Innovations in Patient Safety Trinity Health

1. Innovations in Patient SafetyTrinity Health Paul Conlon, PharmD, JD Vice President, Clinical Quality and Patient Safety

2. Our Scope of Services

3. Trinity Health At - A - Glance * MHS is also affiliated with an additional 13 acute care facilities through Mercy Health Network (a joint operating company in Iowa with Catholic Health Initiatives.)

4. Our Mission We serve together in Trinity Health, in the spirit of the Gospel, to heal body, mind and spirit, to improve the health of our communities and to steward the resources entrusted to us.

5. An Outline to Improve Patient Safety • Educate the organization about patient safety issues • Enhance the cultural awareness around the issues of patient safety • Incorporate patient safety improvement activities into the operational infrastructure • Identify a process to implement patient safety practices across many different member organizations.

6. Educate the Organization - Who • Patients and Families • Boards • Senior management • Local management • Care givers • Physicians • Nurses • Pharmacists • Others • Non-care givers (examples) • Finance • Purchasing • Risk management

7. Educate the Organization - Why • Because patients expect safe care • Because care givers want to provide safe care • Because sometimes we forget that patient safety can be improved • Because we are ALL responsible

8. Educate the Organization - How • Frequently, consistently, and passionately • Be clear about the common themes • It is about systems of care issues not about bad providers • It is everyone’s responsibility • This is a journey not a destination, yet a journey that must be initiated swiftly and effectively. • To all groups with targeted messages • Pay particular attention to the level of the group within an organization. The information that Board members need is different than the information that care givers need. • Focus the message to the sphere of influence of the audience. Make it personal.

9. Educate the Organization - How • Be factual • Relate the facts to your organization • Tell stories (from you organization or groups like NPSF or P4PS or other industries - aviation) • Use outside speakers (e.g., John Nance, Mark Chassin, James Bagian) • Use inside speakers (e.g., staff, Judy Pelham, Bruce VanCleave) • With case studies

10. Educate the Organization - When • At every opportunity

11. Enhance Cultural Awareness • Communicate about safety • Apply safety assessment considerations to all activities • Patient/visitor safety • Staff safety • Conduct visible patient safety activities • Walk the talk • Measure performance • Participate in dialogue about patient safety with external organizations

12. Investments in Infrastructure • Create an “Intelligent Network” • Organizational showplace meetings • Collaborative teams • Leadership groups • Link administrative and clinical leadership groups • Virtual groups (e.g., email, list serves, bulletin boards, teleconferences, video conferences…) • Expand the use of technology • Insist upon “transparent” measurement

13. Investments in Infrastructure Technology • Transfer of clinical information to point of care • EMR • CPOE • Embed notable practices • Supports standardization of care process • Barcoding • Rules processing (e.g., adverse dug event alerts) • Objective: improve care and efficiency • On-line event reporting • PEERs - 1,700 reports a month • Local and system level changes in care

14. Investments in Infrastructure Technology • Intranet connections • Virtual library of toolkits • Patient safety toolkits • Links to other national sites • I2S2 the Trinity Intranet site has 1,500 hits a month • Publication of all organizations performance on all clinical indicators • A place to share notable practices or ideas • Bulletin boards

15. Implement Safety Practices “All politics is local” Tip O’Neil “All care is local” any physician

16. Implement Safety Practices • Solicit improvement opportunities • Many organizations use “Patient Safety Rounds • Act upon improvement opportunities and publicize the improvement (not the unfortunate act) • Incorporate the improvement into standard practices (e.g., order sets, standing orders, electronic orders) • Use infrastructure • Use informal leaders

17. Implement Safety Practices • Make it easier to do what is right • Make a case for why it is best to follow the desired safety practice and to focus on the advantages that will be derived by the person who has to change their practice. • Recognize and reward those who make safety improvements. • Measure with transparency • Set high expectations

18. Implement Safety Practices • Demonstrate how safety links to the Mission • Enlist governance support

19. Discussion