agency for healthcare research and quality (ahrq) - afya inc. · 2015. 11. 30. · enhancing...
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 1 Webinar 4 Meeting Summary – November 18, 2015
Agency for Healthcare Research and Quality (AHRQ)
Enhancing Patient Safety – AHRQ Fall Prevention Program Implementation Sharing Webinars #4
November 18, 2015
Two presentations at the fourth AHRQ Fall Prevention Webinar on Nov. 18, 2015, focused on staff and leadership engagement. Melissa Hiscock and Judith DelMonte presented on behalf of Roswell Park Cancer Institute in Buffalo, NY. Then David McMillan presented second on behalf of Broward Health North in Deerfield Beach, FL. This was followed by a round-robin style of sharing from each of the hospitals participating in the AHRQ Falls Prevention Program. Each hospital shared one or more strategies that they use to engage staff and leadership in their hospitals.
PRESENTATION 1
Roswell’s Story – Involving the Hospital Board
Melissa Hiscock (Core Team Lead) stated the hospital joined the AHRQ project in May 2015. The QI
specialist came in June to do the onsite education. About that time, the AHRQ project was included in a
report to board members. In July, the CNO briefly introduced the AHRQ project at the quarterly board
meeting, and it sparked interest from board member Dr. Thomas Stewart, who is well known in the
wound care community.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 2 Webinar 4 Meeting Summary – November 18, 2015
“… It’s a blessing to us, and
amazing,” Melissa stated. “Not
everyone has access to someone like
him.”
She noted that Dr. Stewart comes to
the weekly meetings, is an active
member, wants to in-service the
staff, and helps us in any way he can.
“It seems very simple, and we are
very fortunate, but that’s how we
got our institute’s board involved,”
she stated.
Senior Leadership Presentation and Project
Charter
Judith stated that once Dr. Stewart came
aboard, the project team presented its “project charter” to the Institute’s Quality Committee, which
meets monthly and has five board members. Staff members who attend the monthly meeting include
the chief medical officer, chief operating officer, chief nursing officer, five physicians, and the vice
presidents of Quality, Managed Care, Clinical Research, Risk Management, Lab Medicine, and Pharmacy,
as well as departmental directors, Quality staff, and the patient safety officer.
Judith stated the project charter included a description of:
The AHRQ project and how the hospital was using the AHRQ toolkits to implement best
practices at the hospital
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 3 Webinar 4 Meeting Summary – November 18, 2015
Critical success factors via the team’s metrics and overall goal, which is to decrease rate of
hospital-acquired pressure ulcers that are stage 2 and above. The team also shared other
metrics for the best practice tools.
The core team members, which included Melissa; Judith herself, who is the nursing quality
analyst that does all the data for the department of nursing; and the nurse bedside leaders.
Judith stated the team did not include all the subject matter experts, because the team has
about 25 people.
The SharePoint Web site, which is how the team posts all the data for the staff and board, and
contains all the materials for the project, meeting minutes, AHRQ tools, implementation items,
action plans, etc. Judith stated the Web site ensures they are all on the same page.
The Project Charter Close-Up and Action Plan
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 4 Webinar 4 Meeting Summary – November 18, 2015
“The board members were really impressed that we really are grounded in keeping up with our goals,
and that we had actually set dates, and that we were meeting a lot of the goals, and that we were really
trying to make progress as part of this team,” Judith noted.
Uncompleted Components of the Action Plan
The second part of the action plan are things the team hasn’t done all the way, which is a lot of the IT
implementation. This got the board’s attention, because there’s a lot of IT issues all the time around the
hospital. With the board’s engagement, the team hopes it can push many of these things forward,
because they’ve been kind of standing out there for a while.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 5 Webinar 4 Meeting Summary – November 18, 2015
Incomplete Components of the Action Plan
The slide to the right presents data that shows the progress of the pilot units since starting the project. There are three pilot units: ICU, leukemia lymphoma unit (6 West), and medical surgery unit (7 East). Judith stated these units had the highest rate of pressure ulcers, noting the team wants to make sure that everyone is aware of the data so they can see where the hospital stands at any given time.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 6 Webinar 4 Meeting Summary – November 18, 2015
Rates and Cost
The slide to the right
grabbed the
attention of the
whole committee,
because when
putting the cost
along with the
measure, then it gets
everybody’s
attention, Judith
stated.
With CMS, anything
that’s above a stage
3 or greater, the
hospital is not
getting paid for. She
stated they ran the
hospital’s pressure ulcer numbers, with each costing $43,000 (the national average cost) for every
inpatient pressure ulcer that was stage 3 or above. Judith stated the team wanted to send the message
that driving down rates means driving down costs.
“When they see over a million dollars—even though it’s estimated—and we’re almost at $700,000, it
really gets their attention,” Judith stated, adding it gives them incentives to get on board with the
project and support efforts to decrease pressure ulcer rates.
Unit Quality Boards
The image to the right
shows the three pilot
units’ unit quality
boards, which are
updated with the
latest data when
there’s new
information. Patients,
families, and staff can
see the boards. If
anyone has questions
or ideas about the
board, the nurse
bedside leaders can
answer them or
Melissa.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 7 Webinar 4 Meeting Summary – November 18, 2015
Summary
Judith stated that the big takeaway from all of this is that using the internal intranet (SharePoint) to
organize the information for the project has worked very well. Everyone is on the same page, and at any
given time, people can see where we are—including leaders.
She stated that adding a finance person to the team was a big help because right now staff are going
through the codes. They are making sure pressure ulcers are coded on admission and appropriately, that
staff are on the same page as the WOC team—because they might have one case that they are calling a
pressure ulcer on admission but the coders call a hospital-acquired pressure ulcer.
Additionally, Judith stated they’ve engaged the board and senior leaders so they know what’s going on.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 8 Webinar 4 Meeting Summary – November 18, 2015
PRESENTATION 2
David McMillian stated that Broward Health North has 409 beds. The focus the AHRQ project is on the
hospital’s NeuroMedical ICU, and measures for that department will start being implemented in two
other in-house ICUs by the end of the month.
Starting Out
David stated the first thing
they did as a group was add
monthly meetings with the
CNO, because managers all
have meetings with a C
Suite, which is whoever
they report to on a monthly
basis, and they decided to
start sharing the AHRQ
project with them, the
requirements, and what the
process was.
“When we actually did the
pre-assessment tools with
our facility, we found many
opportunities,” David
stated. “One of the greatest
was that we did so much education for nursing, but did not do that for the education of radiology,
transporters, and so many other people who touch the patient.”
David stated staff realized they needed to provide education for others, and that’s why the AHRQ
assessment tools were so valuable for the hospital. He added that when he found this downfall, the
Hospital Acquired Pressure Ulcer Committee and AHRQ project committee decided to share the same
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 9 Webinar 4 Meeting Summary – November 18, 2015
assessment tools with all the other committees in-house, which led to those tools being used by CAUTI,
SSI, and a speak-up campaign to trend for similar issues.
These items were presented at the Quality Council to the C Suite with a plan to correct all the
opportunities for improvement.
Education Gap
At this point, the hospital
realized there was a big
educational gap, and the C
Suite became involved
because it felt that
something different was
being offered to solve
problems. The C suite
responded well to the
AHRQ initiative and toolkits,
which has now impacted
every committee in the
building. This has led to the
standardization of all the
committees with all of
them now using the AHRQ
initiative tools.
As a result, a quick meeting, called a rapid cycle improvement, convenes weekly at the Thursday
management huddle at which C Suite attends and implements immediate interventions. David stated
this was put in because there would be a fall out in a unit, and there were lessons for everyone to learn.
He stated that all of this relates to the patients, with a focus on creating no harms to patients. This
engages staff and C Suite more than using numbers and projections.
“Our goal is to cause no harm to patients,” David stated, adding this has led to the 2015 Patient Safety
Guide.
Patient Safety Guide
David stated the guide (pictured on next page) comes out of using the AHRQ toolkit. Every person within
the building—even those who serve food—had to go through this education. That’s nearly 1,100
employees, he noted. Things addressed included how to keep patients from:
Getting a bloodstream infection
Getting a CAUTI
Getting pressure ulcers/bed sores
Falling
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 10 Webinar 4 Meeting Summary – November 18, 2015
David stated that a “Speak Up” campaign has been created to improve communication. The hospital
used a circus theme, and the training offered popcorn. People responded well, he stated, noting: “We
like to have fun while we learn.” This is important when it comes to ensuring it sticks.
Education will be instituted at least every 3 months with managers in all the departments through the
education department and then safety education every 6 months to all staff. “When you have a big push
to make an improvement, you seem to do great for the first 6 months to a year, and then it kind of falls
off,” he stated.
Feedback
Feedback from the departments was positive. They are glad they were educated, and the hospital as a
whole found it educational, David stated. The C Suite didn’t know many of the interventions that are
conducted for pressure ulcers, falls, etc. When numbers are reviewed in the Thursday morning huddles
and Quality meetings, leaders now know what staff are dealing with patients, how it’s supposed to be
done, and this has made them much more savvy in the questions they ask the nurse managers in
providing excellent care for the patient.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 11 Webinar 4 Meeting Summary – November 18, 2015
Staff feedback that was
given to the C Suite has
been great as well, David
stated. For example, EVS
has said they could help
with Foley maintenance by
informing nurses when the
Foley bag should be
drained. Additionally, many
other non-clinical people
found it informational and
felt they were more
empowered to help the
patients.
“We even had a situation
last week where a security
guard was making rounds,”
David stated. “He saw one
of the Foley bags on the floor and notified the staff, and they were able to get it up off the floor,
because the patient had knocked it off while sitting up on the bedside. … It’s definitely a huge thing that
has affected our whole hospital.”
In the MICU, it experienced three to four events every month on average before implementation. In
August and September, there was one incident between the two months.
“We have had very few events from an average of three or four a month,” David stated. “And now that
we’re rolling out to ICU as a whole, I definitely see a big decrease in our harm events. Of course, no one
wants to harm a patient.”
As a whole hospital system, from last calendar year to this calendar year, Broward Health North went
from 58 to 28 harmful events.
“Definitely, the patient care at Broward Health North has benefited tremendously, and the staff on
every level from nursing to EVS and even to our security know what they need to do and how to help
nursing and the hospital cut down these harm events. We’d like to say thank you to AHRQ committee
and all the tools we’ve shared with everyone. So thank you.”
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 12 Webinar 4 Meeting Summary – November 18, 2015
Round Robin – AHRQ Fall Prevention Hospital Strategies to Engage Staff and Leadership
Hospital Strategies to Engage Staff/Leaders
Good Samaritan Hospital San Jose, CA Bedsize: 474 Pilot Units: Medical, Rehab
Use Team STEPPS approach.
Fall prevention is now a standing agenda item on the Patient Safety Committee, which staff nurses attend.
Have policy of transparency with prior events.
Investigate what they find in huddles.
Madonna Rehabilitation Hospital Lincoln, NE Acute Rehab Beds: 48-50 Pilot Unit: Acute Rehab
Set goals for acute rehab: o RN, LPN, NA Annual Evaluation Goal: Total number of patient falls that
occurred due to failure to follow proper procedures as a result of employee disregard for risks, based on the most recent 12-month period to date.
o Nurse Therapist/Supervisor Annual Evaluation Goal: Decrease patient falls with greater than minor injury to 5.0% or less as measured by the Acute Rehab Quality Score Card.
Have quarterly staff meetings to share rates and interventions that work and don’t work. Discuss how to better meet goals.
Report rates to Patient Safety and Quality Committee, Med Exec Team, Admin Team, and Board.
Good Shepherd Medical Center Longview, TX Bedsize: 425 Pilot Units: Rehab, Medical, Cardiac IMC
To engage senior leaders:
Make quarterly presentations to Quality Council (made up of Board members, senior leadership, physicians, and department leaders). Present fall data, project initiatives, and help and resources needed to move forward. Provides a good forum to address barriers.
To engage staff:
Use “Days Since Last Fall” programs. Set unit goals, such as 30 days without a fall. Provide rewards (pizza, cupcakes) for reaching goals.
Units post their fall rates on a board in their own unique way.
Broadlawns Medical Center Des Moines, IA Bedsize: 100 Pilot Units: Med/Surg
Use shared governance approach.
Involve and empower frontline staff in most levels of decision-making, including workgroups, committees, and councils.
Fall prevention team (primarily composed of frontline staff) drive most of the discussion and changes. Leadership has more of a facilitator role.
Staff compliance and ability to embrace change more effective when presented by their peers, with leadership support.
Mayo Clinic Health System—Franciscan Healthcare LaCrosse, WI Bedsize: 150 Pilot Unit: Medical
Standardized Performance Board documents.
Set goal: to reduce falls with injury by reducing falls to less than 2.06 falls per 1000 patient days.
Update run chart quarterly.
Try to get frontline staff to own the process. For example, ICU charge RNs update the falls calendar at the end of each D12/N12 shift by placing a red or green “X” in their shift slot and hand off this information during huddle.
Update falls calendars monthly and post on unit boards.
Discuss the previous month’s calendar results at the next Falls meeting.
Run charts are not always meaningful to frontline staff. So they need to be explained better.
Senior leadership knows what to expect on each department’s Performance Board in their Quality/Safety column.
McDonough District Hospital Macomb, IL Bedsize: 48
Created an electronic audit tool to ease the burden of data collection.
Unit Champions carry an IPad in rooms to conduct live audits. Not someone outside of unit coming in; it’s a peer.
This will allow us to analyze the data quickly and efficiently, and help us prioritize opportunities.
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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2
Falls Prevention Learning Network 13 Webinar 4 Meeting Summary – November 18, 2015
Hospital Strategies to Engage Staff/Leaders
Pilot Units: Acute Care Med/Surg
Anderson Regional Medical Center Meridian, MS Bedsize: 260 Acute Care, 148 Post-Acute Care Pilot Units: 2 East (Med/Surg and Pediatrics) Telemetry and CCU Stepdown
Starting Dec. 1, will display poster boards that are divided into “working” teams.
Each quarter reflects teams for day shift rotations and night shift rotations.
Put tally marks in appropriate boxes.
Allows unit falls to be displayed in a more timely fashion.
Creates transparency and friendly competition.
VA Hudson Valley Health Care System Wappingers Falls & Montrose, NY Bedsize: CLC- 94, Medical Unit -27, Mental Health - 63 Pilot Units: E-2- Medical Unit Home of The Heroes Community Living Center–residents have cognitive loss
During the intentional rounding lean project implementation, we utilized a teaching methodology that required staff members to teach each other at shift change.
The CORE team trained the day shift.
The day shift fall champion trained the evening shift.
The evening shift was to train the night shift and then night shift to train days.
There were some schedule conflicts. So staff that were not trained on the night shift or not working those days were trained by the fall champions on additional days.
UMass Memorial Medical Center
Use a shared leadership model.
Give meeting minutes to leadership.
Interdisciplinary team produce monthly flier (case scenarios, Morse Scale, medications, etc.). Staff discusses flier.
Interdisciplinary team attends meetings.
Present fall rates and initiatives to all patient and family care councils (Quality and Patient Safety, Clinical Practice, etc.).
Steward Good Samaritan Medical Center Brockton, MA Bedsize: 267 Pilot Units: 3B (Cardiac/Telemetry), 4A (Med/Surg), & 4BH (Senior Behavioral Health)
Report all falls to Nurse Practice Council (reps from all units) and Quality and Safety.
Have standardized reporting system.
Senior Leadership makes safety rounds in pilot units and throughout hospital
Doing prevalence-based line data collection.
Looking into posters and marketing tools for patients, patients’ family, and staff.