Do No Harm: Culture, Technology, Teamwork and Design Change

1. Do No Harm: Culture, Technology, Teamwork and Design Change Nancy G. Pratt RN, MSN, SVP, Clinical Effectiveness Sharp HealthCare February 5, 2007

2. Sharp’s Strategic Plan for Patient Safety Develop a Culture of Safety Use Technology to Improve Safety Address Human Factors: Teamwork and Communication Redesign the Processes Culture Human Factors Reduce Harm by 50% over 5 years Design Technology

3. Strategic Priorities: Patient Safety • Implement a Culture of Safety • Anonymous reporting • Collaboration: San Diego Patient Safety Consortium • Adverse Events Program • Teamwork and Communication • Team Resource Management • Standard Work Processes • Use Technology to Improve Safety • Bar Coding • Electronic Safety Triggers • Electronic variance reporting • Smart Pumps – IV, PCA, Syringe • Redesign for Safety • Human Factors Engineering • Design for Six Sigma • Product, supply, process review • JCAHO National Patient Safety Goals

4. Six Sigma Projects: Patient Safety

5. Alternate Actual Process Physician gives order RN can’t get med out of Pyxis RN writes order & faxes to Pharmacy RN faxes & calls pharmacy again! Onset of Complaints! Fax doesn’t go through! Pharmacist not available Drug not available RN Calls pharmacy, faxes order again!! Fills out standard pharmacy complaint – QVR! Pharmacy Tech delivers med someplace in SICU Pharmacy informs RN med has been there for 2 hours

6. Pharmacy Order Cycle Time Pharmacy Staffing Not Matched to Medication Order Volume # Medication Orders Pharmacy Staffing Time of Day

7. Pharmacy Order Cycle Time Baseline After Initial Improves After Pharmacy IT System Changed After Fax Server Installed

8. Pharmacy Order Cycle Time

9. Medication Safety Project: Decrease Interruptions Med Admin Flow Map(Ideal)Average time~ 7 mins RN preps med RN Prompted to give med RN identifies patient RN interprets MAR (5Rs) RN explains med to pt RN performs preadministration assessment / checks allergies RN prepares to admin med (final 5Rs) RN washes hands RN evals effects of med RN gives med RN procures med/IV & supplies (5Rs) RN documents med RN washes hands

10. Med Admin Flow Map(More real)Average time ~ 20 mins RN preps med RN Prompted to give med Wait in line RN identifies patient RN interprets MAR (5Rs) Phone call Phone call Order is questionable RN explains med to pt RN performs preadministration assessment / checks allergies Need to clarify Unexpected nsg task RN prepares to admin med (final 5Rs) Call MD; Wait; Get clarification RN washes hands Locate Missing supply RN evals effects of med Unexpected nsg task RN gives med Phone call RN procures med/IV & supplies (5Rs) Can’t find med; look in 4 places; call pharm RN documents med RN washes hands

11. CR • Waited in line to get meds @ 9:00 • One med grayed out – not here, one gray ed at – in refrigerator • Search refrigerator • Went to P #1, found 1 med – MVI still missing, tapped drawer to get cubie to open • Two meds left to find – may be in room. Crushed meds in paper cups • Piston syringe in room – No date – went to supply room to get another • Found MVI but NO med cups - ? Refrigerator MVI • Searched room for fiber or med cup – on bedside table – no way to administer • Back to med room • Back to room • Mixed meds in cup in admin – DONE 0920 • Medication Delivery Total Time – 13 minutes

12. What Does the Literature Tell Us? Top High Risk Situations Causing Sentinel Events • Distractions before or during administration of meds or treatment • High alert drugs used without double-checks • Multi-tasking • Care provided under a human-error-prone situation (dark, noisy, shift change) without appropriate compensatory actions Reason, JT. Understanding adverse events: human factors. In Vincent CA (ed) Clinical Risk Management. London: BMJ Pub; 1995

13. Medication Safety Action Plan Create a standard environment for medication room design and processes 5’S’ Principles - Sort - Shine - Simplify - Standardize - Sustain Minimize interruptions and distractions during medication administration • Respect med admin as a critical activity • Divert and discourage unnecessary calls • Encourage all disciplines to limit interruptions Create Scripting examples for nurses • Evaluate workload demands during high volume med admin times

14. Medication Safety Action Plan Develop a standard guideline for medication preparation and administration • Avoid conversations in med room • Discourage interruptions/distractions • Verify using 7 “Rights” • Prepare and administer to 1 pt at a time • Independent double check insulin, heparin, warfarin • Use MAR or Pyxis label to verify 7 ‘R’s • Document

15. 24 06 09 12 17 21

16. Number of ‘Unnecessary’ Interruptions During Med Pass: Pre and Post* p=0.000 *No statistical difference in number or route of meds given

17. SGH 5E Pilot Med Pass TimePre and Post* p=0.037 *No statistical difference in number or route of meds given

18. Emergency Department: RME • ED patients expect quick service and to be seen by an ED doctor, regardless of diagnosis • 40% of ED pts are non-emergent • Rapid Medical Exam (RME) designed to promptly and appropriately “treat & release” • Issues: long waits, space, multiple entry points, flow, communication…

19. ED Waits Decrease Satisfaction

20. Growth of ED Visits • 1992: 12 beds = 16,640 visits. 2006: 22 bed =45,456 visits. • 173% increase in visits since current ED was opened in 1992. • 83% increase in beds over same period.

21. ED Outpatient Overall Satisfaction(scale 0-100)

22. Bottlenecks in the ED PHLEBOTOMY TRIAGE LOBBY RME Lack of open ED beds creates bottlenecks. Many patients wait in front lobby area.

23. Key Process Steps

24. RME Project Goals • Take vitals of all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%) • “Arrival noticed quickly” satisfaction = 85th percentile (baseline 18% Dec-06) • Establish RME triage standard to set stage for RME cycle time project

25. ED RME Outcomes • Goal: Vitals on all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%). Improvements: • Guard providing safe environment • LVN assigned to check vitals • Designed EmStat report to monitor lobby patients

26. ED RME Outcomes Goal: 80th %tile

27. Reconciliation of medications across the continuum of care • RoMACC at Grossmont Hospital • Project Description / Vision: • Implement a ‘Lean’ RoMACC process that demonstrates value, not just in terms of patient safety but in efficiency for practitioners. Start Date: September 2006Go Live: December 5thEnd Date: March 2007 Participants: Champion/Green Belt: Julie McCoy Jackie Parson Black Belt: Kurt Hanft Sponsor: Michele Tarbet MD Partner/ Process Owner: Dr. Margaret Elizondo Next Sustain and Improve!

28. Reconciliation of medications across the continuum of care • RoMACC Measurement Method: • Discharge: Physician writes the Discharge Orders and Addresses the Discharge Reconciliation. Unit clerk verifies the reconciliation has been addressed and enters a discharge order Process Measure

29. Reconciliation of medications across the continuum of care • RoMACC and Discharge Measurement: • % RoMACC Complete • Carecast Discharge Order Entry Compliance • Number Of Discharges • Time to Discharge a Patient • Average Time of Day a Patient Leaves. Combined projects

30. Reconciliation of medications across the continuum of care • RoMACC at Grossmont Hospital 75% System Goal Continuous Improvement – Above System Goal of 75%

31. Examples of Patient Safety Improvements: • Use Technology to Improve Safety • Bar Coding • Electronic Safety Triggers • Electronic variance reporting • Smart Pumps – IV, PCA, Syringe Innovation with our partners: Cerner • Bar Code Implementation (Roche) • Real Time Event Triggers “On Watch” (Clinicomp) • Electronic Quality Variance Reporting (Peminic) • Wireless Smart Pumps CQI data (Cardinal) • Standardization of IV infusion concentrations (SDPSC) • Enteral Tubing connections (Viasys, FDA, AHA)

32. System Reprogramming: Safety Achieved Quarter 1 2006 n=145

33. Alaris Guardrails

34. Bag/Bottle of Enteral Feeding Feeding Bag Tubing Set l Enteral Feeding Tube Tubing Misconnections

35. Patient Safety Strategy • Redesign for Safety • Human Factors Engineering • Design for Six Sigma • Product, supply, process review • JCAHO National Patient Safety Goals

36. Patient Safety Actions • Products: • Insulin Syringe • Dopamine Drip Bottle versus Bag • Enteral Feeding Bag versus Bottle • Heparin Flush versus Therapeutic infusion • Anesthesia Tray for Epidural • Cat Scan Contrast Injectors • IV PICC Line Cap Leaking (CLC 2000) • Insulin and Heparin Infusions – standardized • Endotracheal Tube with Sub-glotic suction

37. Magnet Status Sharp Grossmont Excellence in Patient Safety and Health Care Quality, 2006 100 Most Wired Hospitals, 1999-2006 IDG's Computerworld, 2006 Best Integrated Health-Care Network in California, 2007 Best place to work, 2004 Torch Award for Marketplace Ethics San Diego’s Health Care Leader Malcolm Baldrige National Site Visit, 2006 Gold Eureka Award, 2006 Silver Eureka Award, 2005 Bronze Eureka Award, 2004