HEN Statewide Workshop

1. HEN Statewide Workshop July 18 & 19, 2013

2. Today’s Themes • Transparency -Data, Stories, Processes, Tools, Barriers, Solutions • Adopting a Harm Across the Board Philosophy • -Focusing on more than one HAC or “project” at a time • Action Planning Session for duration of the HEN • -Small Ball Strategy

3. 2013 HEN Goals • 1. 100% of hospitals with OB services have a hard stop policy in place or a sustained EED rate of less than 3%-80% • 2. 100% submission of EED measure into CDS-77% • 3. Share a HEN Culture Story (HAB Template)-34% • 4. Submit one progress report each month – 8% • 5. Participation in HEN Week/Physician Leadership Conference/SWW

7. We need your data! - EED • Advocate Condell Medical Center • Crossroads Community Hospital • Gateway Regional Medical Center • Gibson Area Hospital • Hammond-Henry Hospital • MacNeal Hospital • Norwegian American Hospital • Presence Covenant Medical Center • Presence Mercy Medical Center • St. Margaret’s Hospital • Union County Hospital If you have submitted EED data, please ensure that you keep submitting your monitoring data on a month to month basis!

8. We need your data! - NHSN • Midwestern Regional Medical Center • Presence Covenant Medical Center • Presence Mercy Medical Center • Presence Resurrection Medical Center • Presence Saint Francis Hospital • Presence Saint Joseph Hospital • Presence St. Mary’s Hospital • Presence St. Mary and Elizabeth Medical Center • Presence United Samaritans Medical Center • Shriner’s Hospital for Children • St. Joseph’s Hospital, Highland • Thorek Memorial Hospital • Advocate South Suburban Hospital • Centegra Hospital – McHenry • Centegra Hospital – Woodstock • Crossroads Community Hospital • Dr. John Warner Hospital • Franciscan St. James Health – Chicago Heights • Franciscan St. James Health – Olympia Fields • Galesburg Cottage Hospital • Gibson Area Hospital • Hammond Henry Hospital • Hartgrove Hospital • Heartland Regional Medical Center • Jersey Community Hospital • Linden Oaks Hospital • MacNeal Hospital • MetroSouth Medical Center

11. Small Ball Strategy • Use your data to drive targeted improvement efforts for the next 6 months • Bats, Balls, Gloves… • Virtual Collaboratives • HRET Topic Specific Webinars, Implementation Guides and Tools • State Wide Workshops • Individual one-on-one coaching

12. Outcomes already… • In 2012 all 59 of our participating HEN hospitals prevented a collective 356 incidents of harm translating to a cost savings of $4,653,900 • Let’s aim to surpass these numbers in 2013

13. Upcoming Illinois HEN activities • CPHQ Certification • Preparation Classes – 50 max each session. Naperville with video to Springfield • Session 1 – September 19 – 1-5 pm • September 20 – 8-5 pm • Session 2 – October 31 – 1-5 pm • November 1 – 8-5pm • TeamSTEPPS • Training – Naperville NIU – November 18-20

14. Upcoming Illinois HEN activities • Statewide Workshops • October 17 & 18 • December 2 & 3

15. Upcoming Illinois HEN activities • ABQAURP Certification (Health Care Quality & Management Certification HCQM) – 30 Physicians • Application fee, Core Body of Knowledge Course, Exam fee, Membership (no charge) • Sub-specialty certifications • Case Management, • Managed Care, • Risk Management/Patient Safety, • Transitions of Care and • Workers Compensation

16. Questions

17. Hospital Transparency in Improving Outcomes The Rising Tide Will Lift All Boats Kim Werkmeister, RN Steve Tremain, MD

18. Transparency Movement • Public Reporting • Physician Ratings • Pricing

19. Transparency in an organization What does it mean for a hospital to be “transparent”?

20. Levels of Transparency Beginner Intermediate Advanced

21. Beginner Level • Share outcomes data in staff meetings • Post outcomes data in employee areas/physician areas • Report to databases

22. Intermediate Level • Post outcomes data in public areas • Discuss adverse events all the way up to the Board level

23. Advanced Level • Involve patients in bedside rounds • Patient Advisory Committee to discuss public reporting • Patient Advisors as part of Medical Staff/Board committees

24. Types of transparency

25. Data Adverse Events Patient and Family Engagement

26. Transparency and Safety Culture

27. What do patients want? What do patients deserve?

28. Truthful Explanation • Accountability • Apology and Compensation when warranted

29. What do caregivers want? What do caregivers deserve?

30. Truthful Explanation • Reasonable Benchmark against which you judge their actions • Support

31. What do hospitals want? What do hospitals deserve?

32. Truthful Explanation • Opportunity to be Accountable • Opportunity to Improve

33. How transparent are we? • Event reporting • 2009 AHRQ Patient Safety Culture survey-52% of staff reported no errors in the last 12 months • 2005 Physician survey (n>2000)-65% unaware their hospital had an error reporting system • Disclosure to patient • Only 1/3 of harmful errors disclosed to patients • Those disclosures that do occur often go poorly

34. How transparent are we? • Feedback of lessons learned to clinicians • 2005 Physician survey-18% of physicians agreed that current mechanisms to inform them about safety problems were adequate • Suggests shortcomings in our current approach to promoting transparency

35. Are current approaches to transparency integrated? • Key transparency practices largely segregated by specialty • Nurses report events to institution • Physicians disclose events to patients • Most safety culture surveys measure event reporting but not disclosure attitudes or practices

36. Are current approaches to transparency integrated? • Risk management and quality/safety programs often separated • Training usually addresses one transparency practice in isolation • Disclosure training rarely addresses event reporting to institution or communicating about events with colleagues

37. What does it mean to be transparent?

38. Elements of a “Transparent” Response to Adverse Event Process • Reporting • Investigation • Communication • Apology with remediation • Process and performance improvement • Data tracking and analysis

39. Transparency, safety, and quality • Transparency long recognized as key to safety culture and healthcare quality • Yet a decade after To Err Is Human, major gaps in transparency persist • Healthcare workers experience multiple mixed messages about transparency • No accountability around transparency • Limited transparency becomes path of least resistance • Missed opportunities to promote greater synergy among transparency practices

40. Practices in transparent healthcare organizations Optional external reporting Standard quality measures Extreme transparency CEO blog Other aspects of transparency Clinical information (shared decision-making) Price • Discuss events with colleagues, other team members • Formal event reporting • Disclose event to patient • Share lessons learned back with clinicians • Required external reporting

41. What happens in an organization when it becomes transparent?

45. How does my organization become transparent?

46. Questions to Ask as We Become Transparent • What our are goals for transparency? • Are transparency’s deterrent, embarrassment effects good or bad? • Transparency is a skill, not just an attitude • Should training address reporting, communicating with colleagues, and disclosure in tandem? • Interprofessionalimplications • What are the real barriers to “speaking up?” • Will organizations adopt processes to ensure accountability around transparency? • Which of these will be publicly reported? • Will organizations compete on transparency?

47. Safety Climate: Building Block • Executive Walkrounds Study: • Randomized 24 clinical units to receive EWRs or usual patient safety activities and measured safety climate of nurses before and after the walkrounds • At baseline the experimental and control groups had similar safety climate scores • After the intervention, 72.9% of nurses in the walkrounds group reported a positive safety climate versus only 52.5% in the control group • Thomas et al. BMC Health Services Research 2005;5:28. For other data on walkrounds also see Frankel et al. Health Serv Res 2008;Jul 20:2.

48. Teamwork climate: Building Block • Improve teamwork climate by: • SBAR training • Briefings • daily goals checklists • shadowing other providers • Hudson et al. Contemporary Critical Care 2009;7:

49. How do we encourage transparency? Deal with the drivers of human behavior • Fear • Support structure–patients, families and providers • Education • Attack “truth to power” problems head-on • Greed • Financial incentives, disincentives for reporting • Tie to employment, privileges – OPPE, credentialing • Show the ROI – process improvements, claims • Ego – soul • Adopt principles of “just culture” • Handle occurrence reports with discretion • Focus on systems unless reckless, repetitive behavior

50. How else does my organization become transparent?