The 5th Annual Lorraine Tregde Patient Safety Leadership Conference “The Will to Pursue Excellence” June 14, 2012

Quality of Health Care in America “Up to 98,000 people die from preventable medical errors each year.” (1999) Six Aims of Care: Safe Effective Patient Centered Timely Efficient Equitable “The difference between what we know and what we do is not just a gap, but a chasm.” (2001) Are our patients any safer today?

CMS’ Vision for Improvement – The Triple Aim Better Health for Populations Better Health for Individuals Lower Cost through Improvement

Partnership for Patients CMS has invested $500 Million for hospital engagement in quality improvement to achieve The Triple Aim The Pledge This is an Innovation Center (CMMI) initiative, not a regulatory program. Reduce hospital-acquired conditions by 40% Reduce preventable readmissions by 20% TO

An Unprecedented Partnership for New York State Joint Partnership of HANYS and GNYHA to serve as a hospital engagement network to: Leverage collective experience in implementing quality improvement programs that are: effective, comprehensive, and will be sustained beyond NYSPFP Hands on approach to advance goals of better health, better care, and lower costs

Engaging Hospitals in NYS More than 173 hospitals have joined NYSPFP www.nyspfp.org

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NYSPFP Domains Infection Prevention Initiatives 12 focus areas that have been categorized into five core clinical domains: Infection Prevention Initiatives CAUTI; CLABSI; SSI; VAP Nursing Centered Initiatives Pressure Ulcers; Falls; Adverse Drug Events; VTE Preventable Readmissions Initiative Obstetrical Safety Initiative Building Culture and Leadership This is work that hospitals are already doing, NYSPFP provides extra support to carry out these activities in a coordinated way, and learn from your peers, not only within HHC, but across the State and the Country.

NYSPFP Priorities to Ensure Your Success Transform Quality Improvement Put patients first Give patients a voice Build capacity for sustainable quality improvement through culture and leadership Demonstrate and document improvements

NYSPFP Improvement Activities Seeking Active Engagement Through: Collaborative Methodology Defined set of interventions Support from clinical advisors and workgroups Hands-on project manager support and coaching Measurement strategy and technical support Education, training, and program resources Learning Network Approach Educational programming with input from national experts Development and implementation of effective risk assessment tools Measurement and tracking of relevant process and outcomes measures Culture & Leadership

Building Culture & Leadership A multi-pronged strategy designed to inspire change AHRQ Culture of Safety Survey Organizational Readiness for Change Assessment TeamSTEPPS Training Engage leaders Provide new information and assessments Stimulate broader adoption of safety practices Help leaders enhance organizational safety culture Provide opportunities to listen and hear the “patient’s voice”

Ongoing, Dedicated Hospital Resources Hands-on Technical Assistance via Project Manager Support Each participating hospital is assigned a NYSPFP Project Manager Access to Data Support Data and Analytic support from THEORI and DataGen Real-time access to hospital-specific data reports on www.nyspfp.org

Obstetrical Safety Initiative NYS Perinatal Quality Collaborative (NYSPQC) Joint obstetrical safety initiative between NYSPFP and the NYS Department of Health (DOH) To reduce scheduled deliveries performed without appropriate indication for pregnant women of 36 0/7 to 38 6/7 weeks gestation DOH piloted NYSPQC with 18 Regional Perinatal Centers starting in 2010. Participating RPCs reported: 67% decrease in scheduled deliveries without medical indication between 36 0/7 and 38 6/7 weeks gestation, including: 86% decrease in inductions 62% decrease in cesarean sections 66% decrease in primary cesareans sections 61% decrease in admissions to neonatal intensive care units

Nursing-Centered Initiatives Nursing-Centered Workgroup convening in June Learning Network Approach Clinical advisors and workgroups to design and provide education and identify interventions focused on: Fall prevention, pressure ulcer reduction, medication safety, VTE reduction Comprehensive nursing risk assessment to identify current practices and areas for improvement Measurement and tracking of relevant process and outcomes measures related to each focus area

Increased length of stay Transform to a Patient Centered Care System, and avoid the cycle of harm… CAUTI Increased length of stay Immobility Falls VTE Pressure Ulcer Inserted Catheter

NYSPFP Measurement Data will be collected throughout the NYSPFP Leverage current reporting activities (e.g. NHSN, claims data, core measure vendors) Reports will be developed in collaboration with all stakeholders Reports will be available via the NYSPFP data portal to promote improvement

The First Law of Improvement “Every system is perfectly designed to get exactly the results it gets.” Don Berwick, March 1, 2012, NYC NYSPFP strives to instill the will, provide the ideas, and support your execution to achieve true improvement.