1 Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar: Leadership and Leadership Principles for Safety (Safe Practices 1-4) Hosted by NQF and TMIT Attendee dial-in instructions: Toll-free Call-in number (US/Canada): (direct number, no code needed) To join the online webinar, go to: Online Access Password: Webinar1 (case-sensitive)

2 Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program Safe Practices Webinar July 16, 2009 Welcome and Overview of the Culture of Safety Chapter of the 2009 NQF Safe Practices Toll-free Call-in number:

3 Panelists Peter Angood, MDCharles Denham, MDJames Conway, MSDan Ford, MBA Toll-free Call-in number: Peter Angood: Important National Highlights Regarding Leadership and Culture Charles Denham: Leadership and Culture Practices: New Roles for Leaders James Conway: Bringing Boards on Board: Critical Issues in 2009 Dan Ford: Patient Perspective on Involving Patients in Patient Safety

Toll-free Call-in number:

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Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices Consent & Disclosure Culture Workforce Consent and Disclosure Toll-free Call-in number:

CHAPTER 7: Hospital-Associated Infections Hand Hygiene Influenza Prevention Central Venous Catheter-Related Blood Stream Infection Prevention Surgical-Site Infection Prevention Care of the Ventilated Patient and VAP MDRO Prevention UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition-, Site-, and Risk-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy VAP Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge System Patient Care Info. Labeling Studies Culture Meas., FB., and Interv. Structures and Systems ID and Mitigation Risk and Hazards Team Training and Team Interv. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices]  Leadership Structures and Systems  Culture Measurement, Feedback, and Interventions  Teamwork Training and Team Interventions  Identification and Mitigation of Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Studies  Discharge Systems  Safe Adoption of Integrated Clinical Systems including CPOE CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging CHAPTER 8: Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Informed Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure 2009 NQF Report Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control New Material Changes No Material Changes Legend: Pediatric Imaging

99 Important National Highlights Regarding Leadership and Culture Peter B. Angood, MD, FRCS(C), FACS, FCCM Senior Advisor, Patient Safety National Quality Forum Safe Practices Webinar July 16, 2009 Toll-free Call-in number:

Obama Budget Proposal – 7 th of Eight Principles for Healthcare: “Improve patient safety and quality care. The plan must ensure the implementation of proven patient safety measures and provide incentives for changes in the delivery system to reduce unnecessary variability in patient care. It must support the widespread use of health information technology and the development of data on the effectiveness of medical interventions to improve the quality of care delivered.” Toll-free Call-in number:

11 Toll-free Call-in number: Leadership Structures and Systems 2.Culture Measurement, Feedback, and Intervention 3.Teamwork Training and Skill Building 4.Identification and Mitigation of Risks and Hazards Creating and Sustaining a Culture of Safety

12 Toll-free Call-in number: This practice outlines and defines the activities that must be undertaken by governance, administrative, and safety leaders with real specificity regarding activities in generating awareness, accountability, ability, and action. Safe Practice 1: Leadership Structures and Systems

13 Toll-free Call-in number: This practice has no substantive changes to the 2006 practice element. Culture measurement is an evolving area and flexibility was built into the original 2006 practice element to accommodate that evolution. Safe Practice 2: Culture Measurement, Feedback, and Intervention

14 Toll-free Call-in number: Safe Practice 3: Teamwork Training and Skill Building Other than updated references and recognition of the AHRQ-funded TeamSTEPPS program, there are no substantive changes to the practice activities.

15 Toll-free Call-in number: Safe Practice 4: Identification and Mitigation of Risks and Hazards This practice integrates the information flow and actions among Risk Management, Safety, and Performance Improvement Staff and Departments.

16 Leadership is pivotal for improvements in all aspects of patient safety, quality, and the general performance of organizations so that the culture of any individual organization continues to grow in its values, beliefs, and daily behaviors, while providing care to the patients and families. Toll-free Call-in number:

17 Leadership and Culture Practices: New Roles for Leaders Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program Safe Practices Webinar July 16, 2009 Toll-free Call-in number:

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19 “If you lose the patient… Don’t lose the lesson.” Thomas Hamilton Director, Survey & Certification Group Center for Medicaid & State Operations Centers for Medicare & Medicaid Services

IMPROVING PATIENT SAFETY BY CREATING AND SUSTAINING A CULTURE OF SAFETY Values Systems Structures Behaviors Outcomes Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Identification and Mitigation of Risks and Hazards Leadership Structures and Systems Patients and Community NQF 34 Safe Practices

Evolution of Leadership Safe Practices 2003 Safe Practices: Culture related activities provided as a list Lack of standardization Selected reading provided Evidence sample provided 2006 Update: Harmonized across NQF, AHRQ, Joint Commission, CMS, IHI, Leapfrog Group to line item specification Leadership Structures and Systems held firm. Care Settings Standardized Implementation Guides Added Thoroughly Evidence-based and literature cited Update: Harmonization partners grew from 2006 to include CDC, APIC, and HRSA. Leadership Structures and Systems held firm. Added Patient Involvement chapter and included in all practices. Comprehensive update to Evidence. Made care settings standardized to CMS frame.

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24 Safe Practice 1: Leadership Structures and Systems Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served. Safe Practice 2: Culture Measurement, Feedback, and Intervention Healthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk. Safe Practice 3: Teamwork Training and Skill Building Healthcare organizations must establish a proactive, systematic, organization-wide approach to developing team-based care through teamwork training, skill building, and team-led performance improvement interventions that reduce preventable harm to patients. Safe Practice 4: Identification and Mitigation of Risks and Hazards Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm. Safe Practice 1: Leadership Structures and Systems Safe Practice 2: Culture Measurement, Feedback and Intervention Safe Practice 3: Teamwork Training and Skill Building Safe Practice 4: Identification and Mitigation of Risks and Hazards Culture Consent & Disclosure Workforce Info Management & Continuity of Care Medication Management Healthcare Associated Infections Condition & Site Specific Practices You need the Safe Practices for Better Healthcare to use the Implementation Toolboxes below. It may be purchased at Coming Soon

25 Culture Consent & Disclosure Workforce Info Management & Continuity of Care Medication Management Healthcare Associated Infections Condition & Site Specific Practices You need the Safe Practices for Better Healthcare to use the Implementation Toolboxes below. It may be purchased at Safe Practice 1: Leadership Structures and Systems Quick Start Pack SLIDES: Safe Practice 1 Quick Start Guide VIDEOS: Leadership Structures and Systems Wedding: Commitment eC-T-R Level 5 Leaders eC-T-R RESOURCES: Safe Practice 1 Quick Start Guide Safe Practice VideoArticlesSlide SetsCollaborations Practice: Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served. Applicable Clinical Care Settings: This practice is applicable to Centers for Medicare & Medicaid (CMS) care settings, to include ambulatory, ambulatory surgical center, emergency room, dialysis facility, home care, home health services/agency, hospice, inpatient service/ hospital, outpatient hospital, and skilled nursing facility. Awareness Structures and Systems: Structures and systems should be in place to provide a continuous flow of information to leaders from multiple sources about the risks, hazards, and performance gaps that contribute to patient safety issues. DOWNLOAD FULL PACK: Safe Practice 1 Quick Start Pack (ZIP) Coming Soon

Leadership Collaborative: First Speaker Bill George former CEO of Medtronic Practical Issues in Leadership Governance, C-Suite, Mid-Level Managers Interactive Format with Q & A August or September Kick-off Date Leadership Collaborative

29 Bringing Boards On-board: Critical Issues in 2009 James Conway, MS Senior Vice President, Institute for Healthcare Improvement (IHI) Safe Practices Webinar July 16, 2009 Toll-free Call-in number:

30 IHI Boards on Board Intervention NQF Safe Practices: –Execution of Safe Practices –Publicly Verifiable Results –Example Organizations of Great Leadership Concluding Comments For Further Info Questions Outline Toll-free Call-in number:

31 In every way, fully aligned and consistent with NQF Safe Practices Setting aims 2. Getting data and hearing stories 3. Establishing and monitoring system-level measures 4. Changing the environment, policies, and culture 5. Learning 6. Establishing executive accountability Toll-free Call-in number: Boards on Board Plank 5 Million Lives Campaign

32 Toll-free Call-in number: Children’s Hospital, MN –Any sentinel event is reviewed through the Focused Event Review (FER) process and all reviews are presented to the Board Quality Committee. –Children’s distributes a monthly Quality Report that includes measures reviewing all aspects of patient safety and creates a quarterly patient safety report. Indicators include infection rates, medication errors, mortality rates, readmission rates, and measures documenting progress towards patient safety goals. Virginia Mason Medical Center, Seattle, WA –VMMC has one organizational goal – To ensure the safety of our patients through the elimination of avoidable death and injury. This has been the only goal since Children’s Hospital, Cincinnati, OH –The Board set aims for each of the two years (FY2007 to reduce serious safety events by 25% from baseline, and FY2008 to reach an overall reduction in serious safety events of 80% from baseline). SP1 – Leadership Structures and Systems

33 Toll-free Call-in number: Delnor Community Hospital, Geneva, IL –The Board Quality Committee has developed a global Harm-Safety Index measurement indicator for its Clinical Dashboard. This serves as a “surrogate” index for harm events and a specific aim is developed based upon internal historical performance. – A “patient experience” story has been presented at Board meetings since January Each story is specifically selected and connected to highlight a “Big Dot” or “Driver” measure on the Clinical Dashboard. The story is told by either the patient himself, a medical staff member, and/or senior management. Mary Imogene Bassett Hospital, Cooperstown, NY –The Board of Trustees Performance Improvement Committee developed a clinical quality scorecard to ensure its ongoing oversight of significant quality/safety-related processes such as medication events, adverse drug reactions, patient falls, ventilator-associated pneumonia, compliance with hand hygiene, and MRSA transmission rate, to name a few. SP1 – Leadership Structures and Systems (cont’d)

34 Toll-free Call-in number: SP1 – Leadership Structures and Systems (cont’d) Dana-Farber Cancer Institute, Boston, MA –Patient representatives from the adult and pediatric patient and family advisory councils are members of the Board quality committee. Henry Ford Health System, Detroit, MI –All executives, including physician executives, are held accountable for specific, business-unit level quality and safety goals as part of their annual incentive bonus (15% of bonus eligibility, balancing other performance areas such as financial performance, service excellence, employee satisfaction, and individual goals. Employees’ opinions of the culture of safety is one component on each plan. Hot Springs Memorial Hospital, Thermopolis, NY –Formal quality report is presented at every board meeting with the goal of 30% of board time spent on quality. –Patients and families who have suffered medical errors come to board meetings to tell their story.

35 Toll-free Call-in number: Children’s Hospital, Cincinnati, OH –Through the execution of employee safety surveys (AHRQ), safety training for all employees, the institution of a safety coach program, and a culture that promotes 200% accountability for safety (for self and others), CCHMC is highly engaged in changing the environment and the culture with particular emphasis on those at the sharp end of error. Hot Springs County Memorial Hospital, Thermopolis, NY –We have launched a customer service process that involves every staff member in quarterly employee satisfaction surveys, monthly leadership rounding, and employee forums. Dana-Farber Cancer Institute, Boston, MA –The organization adopted and promulgated a set of fair and just culture principles in Demonstrating the organization’s core value of Respect, these principles guide the conduct of root cause analyses and the organization’s response to adverse events and medical errors. SP2 – Culture

36 Toll-free Call-in number: Henry Ford Health System, Detroit, MI –Our Culture of Safety work plan is system-wide and includes several tactics on team communications, routine measurement of our employees and physicians to assess their belief in our culture of safety, implementation of “Just Culture” policies and training, Speak Up and Speak Out approaches, and several other initiatives. Mary Imogene Bassett Hospital, Cooperstown, NY –For a number of years, Bassett has had a very active policy/process governing “Evaluation of Accountability Surrounding Errors and Events,” which has facilitated Bassett being recognized as having a “just culture.” On the AHRQ Patient Safety Culture survey, staff responses were above comparison groups in terms of affirming a “non-punitive” culture surrounding errors and events. SP2 – Culture (cont’d)

37 Contra Costa Regional Medical Center, Martinez, CA –“Tremendous collegiality” … is the result of a conscious effort from the top down and the bottom up to create a culture of collaboration and teamwork. Through teamwork, Contra Costa has been able to improve care processes and patient outcomes in areas ranging from reducing surgical site infections to reducing heart attacks. Dana-Farber Cancer Institute, Boston, MA –Conducted teamwork training with patients and families as part of the team training Lucille Packard Children’s Hospital at Stanford, Palo Alto, CA –Uses actual parents in simulation training exercises IHI Open School – Practicing Like A Rock Star: The Need for a Culture Change in Medicine: Practicing Like A Rock Star: The Need for a Culture Change in Medicine Beth Israel Deaconess, Boston, MA Virginia Mason Medical Center, Seattle, WA SP3 – Organization-wide approach to team-based care

38 Toll-free Call-in number: SP4 – Identify and mitigate patient safety risks and hazards Virginia Mason Medical Center, Seattle, WA –Each month, all patient safety alert [PSA] data are reviewed by the board. Specific cases are looked at in detail and all “red” PSAs must come to the board for approval prior to closure. The accountable executive comes to the committee to review case narrative, timeline, value stream map and mistake-proofing of process. Owensboro Medical Health System, Owensboro, KY –From the board to the front-line staff, everyone at Owensboro Medical Health System (OMHS) is focused on quality improvement. Having implemented all the IHI Campaign interventions, OMHS has, among other things, reduced harm from pressure ulcers, patient falls, and medication errors; nearly eliminated ventilator- associated pneumonia; and significantly decreased its mortality rate to well below the national average.

Could It Happen Here? Healthcare Executive NOV/DEC, 2008 Toll-free Call-in number:

40 Toll-free Call-in number: Thousands of Boards have begun this journey Accountability/responsibility is growing and accelerating Many great organizational journeys to draw from and on The depth and pace of change required is only possible by systematic application of a framework for improvement (aim, foundation, will, ideas, and execution) by: –Governance and executive leadership –Working closely with all staff across the organization –In partnership with patients and families, and with communities In Closing…

41 Toll-free Call-in number: Featured healthcare organizations – mentor_registry_bob.htmhttp:// mentor_registry_bob.htm Board on Board Intervention – BoardsonBoard.htmhttp:// BoardsonBoard.htm IHI Leading Systems Improvement Content – Improvement/ Improvement/ For Further Information

42 Patient Perspective on Involving Patients in Patient Safety Dan Ford, MBA Vice President, FurstGroup Member, Consumers Advancing Patient Safety (CAPS) Safe Practices Webinar July 16, 2009 Toll-free Call-in number:

44 Panelists Peter Angood, MDCharles Denham, MDJames Conway, MSDan Ford, MBA Toll-free Call-in number: Peter Angood: Important National Highlights Regarding Leadership and Culture Charles Denham: Leadership and Culture Practices: New Roles for Leaders James Conway: Bringing Boards on Board: Critical Issues in 2009 Dan Ford: Patient Perspective on Involving Patients in Patient Safety

45 Upcoming Safe Practices Webinars  September 17 – Important Condition and Common Safety Issues (Safe Practices 26-34)  October 22 – Creating Transparency, Openness, and Improved Safety (Safe Practices 5-8)  November 19 – Healthier Communication and Safe Information Management (Safe Practices 12-16)  December 17 – Optimizing a Workforce for Optimal Safe Care (Safe Practices 9-11)

46 Podcast Ready Downloads Quick Start Toolboxes MedMan and Other Collaboratives Global Patient Safety Award in Nice, France Patient Safety Documentary Summary