Designing for Patient Safety: Building Capacity for Statewide ChangeBetsy Lee, BSN, MSPHDirector, Indiana Patient Safety CenterApril 16, 2012

2

Indiana Patient Safety Center Mission

To facilitate the development of safe and reliable health care systems that prevent harm to patients.

Launched July 1, 2006

IndianaFacts:• 6.1 million people• 134 short term acute

hospitals Aim: To facilitate the development of safe and reliable systems to prevent harm to patients

Strategies:• Regional “safety coalitions”• Dynamic alliances and partnerships• Multi-dimensional educational plan• Balance clinical safety topics with

tools and methods• Embed capacity for systems redesign• Engage front line staff and patients

www.indianapatientsafety.org

Indiana’s Bold Aim:

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

4

Inaugural Indiana Patient Safety Summit - March 2010

Transformational Design Principles

• Focus on patients and families• Align statewide efforts and energy• Leverage regional coalitions and

natural groups• Distribute leadership• Encourage “boundarylessness”• Embrace both the personal and

collective nature of change• Emphasize outcomes and transparency

5

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

Partnership for PatientsLaunched April 12, 2011

The 40/20 Goal

• Keep patients from getting injured or sicker. Reduce preventable hospital-acquired conditions by 40%. 1.8 million fewer injuries to patients, with more than

60,000 lives saved over the next three years.

• Help patients heal without complication. Reduce all hospital readmissions by 20% . 1.6 million patients will recover from illness without

suffering a preventable complication requiringre-hospitalization within 30 days of discharge.

7

Hospital Engagement Network Overview

• Support the Partnership for Patients campaign

• Assist hospitals implement best practices to reduce harm & readmissions

• Provide education and build improvement capacity

• Ten Clinical Topics, Leadership, & Safety Culture

8

9

HRET/AHA HEN

34 states / 1,621 hospitals

Preventing Harm – Categories

• Reduce Readmissions• Adverse Drug Events• Catheter Associated Urinary Tract Infections

(CAUTI)• Central Line Associated Blood Stream Infections

(CLABSI)• Surgical Site Infections (SSI)• Ventilator-Associated Pneumonia (VAP)• Harm from Falls and Immobility• Obstetrical Adverse Events• Pressure Ulcers• Venous Thromboembolism (VTE)

10

Additional Topics• Leadership Systems• Culture of Safety• Teamwork and Communications• Lean Training• Innovation and Transformation • Preventing All-Cause Harm

11

Indiana/HRET HEN Summary

• 120 Indiana hospitals aligned with IHA/HRET• Includes:

– 26 critical access hospitals– 8 psychiatric hospitals– 5 rehabilitation hospitals– 4 long term acute hospitals

• Other HENs in Indiana include: Ascension (18), VHA (3), NAPH (1), UHC (1), Ohio Children’s Hospital collaborative (1), Joint Commission Resources (1)

12

Needs AssessmentHRET Survey – Indiana (February 2012):• 111 of 120 hospitals responded• Top requests for support include:– Readmissions - 88– Falls - 60– CAUTI 54– Pressure Ulcers/SSI – 45 each– ADE - 42

• Indiana hospitals report making good progress in VAP, CLABSI, SSI, Pressure Ulcers

IHA’s Plan Design

14

HRET (Prime Contractor)

IHA (Subcontractor)Direct and Shared Services Support:• Regional coalitions and affinity groups• Administrative/organizational support• Local support and facilitation

Technical Assistance:•Purdue Healthcare TAP and CMSA•Individual hospital plans/assessments•Statewide coaching network•Communities of Practice (Lean, Med Safety)

HRET National Education:•Access to National Programs•4 groupings of 10 topics•Plus HCAHPS,TeamSTEPPS (AHRQ funded activities)• Fellowship Programs• Stand-alone programs (Webinars educational sessions, etc)•Learning networks

Indiana Education:•State and regional education:• Key topics from needs assessment • Tools training (Lean certification,

medication safety, etc) • Leadership for cultural improvement

HRET Support:•Measurement warehouse•Best practice clearing house•Access to national experts•Partially defray data collection costs

HRET Resources• HRET State Contacts• Improvement Advisors• AHA/HRET HEN Website• Topic Specific Change Packages• Data Collection System • Fellowship – 4 Regional Offerings• Topic Specific Collaboratives – Only offered in Chicago for 2012 (May, Aug,

Nov)15

HRET HEN Improvement Leader Fellowship Program

Aim:Develop a cadre of front-line hospital improvement leaders in 1,500+ hospitals by 2013Delivery Model: At least 4 series of three 2-day training sessions across the countryProjected Outcome: Increase leadership capacity across the 34 states to lead ongoing improvement efforts

16

HRET Collaborative DesignAim: Provide an integrated approach for hospitals to work together on improving performance in topic specific collaboratives with structured & peer-to-peer exchange of ideas.

17

Share Tools

Implementation Strategies

Support Structure

Networking

Peer-to-Peer

Learning

18

Ten regional coalitions cover Indiana: only state in the country with this model

Members agree not to compete on patient safety

Create layered model of regional coalitions and affinity groups – Indiana’s “transformation grid” to support dissemination

Benefits: • Innovate at the front lines• Align with state and national

efforts, and standardize when beneficial

• Model builds local and hospital-specific capacity for improvement and innovation

• Encourages safety leadership at all levels across multiple professions

Indiana HEN Activities• Statewide improvement activities

around the highest level of need as defined by the needs assessment

• Development of a statewide “coaching” network to support mentoring and sharing best practices as well as support innovation and implementation, and to link high performers to other hospitals in the state

• Regional and statewide support of culture, teamwork, and communications improvement as well as leadership for safety

19

Purdue University Resources• Purdue University HealthcareTAP:

Regional Lean/Six Sigma green belt (2 per hospital) and black belt (1 per hospital) certification and training

Readmission computerized simulationLean Community of Practice

• Purdue Center for Medication Safety AdvancementWeb-based medication safety continuing education

(10 per hospital – RN, PharmD, MD)Medication Safety Community of PracticeThe Role of ADEs in Readmissions

20

Escalating Connections

21

Mentor/CoachingNetwork

Affiliated Societies

Affinity Groups

Communities Of Practice

Regional Patient Safety Coalitions

HRET:• Measurement• National experts• Education• Fellowships• Resources

IHA HEN• Building knowledge and collaboration• Technical assistance•Support regional coalition initiatives• Lean/Six Sigma training (Purdue)• Developing leaders to promote safe cultures• Expanding medication safety competencies (Purdue)•Peer-to-peer coaching

Why is Data Needed?• To demonstrate hospitals have

reduced their Hospital Acquired Conditions and Readmissions over the 2 year period

• To monitor that interventions are working– Part of the PDSA cycle–Measures are used to assess the impact

of changes

What Data is Needed?• At a minimum, 1 process measure

and 1 outcome measure – Process: measures how well the practice

was followed– Outcome: measures the result of the

intervention• Both types may be linked and need

to be monitored

Indiana Sepsis Mortality Rates

1Q2008 2Q2008 3Q2008 4Q2008 1Q2009 2Q2009 3Q2009 4Q2009 1Q2010 2Q2010 3Q2010 4Q2010 1Q2011 2Q2011 3Q20115.00%

7.00%

9.00%

11.00%

13.00%

15.00%

17.00%

19.00%

21.00%

23.00%

25.00%

Septicemia Mortality Rates - Impact of 3 Regional Coalitions

Coalition A Coalition B Coalition C Statewide

Key Elements of Enhancing Cultures

• Teamwork and communication• Leadership engagement in safety

strategies• High reliability principles• Eliminating fear• Effective handovers and transitions

Successful Strategies• Patient Safety Executive Rounds• Patient Safety Ambassadors (front-line

staff on each unit)• Implement “Just Culture” program• Emphasis on patient handoffs• Daily nursing huddles• Storytelling• Regular event review sessions with staff• Bedside change of shift report

26

AHRQ Culture of Safety Survey

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

27

How do hand-offs fail?

Omissions of content are a major cause of failed communication during handoffs.Arora, 2006

28

Key Principles from the Literature

• 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

29

Common 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

30

Clear and Complete Communication

DRAW is a tool to communicate hand-off information

SBAR - a tool to communicate a situation requiring immediate attention, a decision, or action.

SituationBackgroundAssessmentRecommendation

DiagnosisRecent changesAnticipated changesWhat to watch for

Seton Family of Hospitals Austin, TX 2010

DRAWDRAW is a tool to communicate

hand-off information and includes the items outlined by Joint Commission

D – DiagnosisR – Recent ChangesA – Anticipated ChangesW – What to Watch for

Adapted DRAW• Dr. James Buchanan – Ft. Wayne

Medical Residency program• Adapted the DRAW tool to

incorporate:– Interaction between residents (could

apply to nurses, too)– Defined role for sender and receiver for

each step of the tool– Anticipatory critical thinking– Resident evaluation

Adapted DRAW - RolesD – Diagnosis – by SENDERR – Recent Changes – by SENDERA – Anticipated Changes – by SENDER

(what lab results, tests, etc. can be expected on the next shift) AND RECEIVER (what might be expected to occur in the course of this patient’s illness during the coming shift?)

W – What to Watch for? and What might Harm this Patient? RECEIVER

“Flexible Standardization”

• Incorporate the principles• Test different models and roles

before you implement• Both flexibility and standardization

are essential• Customize/adapt to meet the needs

of the local clinical setting.

35

Jorm, et al. Clinical handover: critical communications. Medical Journal of Australia. 190:11, June 2009

IHA’s Aim:To build workforce capacities and cultures of safety in all Indiana hospitals …the rising tide will “raise all boats”

“We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win…”

- President John F. KennedyAddress at Rice University

September 12, 196237

38

ContactsBetsy Lee, RN, MSPHDirector, Indiana Patient Safety CoalitionIndiana Hospital Associationblee@IHAconnect.org317-423-7795

39