Making Indiana the Safest State: The Challenge and the Opportunity Betsy Lee, RN, BSN, MSPH InAHQ Spring Conference May 9, 2014

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 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 measures No 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 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 Source: National and State Healthcare Acquired Infections: Progress Report Centers for Disease Control and Prevention, March 2014 http://www.cdc.gov/hai/pdfs/stateplans/factsheets/in.pdf

Sepsis Mortality Reductions are Promising Began sharing coalition reports

Heart Failure 30 Day Readmission Rate 23.79% Heart Failure 30 day Readmissions 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% KS 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% PA 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% NV 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% MI 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% CA 18.91% 23.75% 24.17% 23.87% 23.98% 24.47% 23.38% 25.17% 23.60% 23.63% 24.55% 24.30% 25.77% 24.43% 26.08% 25.20% 23.92% 19.67% 24.81% 24.50% 24.80% 23.11% 25.37% 24.09% 25.31% 26.50% 23.56% 24.55% 24.73% 24.82% 24.74% 25.61% 23.73% 24.33% 24.73% 25.05% 25.20% 25.99% 24.09% 25.91% 24.43% 26.21% Performance Period – CY 2012 25.80% 24.46% 24.57% 24.68% 25.60% 24.98% 24.23% 23.45% 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 12

Coalition for Care

Partnership for Patients

National HEN Targeted Harm Categories Adverse drug events Birth-related injuries Elimination of Early Elective Deliveries Central line-associated blood stream infections Catheter-acquired urinary tract infections Falls with injury Surgical infections and complications Venous thromboembolism Pressure ulcers Readmissions Ventilator-associated pneumonia Here are the ambitious aims and here are the 10 focus areas…

Additional Priorities Leadership Systems Culture of Safety Teamwork and Communications Lean Training Innovation and Transformation Preventing Harm Across the Board Health Care Disparities

Expansion to other topics: 2014 CMS Topic Expansion Expansion to other topics: Sepsis MRSA Acute Renal Failure - Clostridium difficile Procedural Harm

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 energy Engage front-line teams in patient safety efforts Embrace personal and collective nature of change

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 Resources http://hret-hen.org/

HRET/HPOE Resources 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 Summits IHA 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 practice Site 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: Warfarin, insulin, oral hypoglycemics, and oral antiplatelet agents 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 Resources http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Gap-Analysis-Opioid.pdf http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/opioids/Documents/assessment.pdf

Elimination of EED Policy Scheduling Form Consent

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 Update Hospital: ________________ State: ______ Month: _________

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/events Transparency Share expertise, resources, and tools Develop solutions in coalition and collaborative learning We do not compete on patient safety

Leadership and Culture Staff Engagement Quality Improvement on Harm Reduction Patient/Family Engagement Regional Patient Safety Coalitions: Scope and Focus Not Competing on Safety Culture of Learning Trusting Relationships Transparency Joy in Work, Give it Meaning, Make it Personal, Board Engagement Skilled workforce – technical/safety competencies; coaching Safest State in the Nation Patients and families involved in improving care and reducing harm

Regional Coalition Transparency Hospital Name ADE VTE Pressure Ulcers EED OB Falls VAP CAUTI CLABSI SSI Readmissions ABC Hospital 2 4 3 5 General Hospital 1 St. Elsewhere Health System County Health Memorial Hospital Critical Access Hospital Z Z Hospital does not provide services related to this HAC 3 Demonstrating outstanding improvement Not engaged in work related to HAC 4 Demonstrating sustained high performance or a national benchmark 1 Engaged in work related to HAC, but not submitting data 5 Potential Mentor Hospital 2 Engaged in work related to HAC and submitting data

Partnership for Patients

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

Patient Engagement and Adverse Events “[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. ” 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.

Partnership for Patients

HSOPS: Agency for Healthcare Research and Quality

Indiana HSOPS Results

Key Elements of Enhancing Cultures Teamwork and communication Leadership engagement in safety strategies High reliability principles Eliminating fear Effective 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

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

Characteristics of Effective Handovers Face-to-face, verbal, and interactive Providers 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 foresight Receiver does read-back to verify content Good teamwork as foundation

Handover Components Introduction and brief patient history Overview of current situation Safety concerns or potential problems Plan (what’s next?) Anticipation, reflection, and foresight (what might go wrong?) - provide context Questions and verification

Example: DRAW Diagnosis Recent Changes Anticipated Changes What to Watch For Source: Seton Southwest Hospital, Austin, TX

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

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”: Process of transforming experiences into updated views of the system by “taking the time to make sense out of new and changing circumstances” “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 patients True sensemaking is reactive and proactive Focus of learning organizations – systematically increasing reliability Provides 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 failure Reluctance to simplify interpretations Sensitivity to operations Commitment to resilience Deference 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” caregivers Education and training alone will not work – requires increased “mindfulness” Cultural change requires strong leadership Must improve reliability through new approaches

Leadership for Results Leverage energy and effort at the front line Regionalize technical assistance and education Align measures to mark progress Concentrate on 11 topic areas Build capabilities for future challenges Focus on patients and families Make it personal

Engaging Front Line Teams

The Leadership Challenge Model the Way Inspire a Shared Vision Challenge the Process Enable Others to Act Encourage the Heart The Leadership Challenge Kouzes and Posner, 2002 Paul O’Neil’s quote

Contact Betsy Lee, RN, BSN, MSPH Director, Indiana Patient Safety Center Indiana Hospital Association blee@ihaconnect.org (317) 423-7795