

29. Objectives • Reaffirm the importance and impact of insulin safety in the hospital setting • Learn how the Lean Six Sigma process and tools were applied to improve the dispensing and administration of insulin at Wishard Health Services • Share project insights obtained by Wishard and Lilly around patient safety • Discuss additional opportunities in the hospital setting

30. Team Members Wishard Health Services Team Lisa Harris, CEO/CMO, Executive Sponsor Divya Abraham, Inpatient pharmacy Kerri DeNucci, Clinical pharmacy Abby Mortier, Inpatient pharmacy Jim Fuller, Pharmacy Director Susan Gallagher, RN Burn Unit Crissy Lough, Quality/Safety Cheryl Young, CNS DM Shirley Howell, NP Hospitalist Tracy Martin, ED Director LeeAnn Blue, VP, Nursing Lilly Team Jim Collins, Exec Director, Devices, Sponsor Bill Malatestinic, Outcomes Research, Sponsor Mark Urban, Director B2B, Key Stakeholder Jana Klopp, Privacy Doug Whiteman, Outcomes Research Matt Thomas, Packaging Engineer Jay Yamamoto, Black Belt • RFP • Pre-determined selection criteria • Targeted opportunity • Mutual Benefit

31. Define Charter, Mission statement, SIPOC, Risk analysis, High level process map Measure Baseline data collection Analyze Detailed process maps, “Be the vial” hospital tour, Ishikawa fishbone diagram Improve Solution selection, FMEA Control Adherence activities, RACI, Control plan DMAIC Process and Six Sigma Tool Kit

32. Process Maps Before… After… Check all meds centrally • Quick win, eliminates steps checking @ satellites, delays getting meds to floors

33. Research wishes • Process and methodology of Six Sigma for safe insulin administration within facilities; eliminate steps/rework • Gaps and opportunities analyzing process maps vs. reality • Standard Operating Procedures re: insulin administration • Standard training for physicians, nurses, techs and pharmacists • Report Card on the progress • Work on other issues identified: meal times/tests/procedures and relation to our patients on insulin therapy SPREAD!!!!

34. Other initiatives • OR time out/site verification standardization • Standardization of high risk infusions (collaboration with Purdue PharmaTAP). • Cardinal grant for IV smart pump comparative data base. • Severe sepsis initiative

35. Opportunities for Partnership • Research opportunities • 6 hospital systems • Suburban Health Organization • Gear toward relevant needs in hospital systems • Process measurement/validation • Observational research • Process improvement • Grants, articles, partnerships…many opportunites

36. How to work with ICPS • Come to a meeting. We meet the last Tuesday every other month. • Chat with either of us regarding specific opportunities • Explore grant opportunties on the subjects we discussed

37. Thank you!