BETSY LEE, RN, BSN, MSPHINAHQ SPRING CONFERENCE

MAY 9 , 2014

Making Indiana the Safest State: The Challenge and

the Opportunity

Conflicts of Interest Disclosures

The speaker has nothing to disclose.

Session Objectives

Discuss the status of statewide patient safety improvement in Indiana compared to national benchmarks

 Evaluate potential impact of the Partnership for Patients initiative on patient safety at the local level

 Outline leadership strategies for engaging front line staff in addressing harm across the board

Indiana’s Bold Aim

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

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Inaugural Indiana Patient Safety Summit - March 2010

The Challenge: Indiana Performance

How will we know we are the safest state?Challenge to find comparative data for many

safety measuresNo publicly available comparative data for

ADE’s, Falls, Pressure Ulcers, VTE, VAP, birth-related injuries, early elective deliveries

Infections: CDC HAI Progress report Nationally, CLABSI dropped 44% from 2008 to 2012 The reduction in Indiana was only 34% CLABSI SIR increased from 2011 to 2012

Indiana 2012 Healthcare Acquired Infections

Infection Comment Indiana SIR

Nat’l SIR

CLABSI – 102 hospitals

Indiana’s 2012 state CLABSI SIR is significantly worse than the 2012 national SIR.

0.66 0.56

CAUTI – 104 hospitals

Indiana’s 2012 state CAUTI SIR is similar to the 2012 national SIR.

1.05 1.03

SSI – Colon – 105 hospitals

Indiana’s 2012 state Colon Surgery SSI SIR is significantly worse than the 2012 national SIR.

1.04 0.80

SSI – Abdominal Hysterectomy – 98 hospitals

Indiana’s 2012 state Abdominal Hysterectomy SSI SIR is significantly better than the 2012 national SIR.

0.52 0.89

http://www.cdc.gov/hai/pdfs/stateplans/factsheets/in.pdf

Source: National and State Healthcare Acquired Infections: Progress ReportCenters for Disease Control and Prevention, March 2014

Sepsis Mortality Reductions are Promising

1Q20

08

2Q20

08

3Q20

08

4Q20

08

1Q20

09

2Q20

09

3Q20

09

4Q20

09

1Q20

10

2Q20

10

3Q20

10

4Q20

10

1Q20

11

2Q20

11

3Q20

11

4Q20

11

1Q20

12

2Q20

12

3Q20

12

4Q20

12

1Q20

13

2Q20

13

3Q20

136.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

Indiana Inpatient Septicemia Mortality Rate

Statewide

Began sharing coalition reports

Heart Failure 30 Day Readmission Rate8

24.68%

24.23%

24.73%

25.91%

24.55%

23.56%

26.50%

24.81%

24.98%

24.46%

26.21%

23.45%

23.60%

25.20%

23.38%

18.91%

23.87%

24.30%

23.98%

24.55%

24.50%

24.73%

25.05%

24.57%

23.11%

24.09%

24.47%

23.92%

24.74%

23.63%

24.17%

26.08%

23.75%

23.79%

25.17%

23.73%

19.67%24.80%

25.3

1%

24.82%

25.99%

24.09%25.37%

25.61%25.20% 24.33%

24.43%

25.60%

25.80%

24.43%25.77%

Heart Failure 30 day ReadmissionsRank State Rate Rank State Rate

1 UT 23.11% 27 TX 24.57%2 OR 23.38% 28 AL 24.68%3 HI 23.45% 29 AZ 24.73%4 CO 23.56% 29 KS 24.73%5 ID 23.60% 31 MO 24.74%6 WI 23.63% 32 OH 24.80%7 DE 23.73% 33 CT 24.81%8 VT 23.75% 34 VA 24.82%9 NH 23.79% 35 FL 24.98%

10 MT 23.87% 35 PA 24.98%11 IA 23.92% 37 OK 25.05%12 ND 23.98% 38 MA 25.17%13 NM 24.05% 39 TN 25.20%14 WA 24.07% 39 NV 25.20%15 IN 24.09% 41 WV 25.31%16 ME 24.17% 42 IL 25.37%17 AK 24.23% 43 LA 25.60%18 WY 24.30% 44 KY 25.61%19 NC 24.33% 45 RI 25.77%20 SC 24.43% 46 MS 25.80%20 MI 24.43% 47 AR 25.91%22 GA 24.46% 48 MD 25.99%23 MN 24.47% 49 NY 26.08%24 NE 24.50% 50 DC 26.21%25 SD 24.55% 51 NJ 26.50%25 CA 24.55%

Source: Hospital Compare Release manipulated by WhyNotTheBest.org, , Measure Start – End Dates:7/1/08- 6/30/11

Partnership for Patients Aims

• 40% Reduction in Preventable Hospital Acquired Conditions – 1.8 Million Fewer Injuries – 60,000 Lives Saved

• 20% Reduction in 30-Day Readmissions – 1.6 Million Patients Recover Without Readmission

• Projection: up to $35 Billion dollars will be saved

Impact of Partnership for Patients

Large scale funded national initiative

Aims aligned with Indiana priorities

Takes statewide and regional improvement efforts to scale

Encourages local adaptation with the discipline of organized effort and measurement

AHA/HRET Hospital Engagement Network

34 states / 1,622 hospitals

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Coalition for Care

Partnership for Patients

National HEN Targeted Harm Categories

1) Adverse drug events2) Birth-related injuries

a) Elimination of Early Elective Deliveries

3) Central line-associated blood stream infections

4) Catheter-acquired urinary tract infections5) Falls with injury6) Surgical infections and complications7) Venous thromboembolism8) Pressure ulcers9) Readmissions10) Ventilator-associated pneumonia

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Additional Priorities

Leadership SystemsCulture of SafetyTeamwork and CommunicationsLean TrainingInnovation and Transformation Preventing Harm Across the BoardHealth Care Disparities

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2014 CMS Topic Expansion

Expansion to other topics:- Sepsis- MRSA- Acute Renal Failure- Clostridium difficile

- Procedural Harm

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How Might We Achieve Our Aim?

Focus on initiatives to improve all eleven Partnership for Patients topics

Emphasize measurement, data submission and transparency

Statewide alignment and energyEngage front-line teams in patient safety

effortsEmbrace personal and collective nature of

change

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National Content Development

Change packages for all 10 topic areas are now available at www.hret-hen.org.

National HRET conference calls and webinars to share evidence-based practice solutions

National CMS calls sharing ideas for change from hospitals around the country

Indiana learning opportunities for many topics

HRET HEN Resources20

http://hret-hen.org/

HRET/HPOE Resources

21

http://hret-hen.org/

Education and Technical Assistance

Improvement Leader Fellowship (HRET)

National Collaborative (HRET HEN Week)

National and Indiana webinars

Regional “Roadshows”Indiana Patient Safety

SummitsIHA Annual Meetings

Lean Six Sigma training Medication Safety Essentials courses (MSE 1.0 and advanced course MSE 2.0) - on-line, on-demand continuing education

Readmissions computerized simulation model

Communities of practiceSite visits and coaching

Special Focus: Adverse Drug Events

Significance:• About 1/3 of all hospital adverse events are related to

ADEs• LOS is prolonged by 1.7-4.6 days• ADEs affect 1.9 million hospital stays annually• Cost $4.2 billion annually• Responsible for about 100,000 emergent

hospitalizations in older Americans, annually4 • 2/3 result from just four medication classes:

o Warfarin, insulin, oral hypoglycemics, and oral antiplatelet agents

o 2/3 result from unintentional overdoses

1. Classen DC et al. Health Aff (Millwood) 2011;30:581–9.2. Agency for Healthcare Research and Quality, Rockville, MD, 2011 April. HCUP Statistical Brief #109.3. Classen DC et al. JAMA 997;277:301–6. Bates DW et al. JAMA 1997;277:307–11. 4. Budnitz, DS et al. N Engl J Med 2011:365:2002-12.

ADE Resources24

http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Gap-Analysis-Opioid.pdfhttp://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/opioids/Documents/assessment.pdf

Elimination of EED

Scheduling Form

Policy

Consent

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CMS: Four Calls to Action

Reduce harm across the board. It is a call for hospitals to produce reductions in every type of harm.

Take a systemic approach. It is a call to transform the organization and its practices to eliminate all the

causes of harm. “Using every means at our disposal.” Make your safety transparent to all. It is a call for hospitals to define themselves by their safety performance; define themselves to their employees, doctors, patients and the community.

Make safety personal & compelling. Make every incident of harm a personal patient story that propels the institution to higher levels of performance.

Harm Across the Board (HAB):

Monthly UpdateHospital: ________________ State: ______ Month: _________

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Eleven regional safety coalitions

Members agree not to compete on patient safety

Layered model of regional coalitions and affinity groups supports transformation, learning and spread

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

national efforts, and standardize when beneficial

• Builds local and hospital-specific capacity for improvement and innovation

• Encourages safety leadership at all levels across multiple professions

Why Regional Efforts Are Important

Focus on improving patient safety and decreasing harm

Identify patient safety issues through data/eventsTransparency

Share expertise, resources, and tools Develop solutions in coalition and

collaborative learningWe do not compete on patient safety

Leadership and CultureStaff Engagement

Quality Improvement on Harm Reduction

Patient/Family Engagement

Joy in Work, Give it Meaning, Make it Personal, Board Engagement

Safest State in

the Nation

Patients and families

involved in improving care and reducing

harm

Skilled workforce – technical/safety competencies; coaching

Not Competing on Safety

Trusting Relationships

Transparency

Culture of Learning

Regional Patient Safety Coalitions: Scope and Focus

Regional Coalition Transparency

ZHospital does not provide services related to this HAC

3 Demonstrating outstanding improvement

0 Not engaged in work related to HAC 4Demonstrating sustained high performance or a national benchmark

1Engaged in work related to HAC, but not submitting data

5 Potential Mentor Hospital

2Engaged in work related to HAC and submitting data

Hospital Name ADE VTEPressure

Ulcers EED OB Falls VAP CAUTICLABS

I SSIReadmissions

ABC Hospital 2 2 4 4 4 4 3 4 4 5 4General Hospital 1 1 4 2 4 2 2 4 4 3 2St. Elsewhere Health System 1 4 3 3 4 2 4 4 4 3 4County Health 4 3 5 4 4 5 3 5 5 3 5Memorial Hospital 0 2 2 2 3 2 3 2 4 2 2Critical Access Hospital 4 4 4 Z Z 2 Z 4 4 2 4

Partnership for Patients33

Published in February 2013 Issue of Health Affairs

What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences;

Fewer Data on Costs

Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know

Their Patients’ ‘Scores’

Enhanced Support for Shared Decision-Making Reduced Costs

of Care for Patients with Preference-

Sensitive Conditions

Survey Shows That Fewer Than a Third of Patient-Centered Medical Home Practices Engage Patients

in Quality Improvement

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“[T]here was an inverse relationship between [patient] participation [in their care] and

adverse events . . . [P]atients with high participation were half as

likely to have at least one adverse event during the admission. ”

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Source: Weingart SN et al., Hospitalized patients’ participation and its impact on quality of care and patient safety, International Journal for Quality in Health Care 2011; 1-9.

Patient Engagement and Adverse Events

Partnership for Patients36

HSOPS: Agency for Healthcare Research and Quality

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Indiana HSOPS ResultsT

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Survey of Patient Safety 2007 to 2013

2007 2008 20092010 2011 20122013 2012 AHRQ 90th Percentile 2012 AHRQ 75th Percentile

Key Elements of Enhancing Cultures

Teamwork and communicationLeadership engagement in safety strategies

High reliability principlesEliminating fearEffective handovers and transitions

AHRQ Culture of Safety Survey

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

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What are hand-offs/handovers?

“The process of transferring primary

authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver.”

Patterson & Wears, 2010

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Characteristics of Effective Handovers

Face-to-face, verbal, and interactiveProviders 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 foresightReceiver does read-back to verify contentGood teamwork as foundation

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Handover Components

Introduction and brief patient historyOverview of current situationSafety concerns or potential problemsPlan (what’s next?)Anticipation, reflection, and foresight (what

might go wrong?) - provide contextQuestions and verification

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Example: DRAW

DiagnosisRecent ChangesAnticipated ChangesWhat to Watch For

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Source: Seton Southwest Hospital, Austin, TX

Prof. Patrick Hudson, Leiden University, the Netherlands (From Shell E & P)

Evolution of

Culture

Managing the Unexpected (Weick & Sutcliffe)

“Mindfulness”: Ability to see the significance of early and

weak signals and to take strong decisive action to prevent harm

“Sensemaking”: o Process of transforming experiences into

updated views of the system by “taking the time to make sense out of new and changing circumstances”

o “Trust is a product of sensemaking.” – J. Morath

Tools for Sensemaking (Weick and Battles)

Literally “making sense of events”Building a systems understanding to

eliminate and mitigate risks to patientsTrue sensemaking is reactive and proactiveFocus of learning organizations –

systematically increasing reliabilityProvides data-driven framework for

sensemaking through tools and joint reflection

Importance of staff engagement and curiosity

Characteristics of Mindfulness in High Reliability Organizations (Weick & Sutcliffe)

Preoccupation with failureReluctance to simplify interpretationsSensitivity to operationsCommitment to resilienceDeference to expertise

Mindfulness (Weick & Sutcliffe)

“Struggle for alertness”Trouble starts small and is signaled by

weak symptoms that are easy to miss Small discrepancies can accumulate,

enlarge and have disproportionately large consequences

Engaging Front-Line Staff in Safety

Focus on the systems of care and on redesigning work processes

Must involve “sharp end” caregiversEducation and training alone will not

work – requires increased “mindfulness”Cultural change requires strong

leadershipMust improve reliability through new

approaches

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Leadership for Results

Leverage energy and effort at the front lineRegionalize technical assistance and

educationAlign measures to mark progressConcentrate on 11 topic areas Build capabilities for future challengesFocus on patients and familiesMake it personal

Engaging Front Line Teams

The Leadership Challenge

Model the WayInspire a Shared VisionChallenge the ProcessEnable Others to ActEncourage the Heart

The Leadership Challenge Kouzes and Posner, 2002

Contact

Betsy Lee, RN, BSN, MSPHDirector, Indiana Patient Safety CenterIndiana Hospital Associationblee@ihaconnect.org(317) 423-7795

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