GBHN Order Set Project

1. GBHN Order Set Project An effective solution to the complex challenge of improving patient care and safety

2. Context:Massive Gap Between the Possible and the Actual • Quality • Misuse, under use, overuse on a massive scale: Crossing the Quality Chasm 2001 • Safety • Medical error is common: Institute Of Medicine Report on Error 2000 • Variation in Care • Variability in care not explained by patient preferences or different disease patterns: British Medical Journal 2002; 325: 961-964

3. Solution: Order Sets a Clinical Decision Support Tool • A group of orders with a common functional purpose used by the physician to create orders. • Integrates knowledge into the care delivery process “knowledge where the clinician needs it most” • Organizes clinical knowledge so it is easy to remember, easy to use and has maximum benefit to the patient • Contain evidence-based best practices • Source of education • Can be used in paper or computerized ordering systems

4. Order Sets: Key Benefits • Safety • Reduced transcription errors • Reduced errors of omission • Reduced errors in medication dosing • Quality • Improved compliance with evidence-based best practices • Standardization of care • Efficiency • Decreased time to write and process orders • Reduction in physician call-backs • Reduction in missed orders • Critical enabler for computerized practitioner order entry

6. Data Collection • Primary outcome DVT Prophylaxis Rates: • Random Chart audit from three time periods • October-November 2003 • April – December 2004 • February – March 2005 • DVT prophylaxis rates in the Department of Medicine • April 2003 to March 2005 • Secondary Outcomes: Assess in second chart period • Multiple Quality metrics assessed.

7. DVT: The Preventable Epidemic • DVT is the formation of blood clots in the legs • DVT is very common in hospitalized patients • DVT can cause death or serious disability • There is excellent treatment to prevent DVT if patients get it • Many studies have shown that many patients do not get this treatment which can save their lives • “The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis” - S. GoldHaber, Associate Professor Harvard Medical School, 2003 • The order sets contained a section with treatment to prevent DVT

18. The Order Set Challenge Order Sets Must Be: • Current • Evidence Based and Best Practice • Authoritative • Easy to Use • Comprehensive • Reliable and safe • Clinically Intelligent

19. The Order Set Challenge Order Sets are Complex! • Typical medical admission order set has 130 order elements in the set • Interdisciplinary • Multiproccess • Integration with other care documents and activities • Over 400 different order sets for a typical hospital • Standardization, integration across systems is critical

20. Current Status of Order Sets • Lack of Recognition of Order Set Importance • Order Set Design • Often no standardized structure • Structure is not modular • Lack of integration with other processes/documents • Order set life cycle not well established • No dedicated Order Set Committee at most hospitals • Most often P+T/MAC based process, occasionally process is distributed to the level of the health systems • Best practices often not scaled across departments • Lack of version control • No measurement of metrics • Each hospital has its own structure and approach to order sets

21. Current Status of Order Sets • No good library of content • No standardization of format, content or processes between organizations • Limited ability to share order set content between organizations • Each Organization must create its own order set project • Duplication of effort • Reduced quality • Slow implementation of best practices • Consumption of limited hospital resources • Organization may lack content expertise in all the subject areas need for order sets • Organization may lack knowledge of order set best practices in design and order set lifecycle • External resources for order sets currently are very limited

22. Trillium’s Order Set Project • 2001: Order set development begins in ICU • Rapid Cycle improvement of order set design • 2002: Order set development in other departments • 2003: Standardized order set format established • 2004: Current Order Set Committee established • 2006: Standardized order sets in use in every Health System • Over 250 order sets currently in use • Admission order set use > 90% in most health systems

23. Trillium Order Set Project • Winner of the first Ministry of Health award for Innovation in Patient Safety and Quality • Expanded Commitment to Order Set Development and Implementation • Order Set Project now has six dedicated FTEs • Goal of expanding content by over 400 order sets in the next year • Preparation for CPOE. Order sets developed for use in current paper ordering environment and in CPOE system

24. Trillium Order Set Innovation • Excellence in Order Set Design • 5 years of iterative improvement in order set design • Integration of real world feedback • Intelligent knowledge representation to increase usability and clinical impact • Order Set Process • Real time integration of authoritative content expertise into order sets • Dedicated Interdisciplinary Order Set Committee • 9 member committee that meets weekly • Clearly established processes for all aspects of the order set lifecycle – initiation, development, approval implementation and maintenance • Integration of order sets with other processes and documents

25. Trillium Order Set Innovation • Order Set Content • Over 250 order sets developed • Order sets used in every health system • Content is interdisciplinary addressing all aspects of a patient’s care • Web enabled searchable data base of all clinical decision support tools • Interdisciplinary development teams • Content experts own the content • Order set committee provide process knowledge

26. Open Source Order Sets • Based on Trilliums award winning Order Set Project • Dedicated to improving healthcare in Canada by facilitating the use of high quality, standardized evidence based order sets • Partnering with other Health Care Organizations to standardize and improve the quality and safety of patient care • Niagara Health System • Open Source Order Sets • Provide a complete order set solution • Save organizations time, money and reduce demand on limited organizational resources • Improve quality • Local ownership and adaptation of tools

27. Open Source Order Sets • Standardized Order Set Design • Standardized structure to order set content based on DAVID • Rules of correct formatting at all levels of order set content • Clear syntax of order set content • Designed to anticipate CPOE • Modular Format • Best practices are contained in functional groups • Facilitates the spreading of best practices across different order sets and across health systems • Over 300 modules including many high value best practice modules such as deep vein thrombosis prophylaxis, bowel care, pain control, electrolyte management • Order Set Lifecycle • Order Set Committee • Interdisciplinary membership • Robust methodology for development, approval, implementation and maintenance

28. Open Source Order Sets • Large Library of Developed Content • Over 250 order sets and clinical protocols • Comprehensive interdisciplinary content • Incorporation of real world experience • Will grow to over 600 order sets in the next year • Order Set Web Page • Web accessible data base to store library of order set content • Order sets clearly organized, searchable by many different criteria and relationships between order sets and clinical protocols clearly established • Order Set Project Support • On-site and remote support including physician, nursing, pharmacy • Goal is rapid knowledge transfer

29. Order Set Project Outline • Establish an Order Set Committee • Best practices around order set lifecycle • Catalogue and upgrade existing order set content • Convert to standardized modular format • Integrate new best practice content as appropriate • Standardization of best practices across the organization • Approval of new and upgraded order sets by the Order Set Committee • Develop and Implement Order Sets • Utilization of library of best practice content • Adapt Open Source Order Sets to local health system needs • New sets developed by content experts at Grey Bruce • Comprehensive communication plan to facilitate adoption

30. Order Set Project Outline • Store order sets on an intranet accessible database • Collection of data for metrics • The measurement of improved outcomes is an important part of an order set project • Order sets can have a dramatic impact on easily measured quality metrics in a very short time period • Open Source Order Sets will work with you to select the key metrics that can be used to evaluate your project • Number of order sets in use • Order set adoption • Adherence to best practices • Before/after, cross-sectional analysis

31. Benefits • Save time • Save money • Improve the quality and safety of patient care • Large improvements of easily measured metrics in short periods of time • Improve order set design • Increase order set use by physicians • Increase the clinical impact of order set use • Increase the standardization of best practices across the healthcare system • Increase the knowledge base that can be used for order set development • Hospitals are no longer developing order set content in isolation • Improve the coordination of order sets with other order sets, documents and processes • Improved coordination of health care delivery in Ontario

32. GBHN Order Set Project • First steps now being completed: • Order Set Committee established – members: Jessica Meleskie GBHN, Chair Sharon Musehl Nursing, SBGHC Lisa Laviolette Nursing, GBHS Michelle Scime-Benninger Nursing, HDH Trent Fookes Pharmacy, GBHS Dr. Randy Montag HDH Dr. Paul Eisenbarth HDH Dr. Lisa Roth SBGHC Dr. Roger Skinner GBHS Dr. Brendan Mulroy GBHS Pat Given HIS, Order Sets Susan Downs HIS, Clinical documentation Darlene Young GBHN, Education/Utilization Julia Metzger GBHN, Administrative Assistant Others as needed on an adhoc basis • Meeting 2X per month to move project quickly into implementation

33. GBHN Order Set Project • First steps: • Conversion of all of our current orders into the new modular format • Upload all current order sets on new website • Process in place to print-on-demand directly off website • Icon to be placed on each desktop for easy access to website (similar to Evidence-Based Care Program website icon) – should be this week – HIS working on it • Beginning to merge our content with OSOS content • Next steps: • Implementation – staff need to know how to access orders via website • Removal of old order sets from the units, replacement with new ones (small volumes to ensure most up to date orders always being used, print-on demand for low volume order sets)

34. GBHN Order Set • Website currently available will be on the desktop of all computers soon • Initially see entire list of orders available, can search via key word at the top of the list, or click on “advanced search” to see only Corporate orders, and/or search by many different parameters as can be seen on the website • Can also see the entire library of Open Source Order Sets if click on “Master OS Repository” on the left hand side • Will be releasing a memo each month with the new/changed orders available on the website to ensure staff/physicians are up to date on the latest changes • Also releasing a newsletter as necessary to update staff/physicians on project status

35. Demo- Go check it out on your desktop ! • GBHN Order Sets Website Questions?? Contact Jessica Meleskie 519-364-2341 ext 350 Email jmeleskie@gbhs.on.ca