innovation, advocacy, and lessons learned: how iha implemented a patient safety learning...
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Innovation, Advocacy, Innovation, Advocacy, and Lessons Learned: and Lessons Learned:
How IHA Implemented a How IHA Implemented a Patient Safety Learning Patient Safety Learning
CollaborativeCollaborative
Cathy Grossi and Becky StewardCathy Grossi and Becky StewardIllinois Hospital AssociationIllinois Hospital Association
The Quality ColloquiumThe Quality ColloquiumHarvard UniversityHarvard University
August 21, 2006August 21, 2006
Illinois Facts:Illinois Facts:
55thth most populous state (12.5 M) most populous state (12.5 M) 2525thth largest (57,918 sq. miles) largest (57,918 sq. miles) AgricultureAgriculture Springfield / ChicagoSpringfield / Chicago 200+ Hospitals200+ Hospitals
Academic Centers (19)Academic Centers (19) S & R (90)S & R (90) CAH (51)CAH (51) Top 3 employer in 48 / 102 countiesTop 3 employer in 48 / 102 counties 1.6 Million inpatients1.6 Million inpatients 4.9 Million ED 4.9 Million ED Medicare (40%) / Med (13%)Medicare (40%) / Med (13%) Uncomp care – $1.2 BUncomp care – $1.2 B
About “Land of Lincoln”About “Land of Lincoln”
Hx - Partners in Quality:Hx - Partners in Quality:
Perinatal: 10 Networks / 148 HospitalsPerinatal: 10 Networks / 148 Hospitals Newborn Hearing Screening: 144 reportNewborn Hearing Screening: 144 report Metabolic Screening: Expanded testing (6-30)Metabolic Screening: Expanded testing (6-30) EMS / Trauma: 11 Regions / 67 HospitalsEMS / Trauma: 11 Regions / 67 Hospitals EMSC: 11 Regions / 206 HospitalsEMSC: 11 Regions / 206 Hospitals Organ / Tissue Donation & TransplantOrgan / Tissue Donation & Transplant Communicable DiseaseCommunicable Disease Cancer RegistryCancer Registry
Illinois HospitalsIllinois Hospitals
Hospitals Harm:Hospitals Harm:
Medical ErrorMedical Error Inadequate StaffingInadequate Staffing Poor Infection Control PracticesPoor Infection Control Practices
Patients at RiskPatients at Risk
2002 Springfield’s “New World” Order:2002 Springfield’s “New World” Order:
Democratic sweep of state governmentDemocratic sweep of state government New Governor, DemocratNew Governor, Democrat Leadership of the General AssemblyLeadership of the General Assembly
Largest turnover of state legislators in 25 yrsLargest turnover of state legislators in 25 yrs 46 new legislators (29 in the House, 17 in the 46 new legislators (29 in the House, 17 in the
Senate)Senate)
Union-friendly environment Union-friendly environment
PoliticalPolitical LandscapeLandscape
Multiple Objectives:Multiple Objectives:
Internal improvementInternal improvement
++
Advocacy & leadershipAdvocacy & leadership
IHA Collective InitiativeIHA Collective Initiative
Slam Dunk:Slam Dunk:
4 Billion prescriptions/yr4 Billion prescriptions/yr 20% of medical errors20% of medical errors 2 to 7 per 100 hospital 2 to 7 per 100 hospital
admissionsadmissions ADE – 1 to 5 day extended LOSADE – 1 to 5 day extended LOS Up to add’l $9000 costUp to add’l $9000 cost
Medication SafetyMedication Safety
Criteria:Criteria: Addresses issue of public concernAddresses issue of public concern Contributes to real improvementContributes to real improvement Reasonable and fair to providers & publicReasonable and fair to providers & public Operationally feasible Operationally feasible W/in provider control & consistent w/accredW/in provider control & consistent w/accred Offers measurement activityOffers measurement activity
Drive results bigger than one organizationDrive results bigger than one organization
Proactive FocusProactive Focus
Develop, adopt and/or support Develop, adopt and/or support efforts for: efforts for:
(1)(1) Pt Safety Organizational FrameworkPt Safety Organizational Framework(2)(2) Hospital Compliance/Consumer Guide Hospital Compliance/Consumer Guide (3)(3) Medication Safety InitiativeMedication Safety Initiative(4)(4) Simulation Training (Team Skills)Simulation Training (Team Skills)(5)(5) Networking RoundtablesNetworking Roundtables
Addressing the IssueAddressing the Issue
From accreditation, gov’t, literature & From accreditation, gov’t, literature & member sourcesmember sources
Approved by IHA Board in May, 2003Approved by IHA Board in May, 2003 IHA web site: Pledge ParticipantsIHA web site: Pledge Participants
Member Pledge: 188/194 Hospitals Member Pledge: 188/194 Hospitals (97%)(97%)
Advocacy: On-going Leadership effortAdvocacy: On-going Leadership effort
Organizational Framework Organizational Framework **
* Available at www.ihatoday.org
Update–In-Progress:Update–In-Progress:
IHA Quality/Patient Safety Data GuideIHA Quality/Patient Safety Data Guide Federal/state/private activityFederal/state/private activity Hard copy/PDF formatHard copy/PDF format Initial distribution: Mid-Quarter 2004Initial distribution: Mid-Quarter 2004 New section - Publicly available hospital New section - Publicly available hospital
infoinfo
IHA Resource Guide IHA Resource Guide **
* Available at www.ihatoday.org
From Medication Safety
To Patient Safety Learning Collaborative
IHA Medication SafetyIHA Medication Safety
Med Safety = Do a Collaborative (2003-2004):Med Safety = Do a Collaborative (2003-2004):
Learning curveLearning curve Business planBusiness plan Internal marketingInternal marketing Job descriptionJob description Recruitment Recruitment Marketing planMarketing plan Project management tool Project management tool
Behind the ScenesBehind the Scenes
Project Development :Project Development :
Phases (Pre-work, learning sessions, video-conferences, site Phases (Pre-work, learning sessions, video-conferences, site visits, showcase conference):visits, showcase conference): MarketingMarketing Budget & ContractsBudget & Contracts SpeakersSpeakers Materials & printingMaterials & printing RegistrationRegistration EvaluationsEvaluations Meeting logistics Meeting logistics RevisionRevision
On-going Focus:On-going Focus: Dedicated managerDedicated manager Faculty advisorsFaculty advisors Online ForumOnline Forum Measurement StrategyMeasurement Strategy Participant Feedback & ReportsParticipant Feedback & Reports PSLC VisibilityPSLC Visibility
Just in TimeJust in Time
Three Aims:Three Aims:
Individual Hospital ImprovementIndividual Hospital Improvement Aggregate Hospital ImprovementAggregate Hospital Improvement IHA ProcessIHA Process
IHA Patient Safety IHA Patient Safety Learning CollaborativeLearning Collaborative
BalanceBalance
The Constant ChallengeThe Constant Challenge
PSLC
Unique Illinois Patient Safety NexusUnique Illinois Patient Safety Nexus
Quality Oversights
Coalitions
Safety Champions
Patients & Families
Regulatory & Legislative
Other States
Illinois Hospitals
Media
Becky Steward, BSNManager, Patient Safety Learning Collaborative
Concept to ImplementationConcept to Implementation
FrameworkFramework
Model for ImprovementModel for Improvement Learning from LeadersLearning from Leaders A tool and a philosophyA tool and a philosophy
Advisors and Advisors and FacilitatorsFacilitators RoleRole InvolvementInvolvement
SpeakersSpeakers CriteriaCriteria From external to internalFrom external to internal
Establish FoundationEstablish Foundation
DevelopDevelop Measures and tools Measures and tools
** Processes Processes
StaffStaff Labor intensiveLabor intensive FTEsFTEs
Build InfrastructureBuild Infrastructure
* Available upon request
PreparationPreparation ContentContent Materials and Materials and
resourcesresources EvaluationsEvaluations
Build InfrastructureBuild Infrastructure
MarketingMarketing AudienceAudience Message Message
pointspoints Non-Non-
competitivecompetitive SizeSize
Build Awareness Build Awareness
Overview 2005Overview 2005
Participants Participants Health SystemHealth System 1 1 HospitalsHospitals 2525
Geographical cross-Geographical cross-sectionsection NorthernNorthern 1010 CentralCentral 7 7 SouthernSouthern 9 9
Staffed bedsStaffed beds Less than 100Less than 100 2 2 101 – 300 101 – 300 1717 301 – 500 301 – 500 4 4 More than 500 More than 500 2 2
Bring Program to Participants Bring Program to Participants
1.1. Pre-workPre-work
2.2. ActionAction
3.3. Sharing Sharing
Three Distinct Phases Three Distinct Phases
Engage ParticipantsEngage Participants Letter Letter Conference call Conference call ** Baseline data Baseline data
collection collection **
Phase One: Pre-workPhase One: Pre-work
* Available upon request
Build RelationshipsBuild Relationships AccessAccess Follow-throughFollow-through
Manage expectationsManage expectations Tracking tool Tracking tool **
Critical ElementsCritical Elements
* Available upon request
Information and Networking Information and Networking Learning SessionsLearning Sessions VideoconferencesVideoconferences Issues and adjustmentsIssues and adjustments On-line ForumOn-line Forum Site visitsSite visits
Phase Two: ActionPhase Two: Action
2005 Pre-WorkLearning Session
Video-conference
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctober
TechniquesTechniques Unlabeled profilesUnlabeled profiles Of cameras and candyOf cameras and candy New ways to use dataNew ways to use data
Unify Diverse Groups Unify Diverse Groups
Each event involves one or more handoffs
• # Patients registered for ED 2.8 / minute
• # Patients registered for Out Pt. 12.4 / minute
• A Patient is admitted to hospital 1 / 64 seconds
• A child is born 1/ 10 minutes, 21 seconds
• A surgery begins 1 / 90 seconds
• A patient is discharged 1/ 60 seconds
• A child is discharged 1/ 6 minutes, 15 seconds•A patient with mental health or 1/ 14 minutes, 39 seconds
substance abuse is discharged
2004 IHA Data, Participants 2006
Imagine the number
of handoffs
Are we lucky?
Or are we safe?
HumoHumor r
Imagery
On-line ForumOn-line Forum Limited to participantsLimited to participants ““Voice from which I Voice from which I
speak”speak” Enable direct contactEnable direct contact
Facilitate CommunicationFacilitate Communication
Monthly reportsMonthly reports SuccinctSuccinct Inherent valueInherent value ChallengesChallenges
Measuring progressMeasuring progress DataData ““Are you done yet?”Are you done yet?”
Assess ProgressAssess Progress
Innovation in Measurement Innovation in Measurement **
Implementation across organization, monitoring data
Expanding use beyond pilot units, collecting / reporting data
Testing tool / process on pilot units, collecting preliminary data
Developing initial tool / process
Having preliminary discussions
Level 1 Level 2 Level 3 Level 4 Level 5
Healthy Hospital in Jan-05 Healthy Hospital in Jun-05 Healthy Hospital in Sep-05
No Process Process Established
Progress over Progress over timetime
* Available upon request
By facilitatorsBy facilitators
Reports to Reports to participantsparticipants IndividualIndividual AggregateAggregate
Provide FeedbackProvide Feedback
Excerpt – 2005 Final Excerpt – 2005 Final ReportReport
Excerpt – 2005 Final ReportExcerpt – 2005 Final Report
Excerpt – 2005 Final ReportExcerpt – 2005 Final Report
Excerpt – 2005 Final ReportExcerpt – 2005 Final Report
Outcomes CongressOutcomes CongressOctober 18, 2006October 18, 2006Bloomington, ILBloomington, IL
Phase Three : SharingPhase Three : Sharing
Highlights:AttendanceEngagement
Challenges
Beyond Illinois
Common ThemesCommon Themes CommitmentCommitment ExpectationsExpectations ResourcesResources CompositionComposition Effective meetingsEffective meetings Small tests of changeSmall tests of change
Elements for Success Elements for Success
Building on 2005Building on 2005 17 of 26 return17 of 26 return ExperienceExperience
Unique Challenges in 2006 Unique Challenges in 2006 Unique Challenges in 2006 Unique Challenges in 2006
Breaking new Breaking new groundground
Participants Participants Health SystemsHealth Systems 4 4 HospitalsHospitals 2121
Geographical cross-Geographical cross-sectionsection Cook CountyCook County 1515 NorthernNorthern 1010 CentralCentral 6 6 SouthernSouthern 1010
Staffed bedsStaffed beds Less than 100Less than 100 4 4 101 – 300 101 – 300 2626 301 – 500 301 – 500 9 9 More than 500 More than 500 2 2
2006 - Handoff 2006 - Handoff CommunicationCommunication
Master calendar / timelineMaster calendar / timeline
Role changesRole changes
Changes to reportingChanges to reporting
SizeSize
Adjustments in 2006 Adjustments in 2006
Save the Date!
IHA Safety IHA Safety Connections:Connections:Relaying the Lessons Relaying the Lessons LearnedLearned
November 14, 2006Hilton HotelLisle / Naperville
Registration limitedwww.ihatoday.org
““It's a job that's never started that takes the longest to finish.”It's a job that's never started that takes the longest to finish.”
J.R.R. TolkienJ.R.R. TolkienBritish scholar & fantasy novelist (1892 - 1973)British scholar & fantasy novelist (1892 - 1973)
Questions? Questions?