Patient Safety at SSM Health Care Paul Convery MD EVP/CMO SSM Health Care – St. Louis

1. Patient Safety at SSM Health Care Paul Convery MD EVP/CMO SSM Health Care – St. Louis

3. SSM Health Care SSM Health Care St. Louis Cardinal Glennon Children’s Hospital St. Joseph Health Center St. Joseph Health Center West DePaul Health Center St. Joseph Hospital St. Mary’s Health Center SSM Rehab Managed Care Organization Physician Organization SSM Home Care SSM Health Care of Wisconsin St. Clare Hospital, Baraboo WI St. Marys Care Center St. Marys Hospital Medical Center Blue Island, IL St. Francis Hospital Health Center Maryville, MO St. Francis Hospital & Health Services SSM Health Care of Oklahoma St. Anthony Hospital Bone & Joint Hospital Centralia, IL St. Mary's Hospital Mt. Vernon, IL Good Samaritan Regional Health Center Jefferson City, MO St. Marys Health Center Villa Marie Skilled Nursing Facility

4. Our Quality Journey

5. Building a Culture of Improvement

6. Beginning the Baldrige Process

7. Baldrige Framework for Organizational Excellence Strategic Planning Staff Focus Organizational Performance Results Leadership Focus on Patients, Other Customers, and Markets Process Management Information and Analysis

8. Lessons from the MBNQA Process • Framework • Focus • Balance • Discipline • Linkages • Accountability

9. Our Mission Through our exceptional health care services, we reveal the healing presence of God.

10. Our Mission Statement Through our exceptional health care services, we reveal the healing presence of God. Exceptional clinical outcomes Exceptional Patient, Employee & Physician Satisfaction Exceptional financial performance

11. System Network Performance Indicators Exceptional Results Entity Department Cascading Indicators

12. Deploying Our Mission Passports Poster

13. A Culture of Patient Safety • Safety Comes First / Organizational Commitment • All Leadership Involved • Standards Are High and Well Communicated • Line Management Accountability • If Work Cannot be Done Safely… • Openness and Transparency • Safety Systems, Processes in Place with Consistent Training Jack Silversin, DMD, DrPH IHI National Forum on Quality 2003

14. Patient Safety at SSM • 1999 - IOM Report “To Err is Human” • 2000 - “Enhancing Patient Safety” • 2001 - IOM Report “ Crossing the Quality Chasm” • 2001 - SSMHC Patient Safety Plan • 2002 - “Achieving Exceptional Safety” • 2003 - Clinical Transformation / Technology

15. SSMHC Patient Safety Plan • System Wide Approach to Patient Safety • SSM Patient Safety and Performance Improvement Plan • Philosophy of the Patient Safety Plan • Provide and Enhance a Safe Environment • Errors are Due to Breakdown in Systems and Processes • Leadership Commitment to Patient Safety • Blame Free Culture • System Wide Safety Reports to Senior Management and Regional Boards

16. SSM Disclosure Policy • System wide policy to disclose serious, unanticipated, adverse outcomes and sentinel events • An event that results in significant change in patient’s condition; significant new level of monitoring; need for unforeseen medical care; could have contributed to a patient’s unanticipated injury or death • Assure that the patient is treated fairly • Support for the physician and staff involved • Support of Risk Management, Social Service, Pastoral Care, Ethics Committee • System wide Disclosure Education for physicians, nurses, staff

17. SSMHC Clinical Collaboratives • AES Collaborative • One of Series of Clinical Collaboratives begun in 1998 • Collaboratives Mission is to Advance Clinical Improvements Across SSM

18. Clinical Collaboratives • The Collaborative mission • To provide an environment conducive to the discovery and development of clinical improvements that can be easily and rapidly diffused so that all entities and SSMHC patients can benefit from the improved value of care

19. Design Collaborative Prework Phase Send out invitation Learning session #1 Team formation and data collection Project work and completion Active phase Learning session #2 (and if applicable, #3, #4, etc) Data collection every 3 months Continuous Improvement Phase Conference calls every 2 months Clinical Collaboratives Start of Collaborative

20. Achieving Exceptional Safety in Health CareRecommended Practices • Implement a near miss reporting system • Eliminate dangerous abbreviations • Design and implement an accurate patient medication list at admission and discharge; avoid “blanket orders” • Implement an effective disclosure of unanticipated outcomes process • Provide and use protocols for high risk medications • Implement a fall reduction program • Implement a sentinel event review process • Establish an entity Safety Center

21. Achieving Exceptional Safety in Health CareRecommended Practices (con’t) • Provide pharmacy rounding in ICU’s • Implement all recommended safety information technology • Implement 24 hr pharmacy coverage • Provide a quarterly “State of Safety Report” • Develop and use a protocol for proper timing of surgical antibiotic prophylaxis • Institute a “needleless” IV system • Implement a protocol for glucose management of diabetic patients under going surgery

22. Achieving Exceptional Safety in Health Care Recommended Practices (con’t) • Develop and implement an effective surgical site marking procedure to avoid wrong site surgery • Reduce risk of health care-acquired infections by complying with current CDC hand hygiene guidelines • Medication reconciliation process at hand offs • Central line bundles • Ventilator care bundles to prevent ventilator associated pneumonias • Deploy rapid response teams

24. Quarterly “State of Safely Report” • All entities have established a “Safety Center” • All entities provide quarterly “State of Safety” reports to their entity leadership, medical staff, employees and governing boards

25. Implement 24 Hour Pharmacy Coverage • This practice was implemented in November 2003 • Relevant for 20 hospitals • Baseline data indicates that 14 have 24 hour coverage • Processes in place to extend coverage to all hospitals

26. SSM Health Care – St. LouisAverage Fall Rate Per 100 Patient Days

27. SSM Health Care – St. LouisSurgical Site Marking

28. SSM Health Care-St. LouisUse of Dangerous Abbreviations

29. SSM Health Care- St. LouisHand Hygiene Compliance

30. Senior Leadership Communicates that Safety is a High Priority – Employee Survey

31. My Department Places Blame on an Individual When an Error is Reported- Employee Survey

32. I Work in an Environment Where I Can Communicate My Opinions About Patient Care Practices – Physician Survey

33. Technology and Patient Safety / Clinical Transformation • Pharmacy Computerized Alerts • Pyxis Systems for Medications • Medication Bar Coding • Physician and Nursing Technology Committees • Physician and Nursing Portals • Protocols Available Electronically • PDA’s for Labs and Results • Clinical Transformation Executive Steering Team • Implementation of System Wide EHR and CPOE

34. The Future of Patient Safety • Leadership Commitment • Eliminate the Barriers • Strong Safety Culture • Process Improvements • The Role of Technology