Transcript Slide 1

Welcome to the
NQF Safe Practices for Better Healthcare
2009 Update Webinar:
Leadership Lessons for Pharmacy,
Nursing, and Hospital Leaders
Featured Speaker: Bill George
Hosted by NQF and TMIT
Attendee dial-in instructions:
Toll-free Call-in number (US/Canada): 1-866-764-6260
(direct number, no code needed)
To join the online webinar, go to:
www.safetyleaders.org
Online Access Password: Webinar1 (case-sensitive)
1
Welcome and Review of
Specifications for Safe Practice 1,
Leadership Structures and
Systems
Charles Denham, MD
Chairman, TMIT
Co-chairman, NQF Safe Practices Consensus Committee
Chairman, Leapfrog Safe Practices Program
Safe Practices Webinar
August 25, 2009
Toll-free Call-in number: 1-866-764-6260
2
Panelists
Charles Denham
Jennifer Dingman
Hayley Burgess
Bill George
Charles Denham:
Welcome and Review of Specifications for Safe
Practice 1, Leadership Structures and Systems
Jennifer Dingman: Patient and Family Involvement
Hayley Burgess:
Review of Specifications for Safe Practice 18,
Pharmacist Leadership Structures and Systems
Bill George:
7 Lessons for Leading in Crisis
Peter Angood
(Featured Speaker)
Peter Angood:
National Perspective on Leadership Issues and Closing Remarks
3
4
5
Patient and Family Involvement
Jennifer Dingman, Patient Safety Advocate;
Founder, Persons United Limiting Substandards
and Errors in Healthcare (PULSE), Colorado Div.;
Co-founder, PULSE American Division
Safe Practices Webinar
August 25, 2009
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7
2009 NQF Safe Practices for Better
Healthcare: A Consensus Report
34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness
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Changes of 2006 Version to 2009 Update
Practice Line-Up Changes:
• From 30 to 34 practices
• Culture Practice Elements
Broken Up into 4 Practices
• 2 Practices Discontinued
• 4 Medication Management
Practices Combined into 1
• 2 Communication Practices
Combined into 1
• 8 New Practices Added
• CMS Care Settings Defined
• Patient and Family Involvement
Section Added
Final Report:
• Format Structure Preserved
• Lightly Edited Text of Most
Practices
• New Practices
• Updated References
• Corrections and Clarification
• Care Setting Clarification Using
CMS Classification
• Measures To Be Considered (in
formulation)
• Soft Copy Document Hyperlinks
• Crosswalk Tables
• Glossary
10
11
Harmonization – The Quality Choir
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The Patient – Our Conductor
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Culture
Consent & Disclosure
Consent and Disclosure
Workforce
Information Management and
Continuity of Care
Medication Management
Healthcare-Associated
Infections
Condition- &
Site-Specific Practices
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Culture
Structures
and Systems
Culture Meas.,
FB., and Interv.
Team Training
and Team Interv.
ID and Mitigation
Risk and Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety (Separated into Practices]
 Leadership Structures and Systems
 Culture Measurement, Feedback, and Interventions
 Teamwork Training and Team Interventions
 Identification and Mitigation of Risks and Hazards
Consent
& Disclosure
Consent
and
Informed
Consent
Life-Sustaining
Treatment
Care of
Caregiver
Disclosure
Workforce
2009
NQF Report
Nursing
Workforce
Direct
Caregivers
CHAPTER 3: Informed Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
Legend:
No Material
Changes
Information Management and Continuity of Care
Patient
Care Info.
Material
Changes
Read-Back
& Abbrev.
Labeling
Studies
Discharge
System
CPOE
CHAPTER 5: Information Management and Continuity
of Care
 Patient Care Information
 Order Read-Back and Abbreviations
 Labeling Studies
 Discharge Systems
 Safe Adoption of Integrated Clinical Systems
including CPOE
New
Medication Management
CHAPTER 6: Medication Management
 Medication Reconciliation
 Pharmacist Leadership Role Including: High-Alert
Med. and Unit-Dose Standardized Medication
Labeling and Packaging
Med. Recon.
Pharmacist Systems Leadership:
High-Alert, Std. Labeling/Pkg., and Unit-Dose
Healthcare-Associated Infections
Influenza
Prevention
Hand Hygiene
Sx-Site Inf.
Prevention
VAP
Prevention
Central V. Cath.
BSI Prevention
MDRO
Prevention
UTI
Prevention
Condition-, Site-, and Risk-Specific Practices
Wrong-site
Sx Prevention
Contrast
Media Use
Organ
Donation
Press. Ulcer
Prevention
Glycemic
Control
DVT/VTE
Prevention
Falls
Prevention
Anticoag.
Therapy
Pediatric
Imaging
CHAPTER 7: Hospital-Associated Infections
• Hand Hygiene
• Influenza Prevention
• Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical-Site Infection Prevention
• Care of the Ventilated Patient and VAP
• MDRO Prevention
• UTI Prevention
CHAPTER 8:
• Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
• Organ Donation
• Glycemic Control
• Falls Prevention
• Pediatric Imaging
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LEADERSHIP STRUCTURES and SYSTEMS
Patients and
Community
Values
Systems
Structures
Leadership Structures
and Systems
Culture Measurement,
Feedback, and Intervention
Teamwork Training
and Skill Building
Behaviors
Outcomes
Identification and Mitigation
of Risks and Hazards
NQF 34 Safe
Practices
16
Awareness
Accountability
Ability
Action
Safe Practice Statement: Leadership Structures and Systems
Leadership structures and systems must be established to ensure that there is
organization-wide awareness of patient safety performance gaps, direct
accountability of leaders for those gaps, and adequate investment in
performance improvement abilities, and that actions are taken to ensure safe
care of every patient served.
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Awareness
Accountability
Ability
Action
Awareness Structures and Systems: Structures and systems should be in
place to provide a continuous flow of information to leaders from multiple sources
about the risks, hazards, and performance gaps that contribute to patient safety
issues.
•
•
•
•
Identification of Risks and Hazards
Culture Measurement, Feedback, and Intervention
Direct Patient Input
Governance Board and Senior Management Briefings/Meetings
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18
Awareness
Accountability
Ability
Action
Accountability Structures and Systems: Structures and systems
should be established to ensure that there is direct accountability of the
governance board, senior administrative management, midlevel
management, physician leaders (independent and employed by the
organization), and frontline caregivers to close certain performance
gaps and to adopt certain patient safety practices.
•
•
•
•
•
Patient Safety Program
Patient Safety Officer
Direct Organization-Wide Leadership Accountability
Interdisciplinary Patient Safety Committee
External Reporting Activities
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Awareness
Accountability
Ability
Action
Structures- and Systems-Driving Ability: Capacity, resources, and competency
are critical to the ability of organizations to implement changes in their culture and
in patient safety performance. Systematic and regular assessment of resource
allocations to key systems should be undertaken to ensure performance in patient
safety. On a regular, periodic basis determined by the organization, governance
boards and senior administrative leaders should assess each of the following areas
for the adequacy of funding and should document the actions taken to adjust
resource allocations to ensure that patient safety is adequately funded:
•
•
•
•
Patient Safety Budgets
People Systems
Quality Systems
Technology Systems
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Awareness
Accountability
Ability
Action
Action Structures and Systems: Structures and systems should be put in place to
ensure that leaders take direct and specific actions, including those defined below.
• Performance Improvement Programs:
• Regular Actions of Governance:
• Confirmation of Values
• Basic Teamwork Training and Interventions Briefings
• Governance Board Competency in Patient Safety
• Regular Actions of Senior Administrative Leadership: The actions of the
CEO and senior leaders have a critical impact on the safety of every
organization.
• Time Commitment to Patient Safety
• Culture Measurement, Feedback, and Interventions
• Basic Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
• Regular Actions of Unit, Service Line, Departmental, and Midlevel
Management Leaders
• Regular Actions with Respect to Independent Medical Leaders
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Review of Specifications for Safe
Practice 18, Pharmacist Leadership
Structures and Systems
Hayley Burgess, PharmD, BCPP
Director, Performance Improvement
Measures, Standards, and Practices
TMIT
Toll-free Call-in number: 1-866-764-6260
Safe Practices Webinar
August 25, 2009
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Continuity of Adverse
Drug Events (ADEs)
• Admission: More than 50% of patients
admitted to the hospital have ≥ 1 unintended
medication discrepancy. 39% of those have
potential for moderate to severe patient harm.
• Hospitalization: 10.4% ADE rate, equal to one
ADE per 10 inpatients.
• Discharge: ADEs are most often the cause of
patient injury during the peri-discharge period.
Cornish PL, et al. Arch Intern Med. 2005;165:424-429. Bates D, et al. Massachusetts Technology
Collaborative. 2008 Feb. Forster AJ, et al. Ann Intern Med. 2003;138:161-167.
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Reasons for Pharmacy Leaders
to be Quality Focused
1) The PATIENT– quality for the sake of
protecting human life
2) Growing number of standards and
measures focused on medication use = $$
3) Data transparency: Organizational
Branding, Competition, Consumer/Purchaser
empowerment
4) Recognition of the importance of the role of the
pharmacist in quality
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Standards and Measures
Relating to Medication Use
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Standards and Measures Relating to Medication Use
NQF
Endorsed Measures
34 Safe Practices
28 Serious Reportable Events
http://www.qualityforum.org/Home.aspx
IOM
20 Priority Areas; Preventing Med.
Errors and Overuse of Antibiotics
http://www.iom.edu/?id=19752
AHRQ
32 Quality Indicators
27 Patient Safety Indicators
http://www.qualityindicators.ahrq.gov/iqi_over
view.htm
http://www.qualityindicators.ahrq.gov/psi_over
view.htm
CMS
Core Measures
27 HCAHPS
http://www.qualitynet.org
http://www.hcahpsonline.org
Joint
Commission
National Patient Safety Goals
Med. Management Standards
http://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/09_hap_npsgs.htm
http://www.jointcommission.org/Standards/
Leapfrog
Leaps Survey, CPOE Simulator
http://www.leapfroggroup.org/
NPP
National Priority Partnership
http://www.nationalprioritiespartnership.org
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http://www.ashp.org/qii/npp
NQF Safe Practices Specifically Related to Medication Process or Use
Safe Practice 12
Communication of Patient Care Information
Safe Practice 13
Order Read-back and Abbreviations
Safe Practice 15
Discharge Systems
Safe Practice 16
Safe Adoption of Computerized Prescriber Order Entry
Safe Practice 17
Medication Reconciliation
Safe Practice 18
Pharmacist Leadership Structures/Systems (Includes SPs 1-4 framework)
Safe Practice 20
Influenza Prevention
Safe Practice 22
Surgical-Site Infection Prevention
Safe Practice 23
Care of the Ventilated Patient
Safe Practice 24
Multidrug-Resistant Organism Prevention
Safe Practice 28
Venous Thromboembolism (VTE)
Safe Practice 29
Anticoagulation Therapy
Safe Practice 30
Contrast Media-Induced Renal Failure Prevention
Safe Practice 32
Glycemic Control
Safe Practice 33
Falls Prevention
15/34 Safe
Practices
27
http://www.qualityforum.org/Projects/s-z/Safe_Practices_2009/Safe_Practices_for_Better_Healthcare_2009_Update.aspx
CMS Quality Measure Category
Medication-Related
Indicator
Acute Myocardial Infarction (AMI)
7 of 12
Heart Failure (HF)
2 of 4
Pneumonia (PNE)
5 of 7
Surgical Care Improvement Project (SCIP)
• SCIP—Infection
25 of 28
• SCIP—Cardiac
• SCIP—VTE
Pregnancy and Related Conditions (PRC)
Children’s Asthma Care (CAC)
66 of 98
Core
Measures
1 of 1
2 of 2
0 of 3
9 of 9
Venous Thromboembolism (VTE)
5 of 6
Stroke (STK)
6 of 8
Emergency Department (ED)
0 of 7
Hospital Outpatient Measures (HOP): AMI, CP, Surgical, Imaging
4 of 11
CMS Outcome Measures (Claims-Based)
• 30-day Mortality for AMI, HF, PN; 30-day Readmission AMI, HF, PN
http://www.qualitynet.org/dcs
immeasurable
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CMS: Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS)
• Patients’ perspectives on hospital care
• Eight key topics: communication with doctors,
communication with nurses, responsiveness of
hospital staff, pain management,
communication about medicines, discharge
information, cleanliness of the hospital
environment, and quietness of the hospital
environment
http://www.hcahpsonline.org
Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' Perception of Hospital Care in the United States.
NEJM. 2008 Oct;339(18):1921-1931
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CMS: Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS)
• Medication use-related questions:
–How often was your pain well controlled?
–How often did the hospital staff do everything they could
to help you with your pain?
–How often did the hospital staff tell you what your
medication was for?
–How often did the hospital staff describe possible side
effects in a way you could understand?
–Did you receive information in writing about what
symptoms or health problems to look out for?
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CMS Recognition of Pharmacist Role
• Core Measures Specification Manual
–Previously specified physician/APN/PA only for
documentation of contraindications to medications
–Beginning in Version 2.4b
•Effective for discharges beginning 4/01/08
•Acceptable for PHARMACIST to document
contraindications
www.qualitynet.org (“Hospitals–Inpatient” →”Specifications Manual”
→”Version 3.0b” →”Alphabetical Data Dictionary” → then review sections
related to various medication contraindications
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National Priority Partnership
• Care Coordination
This priority focuses on ensuring that patients receive well-coordinated care
within and across all healthcare organizations, settings, and levels of care.
• Overuse
This priority focuses on eliminating overuse while ensuring the delivery of
appropriate care.
• Palliative and End-of-Life Care
This priority focuses on guaranteeing appropriate and compassionate care for
patients with life-limiting illnesses.
• Patient and Family Engagement
This priority focuses on engaging patients and families in managing their
health and making decisions about their care.
• Population Health
This priority focuses on improving the health of the overall population.
• Safety
This priority focuses on improving the safety and reliability of America’s
healthcare system.
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Safe Practice 18
Pharmacy Leadership Structures
and Systems
[Combined 2006 SPs 15-16-17-18]
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33
Objective
Pharmacy leadership is the core of a
successful medication safety program.
Pharmacy leadership structures and
systems ensure a multidisciplinary focus
and a streamlined operational approach
to achieve organization-wide safe
medication use.
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34
Safe Practice 18 Statement:
Pharmacy leaders should have an active
role on the administrative leadership
team that reflects their authority and
accountability for medication
management systems performance
across the organization.
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35
Additional Specifications:
Leadership and Culture of Safety
• A structure should be established and
maintained to ensure that pharmacy leaders
engage in regular, direct communications with
the administrative leaders and the board of
directors about medication management
systems performance.
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36
Additional Specifications:
Leadership and Culture of Safety
• Pharmacists should actively participate in
medication management processes, structures
and systems, including, at a minimum:
–awareness of medication safety gaps
–direct accountability of senior leadership for those gaps
–ability with adequate budget available for performance improvement
–action is taken
–culture of safe medication use
–team-based care
–identify and mitigate medication safety risks and hazards
–evidence-based medication regimens for all patients
–medication safety committee and report data and prevention strategies
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to senior leadership
Additional Specifications:
Leadership Structures and Systems Sections
• Selection and Procurement
• Storage
• Ordering and Transcribing
• Preparing and Dispensing
• Medication Administration
• Monitoring
• High Alert Medications
• Evaluation
38
Opportunities for Patient
and Family Involvement
• Educate patient and family members about the common incidence of
medication errors.
• Encourage patient and family members to ask questions about their
medication regimens and to request consultation with a pharmacist
when necessary.
• Involve patient and family members on medication safety committees..
• Use teach-back method to ensure patient/family understanding of
appropriate medication use. Example: Medication that involves
injections or inhalation devices; proper storage and disposal.
• Patient and family members should be instructed how to identify and
manage routine side effects, and to know when and whom to contact if
they believe they are experiencing any serious adverse effects of drug
therapy.
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39
So What…for Pharmacists?
• The majority of quality standards and measures
are medication management-related.
• Pharmacists can make a major difference
through aligning initiatives and services with
current P4P and public reporting programs.
• Pay-for-Improvement is coming! Pharmacists
can truly be an integral solution for patient
safety and medication use issues!
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40
Opportunities for Pharmacists





Collect, analyze, and disseminate data that
measure medication-related healthcare quality.
Encourage error reporting – internal and external (see “ISMP Med
Safety Alert! Pump up the volume – tips for increasing reporting.
Feb 9, 2006 “)
http://www.ismp.org/Newsletters/acutecare/articles/20060209.
asp
Identify and publicize important pharmacist roles.
Educate other healthcare practitioners and the public about
healthcare quality improvement initiatives.
Utilize data and resources to create the business case that supports
the pharmacist’s role in quality improvement in your institution.
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42
Leadership for Pharmacists,
Hospital Administrators, and
Nursing Leaders:
7 Lessons for Leading in Crisis
William W. George, MBA
Professor , Harvard Business School
Former Chair & CEO, Medtronic
Safe Practices Webinar
August 25, 2009
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43
Agenda
•
•
•
•
•
•
Overview of “7 LESSONS”
Lessons 1-4
Q&A
Lessons 5-7
Q&A
Conclusion
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45
7 Lessons for Leading in Crisis
•
•
•
•
Crisis is the ultimate test for a leader
Best form of leadership development
Following your True North in a crisis
Need: Self-awareness
Self-confidence
Resilience
“A smooth sea never made a skilled mariner”
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46
Global Economic Crisis of 2008-09
• Not result of subprime mortgages, credit
default swaps, or excessive greed
- only symptoms of real problem
• Root cause: failed leadership that ignored risk
and placed S-T gain ahead of L-T value
• Long roots: dates back to 1970s and focuses
on S-T shareholder value
• Wall St. ignored lessons of LTCM & Enron
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The 7 Lessons
#1 Face reality, starting with yourself
#2 Don’t be Atlas: get the world off your
shoulders
#3 Dig deep for the root cause
#4 Get ready for the long haul
#5 Never waste a good crisis
#6 You’re in the spotlight: follow True North
#7 Go on offense: focus on winning now
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Lesson #1: Face Reality,
Starting with Yourself
•
•
•
•
De-nial is not a river in Egypt
Why it’s so hard to face reality
Don’t shoot the messenger
It’s hard to admit your mistakes . . .
until you acknowledge your role in the
problems
Lesson: Denying reality only makes things worse
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Lesson #2: Don’t Be Atlas –
Get World off your Shoulders
• Dangers of turning inward
• Turn to your teammates for help
• Look to your external team
• Be willing to be vulnerable
• Build your resilience
Lesson: You’re much more effective when you
ask for help
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50
Lesson #3: Dig Deep
for Root Cause
• Trust, but verify
• Dangers of treating symptoms
• Bring your team together
• Keep digging to get to bottom of problem
• How do you know when you’re there?
Lesson: Overcome fears of digging deeper
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51
Lesson #4: Get Ready
for Long Haul
• Things will get worse before getting better
• Respond to early warning signals
• Crises have long roots
• Take decisive action
• In a crisis, cash is king
Lesson: Don’t underestimate severity of crisis
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52
Q&A
• Pharmacy and Nursing Leadership Issues
• General Administrative Issues
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53
Lesson #5: Never Waste
a Good Crisis
• Crisis is best opportunity to make
fundamental changes in organization
• Avoid tendency to hunker down until storm
passes
• Anticipate what lies ahead and create crisis
to get things done
Lesson: Take advantage of crises to reinvent your
organization
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54
Lesson #6: You’re in the Spotlight:
Follow True North
• Internal and external communications have
morphed into one
• Essential to be transparent to be credible
• Create a culture of candor
• Dealing with public confidence, private doubts
• Taking public responsibility for the problems
Lesson: Get in front of crisis by being open
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55
Lesson #7: Go on Offense,
Focus on Winning Now
• To succeed in a crisis, play offense as well as
defense
• Transform your market
• Invest during downturns
Lesson: Crisis is best opportunity to shape
markets to your advantage
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56
7 Steps to Focus on Winning
Step 1: Rethink your industry strategy
Step 2: Shed your weaknesses
Step 3: Reshape industry around strengths
Step 4: Make investments during downturn
Step 5: Keep key people focused on winning
Step 6: Company image as industry leader
Step 7: Implement rigorous execution plans
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57
Q&A
• Pharmacy and Nursing Leadership Issues
• General Administrative Issues
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58
Conclusion
• Is this crisis your defining moment?
• Are you prepared to step up and lead?
• Stay on course of True North, no matter how
great the pressures or temptations
• You can make a difference in the world:
This is ultimate fulfillment of leading in crisis
“Never doubt the power of a small group to change the
world. Indeed, it is the only thing that ever has.”
- Anthropologist Margaret Mead
59
More Information on 7 LESSONS
•
.
• Go to www.billgeorge.org
• To purchase 7 Lessons, go to:
www.amazon.com
www.barnesandnoble.com
www.borders.com
• To receive your free copy of
Study Guide to 7 Lessons,
e-mail: [email protected]
60
National Perspective on
Leadership Issues
and Closing Remarks
Peter B. Angood, MD, FRCS(C), FACS, FCCM
Senior Advisor, Patient Safety
National Quality Forum
Safe Practices Webinar
August 25, 2009
61
Patient and Family Involvement
Jennifer Dingman, Patient Safety Advocate;
Founder, Persons United Limiting Substandards
and Errors in Healthcare (PULSE), Colorado Div.;
Co-founder, PULSE American Division
Safe Practices Webinar
August 25, 2009
62
Upcoming Safe Practices Webinars
 September 17 – Important Condition and Common Safety
Issues (Safe Practices 26-34)
 October 22 – Creating Transparency, Openness, and
Improved Safety (Safe Practices 5-8)
 November 19 – Healthier Communication and Safe
Information Management (Safe Practices 12-16)
 December 17 – Optimizing a Workforce for Optimal Safe
Care (Safe Practices 9-11)
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