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Models for Effective Work Flow:
Promoting Efficiency, Awareness and Data-Driven Improvements
Rhonda Fontaine, PMP
Sr. System Analyst
Sharp Healthcare
Cynthia Gordon, RN
Administrative Director
Duke University Health System
Lydia McMahon, MS, MPA
Project Manager
Kaiser Permanente
Tim Cheng Mithula Bavanandan Client Management Advisor
RL Solutions Professional Services Analyst
RL Solutions
• Sharp Healthcare-Concept, Execution and Evolution
• Duke Health System-Awareness and Data-Driven Improvements
• Kaiser Permanente-Data-Driven Patient Safety in Ambulatory Care
Sharp Healthcare
About Us • 4 Acute Care Facilities • 4 Specialty Facilities • 1,730 Total Beds • 2 Medical Groups
• SRS – 22 Clinics, 5 Urgent Cares, 7 on site Pharmacies • SCMG – 400 Physician Group
• 1 Sharp Healthplan – Largest in San Diego County • 17,000 Employees
Sharp Healthcare
Concept • Went from Paper to Electronic to RL • Went from 12 event types to 14 • Created 3 Risk Roles – YAHOO we are on the road
Execution • The - Why did I get this event? Started • Quickly identified need for additional roles with conditional
formatting to fit workflow.
Sharp Healthcare
Evolution with RL Solutions • Re-evaluated event types and what we truly wanted the role to do • Created New Roles • Worked with RL to upload updated user file with new roles assigned • Evolution continues never really done
Work Flow Expectations
Evolution with RL Solutions
Duke Health System
Incorporating Champion Driven Work Flows
Duke University Health System • RL6:
• >17,000 users • >2,100 SRS events/month • 1500 File Managers • Risk, RCA, Feedback
(Launched June 2014) • Staff:
• >16,000 Full Time Employees • >2,000 Medical Staff
• Patient Care: • >2.4M outpatient visits/yr • >65K inpatient admissions/yr • >90K surgical cases/yr
Duke University Health System
Duke University Hospital 957 Beds
Duke Regional Hospital 369 Beds
Duke Primary Care
Duke Home Care and Hospice
Duke Clinical Labs
Duke Raleigh Hospital 186 Beds
Private Diagnostic
Clinics
Unit Based SRS Champions
Unit based SRS champions support/provide day-to-day management and timely review of all SRS.
• Champions are identified by managers on each unit • Champions help to assure timely, thorough review of SRS • Champions are empowered by their manager to provide feedback to
staff and share lessons learned locally • Champions responsible for presenting data at departmental safety
and quality meetings (i.e. Core Safety Unit) • Champions lead local process improvement projects
Unit Based Champions Across Duke Health System
Risk - Unit Champion Diabetes 90
Risk - Unit Champion Falls 91
Risk - Unit Champion Skin/Wound 171
Risk - Unit Expert ADR/Med 35
Total 387
Unit Based SRS Champion File Manager Training • Training materials developed tailored to needs of
adverse drug events (ADE), diabetes, skin/wound, and falls
• Training deployed over 4 week time frame, 2 hour blocks
• Training completed by entity patient safety office via live, interactive sessions for ADE, Diabetes
• Training resources available on a health system intranet site
Use of Champions to Drive Improvements Champion Special features and processes
Skin/Wound When a pressure ulcer is identified, a “Mini RCA” done and attached through “Work Done on File”. When attachment is present, alert is fire to Skin and Wound Advance Practice Team for final review.
Falls Dedicated health system nursing “falls” champion reviews/scores data and reports data to entity and health system nursing. Data also used for NDNQI (Press Ganey Nursing Quality) reporting.
Diabetes Champions use a template narrative format to submit low blood glucose events. Events are reviewed by local committees to identify opportunities for practice improvements.
Medication Safety Dedicated med safety pharmacists investigate events daily to determine final severity level, risk priority number (severity X probability X detection), attributable causes, system processes and failures, and conclusion.
Kaiser Permanente
Data-Driven Patient Safety in Ambulatory Care
Kaiser Permanente Colorado
Existing KPCO Medical Office Building
Newest KPCO Medical Office Building
KPCO Service Area
22 Medical Office Buildings
in Denver/Boulder
3 Medical Office Buildings in
Southern Colorado
3 Medical Office Buildings in Northern Colorado
2016
Mem
bers
hip
2 Medical Office Buildings in Mountain Colorado
Adverse Event Reporting Prior to RL
► Various mechanisms for reporting
► No clear event management lifecycle
► No mechanism to confidentially collaborate between event managers
► Lost paper forms
Post RL Implementation Increase in Reporting
Post RL Implementation Increase in Users
Risk Module Configuration Variables
Roles Scopes Info. Centers
Report Centers
Active Alerts
11 184 9 7 14
Access to Reports for Action Planning
Rhonda Fontaine, PMP
Sr. System Analyst Sharp Healthcare
Cynthia Gordon, RN
Administrative Director Duke University Health System
Lydia McMahon, MS, MPA
Project Manager Kaiser Permanente