using transparency to drive patient safety -...
TRANSCRIPT
Using Transparency to Drive Patient Safety Doug Salvador, MD MPH Chief Quality Officer, Baystate Health Chief Medical Officer, Baystate Medical Center
Karen Johnson, BSN, RN, CCMSCP Director, Performance Improvement Baystate Medical Center
Mary Beth Collins, BSN, RN Performance Improvement Coordinator Baystate Medical Center
Session Code These presenter s have
nothing to disclose
December 12, 2017
#IHIFORUM
No Conflicts to Disclose
Session Objectives Discuss multiple ways to increase transparency in their organizations to improve patient safety
Understand one medical center’s program for strategically using transparency
Discuss three structures that could be implemented to improve the safety event review and systems improvement process
P3
#IHIFORUM
Baystate by the Numbers Safety Reporting System Reports – 8,000 per year
Peer Reviews – 350 per year
RCA – 50 per year
P4
P5 Patient Safety Proactive Reactive Regulatory
Culture of Safety
Failure Mode & Effects Analysis
External Requirements & Best Practices
BORM TJC
DPH CMS
Peer Review
Communication, Apology & Resolution
Peer Support
Root Cause Analysis
Education & Training
Safety Reporting System
PI Huddle, Sentinel Event Reviews
Background
P6
Five Transforming Concepts P7
• Transparency • Care Integration • Patient Engagement • Restoring Joy and Meaning in Work • Medical Education Reform
Leape L, Berwick D, Clancy C et al Transforming Healthcare: a Safety Imperative, Qual Saf Health Care 2009; 18:424-428.
National Patient Safety Foundation’s Lucian Leape Institute. Shining a Light: Safer Health Care Through Transparency.
Boston, MA: National Patient Safety Foundation; 2015.
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• Transparency • Care Integration • Patient Engagement • Restoring Joy and Meaning
in Work • Medical Education Reform
IHI Framework for Safe and Reliable Care
P9
Transparency
Leadership
Psychological Safety
Negotiation
Teamwork & Communication
Accountability
Reliability Improvement
&
Measurement
Continuous Learning
Engagement of Patients & Family
What Did We Want To Improve? Timeliness Getting the Right People to the Case Review Ownership by Operational Teams Follow Through
Trends
P10
Baystate’s Process for Managing
Serious Safety Events:
A Patient Story
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Patient Story A 47 year old male admitted for a primarily surgical issue. Patient has a history of DM and utilizes an insulin pump. No insulin orders are entered for the patient on admission. No consult to the in-patient diabetes team. Patient’s blood sugar is noted to be in the 400’s the day after admission. Patient requires monitoring at a higher level of care.
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AN EXERCISE
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Transparency Exercise Transparency can be used in many small and large ways to drive change.
Think of a time when you personally or your organization have attempted to use transparency to make change in patient safety.
Was it helpful or not? Why?
Pair with a neighbor and share your story, including why it was or was not helpful.
Be prepared to share what you heard from your neighbor with the larger workshop group.
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P15 Peer Review Filter Tool
PI Huddle P16
P17 Performance Improvement Huddle News
Compass Huddle P18
Making Changes to Increase Transparency
P19
#IHIFORUM
Leader’s Harm Report Rolling It Out
Making the Case to Leaders Testing Changes Getting Feedback
Making it Work Two Grids Real-time documentation
Trends Analyze data Revise tool- SharePoint
P20
Leader’s Harm Grid P21
New SharePoint Tool P22
Results
P23
Analysis of PI Huddle Cases P24
Row Labels Count of Patient Name
ED 1 Surgery 1 Hospital Medicine 2 Radiology 3 Women’s Services 4 Medicine Specialty 6 Neurosciences 7 Nursing 8 Heart + Vascular 9 Critical Care 10 Children’s 11 Other 36 Anesthesia 41 Blank 62
Grand Total 201
Cases by Location P25
ED 85 Surgery 37 Hospital Medicine 25 Radiology 21 Women’s Services 21 Medicine Specialty 19 Neurosciences 18 Nursing 16 Heart + Vascular 14 Critical Care 12 Children’s 9 Other 8 Anesthesia 6 Blank 5 Trauma 3 Psychiatry 1
Location Case Count
Test of Change – RCA RCA Case Summary:
P26
RCA Story:
GAPS: Opportunities Status of Actions:
Next Steps Bring Transparency Down to the Frontline
Share learnings widely – Compass Huddle
Drill down of data to identify trends/patterns in a timely manner
RCA issue resolution spread
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Acknowledgements Heather Beattie Diane Tillman Judy Richardson Deb Abel Diane Thomas Sean LaValley Brenda Waterman Doug Salvador Mary Ryan-Kusiak Barbara Stoll Maria Pouliot Shannon Dillard
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Executive Summary Transparency is a powerful tool to motivate and ensure accountability; over the past 13 months we have seen first-hand the power of this tool.
To be successful: Prepare people for transparency and show them you don’t want to blame or shame them; Test and improve a repeatable process that can be sustained; Start with a subset of important issues/cases to share; Don’t forget to check in and ask whether the process is helping; Always look for opportunities to spread – PI News &Compass Huddle.
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