Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast

1. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month July 24 2008Patient Safety: Operational • PI Plan includes Safety Program • Patient Safety Goals addressed • Technology's role in Safety Program • Technology plan integrated with • Safety Program • Patient Safety & Risk Management Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html

2. Register your Attendance Hopefully you provided your name & organization when you signed in. • If so: Say Hi in the Chat Pod and we’ll capture your name and organization in the log. • If not: Identify yourself and organization in the Chat Pod to the left of your screen. If there is more than one attending on your sign-in, tell us how many by saying “Hi (number of attendees)”

3. Poll: Who is Attending this Session ? • Rural / Out state ? • Metropolitan area ? • Organization that has (or serves) both ?

4. Healthcare system Hospital Clinic or clinic system Long term care Health plan Home care / Hospice Quality support organization Other ? (Define other in Chat Pod) Poll: Organization Type ?

5. Poll: What do you hope to gain by participating? • CPHQ and want to obtain CEU’s (Note: not guaranteed at this time; still working on it) • Healthcare quality professional and am interested in additional education • Healthcare professional interested in developing quality skills • Healthcare professional interested in learning more about healthcare quality

6. Agenda • PI Plan includes Safety Program • Patient Safety Goals addressed • Technology's role in Safety Program • Technology plan integrated with Safety Program • Patient Safety & Risk Management

7. Minnesota Alliance for Patient Safety (MAPS): What is it? • Representatives from healthcare providers, regulators, payers, associations, consumers, etc. • Purpose: Leverage unique membership to improve patient safety in Minnesota • How: Educate, influence and convene • Initiative examples: • Informed consent • My Medication list

8. MAPS 2008 Patient Safety Conference • Bi-Annual • November 13-14 • Northland Inn; Brooklyn Center • Keynote: Lucian Leape from Harvard • Theme • Road Map to Patient Safety: Accelerating for change • Track-specific workshops

9. Safety Plans • Safety plans should be: • Driven by data from multiple sensing sources • Measurable • Realistic • Integrated with current organizational efforts or strategic direction • Happening at/supported by the front line • An opportunity to coordinate externally driven safety initiatives

10. Operational Measures of Safety Assessment done by First Consulting Group with Scottsdale Institute

11. Safety Plan: Regions • Three year rolling format • Structured based on characteristics of highly reliable organizations • Reviewed and approved by the Quality Committee of the Board • Mixture of “have to’s” and “want to’s” • Must be dynamic; RCA action plans can totally redirect efforts

12. PI Plans with Safety Integrated:Sleepy Eye • Safety plans/initiatives are reviewed & approved by the QI committee, and discussed at Managers meetings to engage all areas of the organization • Initiatives are driven by: • Safety events • Analysis of risk • Identified best practices

13. Agenda • PI Plan includes Safety Program • Patient Safety Goals addressed • Technology's role in Safety Program • Technology plan integrated with Safety Program • Patient Safety & Risk Management

14. TJC National Patient Safety Goals • Introduced in 2003 • More are added every year (2009 are out) • Many: • require measures of success • should be measured if you’re wise • are hard to measure • are controversial • organizations are failing NPSGs during survey • are activated at the caregiver level

15. TJC NPSGs: Hospitals • Use two approved patient identifiers: • Prior to providing care; especially invasive procedures • Prior to administering blood products • When collecting laboratory/pathology specimens • Improve the effectiveness of communication among caregivers: • Verbal/telephone order read backs • No unsafe abbreviations • Hand offs • Critical results reporting

16. TJC NPSGs: Hospitals • Improve the safety of using medications. • Look alike/sound alike medications • Labeling solutions on/off the sterile field • Management of anticoagulants • Accurately and completely reconcile medications across the continuum of care • Compare hospital meds to “at home” meds • Communicate across continuum • Give list of current meds to patient • Modified med rec can occur in outpt settings

17. TJC NPSGs: Hospitals • Encourage patients’ active involvement in their own care and report safety concerns • Identify patients at risk for suicide • Implement at Rapid Response Team • Universal protocol • Pre-procedure verification • Mark site • Perform time out

18. TJC NPSGs: Hospitals • Reduce the risk of health care-associated infections • Hand hygiene per WHO guidelines • RCAs for deaths or permanent loss of function due to HAI • Prevent BSIs • Prevent SSIs • Manage MRSA • Reduce the risk of patient harm resulting from falls

19. How Regions Addresses TJC Patient Safety Goals • Determine organizational impact at the unit level • Assign/elect/pick champions • Develop processes and create structure to support the desired outcome • Decide how to measure – compliance • Use PDSA again and again and again and • We whine – a lot!

20. How Sleepy Eye Addresses TJC Patient Safety Goals • We do implement the practices • State surveyed, not JCAHO –not the same standard of data required to demonstrate compliance • Challenge to determine how some of them apply, i.e. SSI reduction initiatives as we do limited types of procedures • Types of resources in a small CAH differ from a larger institution, i.e. 24 Pharmacy

21. Agenda • PI Plan includes Safety Program • Patient Safety Goals addressed • Technology's role in Safety Program • Technology plan integrated with Safety Program • Patient Safety & Risk Management

22. IT Measures of Safety SurveyFirst Consulting Group with Scottsdale Institute

23. Regions: Examples • The hospital is able to bring the recommendations of quality improvement projects quickly to the point of care through the use of clinical decision support in an electronic medical record. • Order sets drive practice • Links to guidelines and policies • Procedure notes structured to capture compliance with UP • Hard stops drive data capture

24. Regions: Examples • All medication orders entered by physicians are screened for contraindications such as drug-drug and drug-allergy interactions, therapeutic duplication, and appropriate dosing • Formulary controls • Pre-set routes and dosages • Alerts at prescribing and verification steps • Automatic consults to pharmacy • Leapfrog expectations

25. Sleepy Eye Examples: • At SEMC we are in the process of planning and actively assessing clinical software to transition to electronic health records • We are using these safety standards and capabilities as evaluation criteria in our selection process

26. Agenda • PI Plan includes Safety Program • Patient Safety Goals addressed • Technology's role in Safety Program • Technology plan integrated with Safety Program • Patient Safety & Risk Management

27. Regions: Example of Integration of Technology and Patient Safety Plans • Bar coding • Laboratory specimens • Matches order with patient’s ID band • Prints label(s) at the time of collection • Documents time, date and collector • Medication administration • Matches medication, patient, dose, route, nurse, and time • Records administration on MAR

28. Sleepy Eye:Examples how Technology Plan integrates with Patient Safety Plan Two ways that technology supports safety: • by proactively driving safe work practices and, • through retrospective data retrieval/ reports that let you evaluate the effectiveness of your work practices At SEMC we are mindful of this in our clinical software evaluation and selection process

29. Poll: How integrated are your EHR and Safety Plan ? • We don’t have an EHR yet. • The EHR is a documentation tool not yet related to assisting patient safety efforts. • The EHR is helping us meet several patient safety goals. (identify in Chat pod) • The plan for each new goal includes EHR support.

30. Poll: Are safety goals & core measures being tracked via your EHR ? • How can the EHR help these measures? • The EHR is helping us with core measures but we haven’t managed to use it to achieve patient safety goals. • The EHR is helping us achieve safety goals but haven’t addressed core measures. • The EHR is helping us with both.

31. Poll: Is infection surveillance supported by automation such that your ICP’s have a “morning report” based on last night’s lab values that drives their daily activity ? • Yes and we’ve been able to track and prove significant reductions. (say more in Chat Pod) • Yes but we’re not tracking impact yet • We’ve got a home-grown tool that works pretty well. • We’ve got a home-grown tool but it doesn’t work well. • No. Surveillance is the still the manual method.

32. Agenda • PI Plan includes Safety Program • Patient Safety Goals addressed • Technology's role in Safety Program • Technology plan integrated with Safety Program • Patient Safety & Risk Management

33. Regions Patient Safety & Risk Management • Risk management is corporate level function: financially oriented • Safety is organization-based: practice oriented • Safety is a subset of risk mitigation strategy • Databases are unique due to peer review protection • Both are more reactive than proactive; largely due to resource and time constraints

34. Sleepy EyePatient Safety & Risk Management Recent changes in how this is structured: One person to lead both Patient Safety and Risk Management Functions under the peer protected Quality umbrella Leads an interdisciplinary Safety Team engaged in identifying, developing, and implementing safe practices throughout the organization Developing a focus on an understanding of human factors, engineering risk out of processes, and developing forcing functions to support safety Developing a value of reporting as a learning opportunity to make SEMC safer for patients, visitors, and staff

35. Summary Patient Safety: Operational • PI Plans should support your safety program • Leadership should support JC NPSG efforts • Technology can play a significant role in your safety program • Technology & safety plans should be integrated • Patient safety & risk management are separate functions that join at events. Your culture will determine how those events are addressed.

36. Reminder to Register your Attendance Hopefully you provided your name & organization when you signed in. • If so: Say Hi in the Chat Pod and we’ll capture your name and organization in the log. • If not: Identify yourself and organization in the Chat Pod to the left of your screen. If there is more than one attending on your sign-in, tell us how many by saying “Hi (number of attendees)”

37. Interest in CPHQ Prep Class in March 2009? • If you would like to take this prep course in March somewhere in the Twin Cities, contact Skip • Registration will be between $150 to $200 for 1.5 days (Saturday and half day Sunday) • We might be able to pair you with a Twin Cities buddy to save on room expenses • Any Interest?

38. Thank you for joining us in this informal quality forum !!!

39. Next Session August 28Information Management : Data & Measurement • DATA • Requirements Determination (vs Requirements Analysis) • Data Governance, data quality, security • Evaluating reporting aspects of software applications • Organizing for the reporting function • Qualitative and Quantitative data; Information for Committee Meetings • Data capture alternatives • MEASUREMENT • Data displays • Basic statistics • SPC representations ; baselines; benchmarking • Next-level statistics: regression; correlation • Organizational vs project measurement

40. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month Aug 28 2008 • DATA • Requirements • Governance • Evaluating reporting aspects of software • applications • Organizing for the reporting function • Qualitative and Quantitative data; • Information for Committee Meetings • Data capture alternatives • MEASUREMENT • Data displays • Basic statistics • SPC representations ; • baselines; benchmarking • Next-level statistics: regression; correlation • Organizational vs project measurement Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html