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

2. 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?

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

4. 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

5. 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

6. Engaging Hospitals in NYS
More than 173 hospitals have joined NYSPFP

7. Nancy

8. 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.

9. 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

10. 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

11. 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”

12. 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

13. 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 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

14. 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

15. 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

16. 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

17. 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.