Transcript Harm Nimby

Harm?
N.I.M.B.Y.!
Diane M. Wilhite, RHIA, CPHRM
Director, Quality
Inova Fair Oaks
Inova Fair Oaks Hospital
• Inova Fair Oaks Hospital is a 182-bed advanced acute care
community hospital.
• Inova Fair Oaks Hospital is part of Inova Health System, a not-forprofit, community-based, mission-driven healthcare system serving
Northern Virginia.
• Ranked in the top 10 of the nation’s 100 most integrated health systems
• Inova Health System is governed by a voluntary board of community
members.
The numbers game: Harm Happens
rd
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Harm Happens: But at what
cost??
$37.6 billion
$4 billion
$17.1 billion
Call to Action
What is real picture?
Green is good, right?
What about this?
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This is what green really means?
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147 patients were “harmed” according to our definition
That is an average of 12 patients per month
With a 25% reduction goal, that still means 100+ patients!
What it really looks like….
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Gregory F
Leo D
Walter K
Carroll T
Vergie B
Alice H
Rokia Z
Jane R
Mary L
Sediqa F
Yvonne B
Laine H
John D
Diane A
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Mary Ann B
Sediqa F
Nancy A
Peggy P
Joanne
Guillermo
Hector O
Tran N
Paramjit K
Irene M
Zohar B
John M
Madeline
Ama
Stephen K
Dilia M
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Karen M
Alan S
Tamara E
Alexandra
Jeremy C
Patricia C
Kenyon D
Andrew G
Scott F
Alice H
Victoria D
Lawrence P
Mary S
Mercedes M
Santos C
Myung C
Robert R
Patricia G
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Tarlok A
Harvey H
Mary L
Mercedes M
Shirley W
Jacqueline J
Deborah
Alan
Francis
An D
Carl R
Cleva B
Joan G
Myung C
Carol
Mary Jo
Albert
Alexis
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Shirzad F
Rahimullah E
Barbara C
Khalida
Freda
Floyd D
Barbara C
Einelhayat S
Gregory
Gary
Dead By Mistake
When?
Making it Real for the Staff
Lean
Management
System
What is a Lean Management System?
A System by which we:
1) Run our Business based on real time indication of the
Value we are delivering to our Customer
2) Continuously Improve our Business and Sustain those
Improvements
Foundational Principles:
Respect for People
Elimination of Waste
Sustainment = Standardization + Connected Checking
Why?
Current State Opportunities:
•Inability to sustain improvements
•Competing priorities under each Strategic Priority
•Critical processes are not defined or standardized
•Lack of prioritizing what’s important to the customer
•No visibility to whether we are meeting customer
expectations on a real-time basis
•Lagging performance data
How do we Implement this System?
1. Understand what’s important to the Customer
(the value we are delivering)
2. Determine the Processes that are Critical to
deliver that Value & Standardize those processes
3. Measure Our Performance Daily
•
Key Performance Indicators for processes that are
critical to delivering the Value
4. Structured Governance and Report Out
•
•
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Performance – Target, Actual, Gap
What we are doing to close the Gap
Issues that need to be escalated for support
Lean Management Model
S
Validation & Coaching
Leader Standard
Work
Leader Standard
Work
A
P
True North KPI’s based on
Customer Requirements
IFOH
CEO
CNO
CFO
Level 3 KPI’s
Monthly Review
CMO
CEO
Level 2 KPI’s
Weekly Review
Leader Standard
Work
Directors
Leader Standard
Work
Depts
Standard Work
Directors
Directors
Directors
Depts
Depts
Depts
Staff
Level 1 KPI’s
Daily Review
Review Performance
Escalate Issues
Q
Accountability and Engagement
“Hardwiring Accountability at the Front Line”, The Advisory Board, 2012
Medical Unit True North Huddle
Building in Accountability
Lean Management System
Scorecard
Inova Fair Oaks
Area:_______________________
1. Visual Management
Run the Business KPI's- Target, Actual, Gap
Lagging Metrics (Press Ganey, etc.)
2. A3 Problem Solving
Root Cause Analysis
Visualize Cause & Effect
Follow Up of Action Items
3. Standard Work for Critical Processes- clear, visual, one page Standard Work where Staff can see it
4. Leader Standard Work to Validate Critical Process Standard Work
A. Supervisor -> Staff
B. Manager -> Supervisor and Staff
C. Director -> Manager
D. Executive -> Director
5. Team Huddle- True North Huddle
Review Performance, Discuss Barriers, Review A3/Action Progress, Escalate Issues
6. Staff Engagement in Standard Work, Barriers, and Empowered to Improve
Definitions:
No activity / large gaps
Active but needs improvement
Fully active and robust
Standard Work
What is Standard Work?
• The Standard Method for performing a process or task
• The best known approach
• The Expected way to perform a process or task
• The foundation for Process Control, Stability, and
Sustainment
Expected
Outcome
Not Expected
Outcome
Why do we need Standard Work?
Sustainment = Standardization
+ Connected Checking
Staff Satisfaction = Know what is expected
Standard Work Best Practice
 Created by those that do the work
 Has an “Owner” , who is the point person for
keeping the Standard updated
 Continuously Improved (PDSA)
 Simple, Visual, One-Pager
 1-5 Days to Create
Includes any important behaviors
 Critical Process Standard Work is checked daily to
ensure we are performing to our customer’s expectations
Standard Work Document
Operating Unit
Process Name
Process Location
Target Time
Created
Intentional Hourly Rounding
6 – 12
Onsite @ Hospitals
7/16/14
(Inpatient Units)
minutes
Purpose: Round on patients with Purpose to actively engage patients and families, build trust, reduce anxiety, prevent harm, and meet their needs
IHS – All Hospitals
Step
Process Step
Responsible
Reviewed/
Revised
Author
8/14/14
Christie E. Rust
Time Goal
Critical Notes on Step
Explain what you’re doing during the rounding
process. Make sure the patient understands
hourly rounding and know why we perform hourly
rounding.
1
Use AIDET & opening key words to reduce anxiety.
Caregiver
20 seconds
2
Perform scheduled tasks.
Caregiver
3
Ask the patient about their number one concern and address this concern for him/her.
Caregiver
Varies
1–2
minutes
4
Address the 6 Ps and 2 Qs – “Mind Your Ps &Qs”:
1) Pain: assessment of patient’s pain level
2) Position: check to validate patient’s comfort
3) Potty: ask the patient if he/she needs to use the bathroom
4) Possessions: validate the patient’s belongings are within reach
5) Pump: check the IV bag; if it will empty before the next hourly round, replace the bag now to prevent
beeping of the IV pump
6) Plan of Care: review with the patient their plan of care and update the patient about any changes that
have occurred since the previous review
7) Quiet: ask the patient if it’s quiet enough for them to rest; address noise concerns as appropriate
8) Questions: Ask the patient if he/she has any questions
Caregiver
2–5
minutes
5
Assess additional comfort needs.
Caregiver
1–2
minutes
6
Conduct an environmental assessment
Caregiver
1 minute
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Close the conversation.
Tell the patient when you or a care team member will return.
Caregiver
Caregiver
20 seconds
10 seconds
Additional comfort needs may include blankets,
water, food, etc.
 Empty trash cans if they’re full
 Pick up debris from the floor
 Tidy the room
 Ensure the bedside table, phone, call bell,
tissues, personal belongings, etc. are within
the patient’s reach.
Explain to the patient what you’re documenting
and why (ie, “I want you to be informed). Narrate
the care!
Explain to the patient what you’re documenting
10
Document/update all other pertinent information on the communication board (ie, pain rating, etc.)
Caregiver
1 minute
and why (ie, “I want you to be informed). Narrate
the care!
Expected Outcome: Process Completed Hourly, Patient Feels Cared For and Understands Plan of Care, Falls Prevented, Call Lights Prevented => Patient Satisfaction
Critical Notes on Overall Process
9
N1
N2
Document/update the patient’s activities and plan of care on the communication board using the removable
magnetic tool.
Caregiver
1 minute
Intentional hourly rounding will be completed for each patient every hour between 6 am – 10 pm and every two hours between 10 pm – 6 am.
Intentional hourly rounding is completed by nurses and clin techs. Each unit must identify a process that fits into their workflow for completing hourly rounding (ie, nurses
round on even hours, clin techs round on odd hours, etc.).
How do we measure the Value?
•“Key Process Indicator” or “KPI”
•What purpose do KPIs serve?
oTo understand if we are delivering customer’s expectations
oMeasure of Performance to Target
oAlign and focus the organization’s efforts
oVisibility to trends- improvement or decline
oFocus improvement efforts -> Strategic Improvement
oUnderstand if actions are effective
•Outcomes are a product of
what you measure and check
Critical Process KPI’s
Basic premise: Any process that is Critical to meeting Customer
expectations/needs should be visible in a Daily KPI
Example:
Customer: Patient
Expectation: Keeping patients free from injury from falls
Critical Processes:
• Falls assessment
• Bed alarms
• Hourly Rounding
Daily KPI: % Always Quality
Medical Unit Service
Daily Run the Business
Daily KPI
Performance
Daily Defect Tracker
for Critical Processes
•Hourly Rounding
•Falls Assessment
•Bed Alarms
Q
A3 Problem
Solving
A3 Elements
1.
Problem Statement
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Impact to
Customer
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Measurable
2.
Problem Solving Team
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Staff Champions
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Cross-functional
3. Problem Analysis
A. Pareto of Causes
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Data or Barrier
Analysis
B. Root Cause Analysis
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5 Why’s
4. Hypothesis
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If we do ___ we
will achieve ___
improvement.
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Tied Directly to
Problem Statement
5.
Action
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1-2 Actions to remove
Root Cause
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Active Small Test of
Change – PDSA
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KPI to measure
Action- are we doing
it?
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If no Standard Work,
start with Standard
Work as Action
6. Verification
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Test Cause and Effect
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Are we doing
Action
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Is it making an
impact on the
results
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Tied to Problem
Statement
Now Back to Harm
What is Harm?
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Criteria used for inclusion:
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Confident in data integrity due to multiple verification processes
Familiarity with data set and previously reported
Well defined and readily available
After several versions, we settled on the following harm definition:
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5 Condition Medicare Readmissions
NQF Serious Reportable events
PSI 90
HAIs (CAUTI, CLABSI, C Diff, MRSA, Colon and Abd Hyst SSI)
Falls with Injury
Driving to Zero
• Driving to Zero Harm means:
• We had to think in terms of raw numbers.
• Rates did not give us the real story
• We had to identify our top harm opportunities and the departments
that could influence those opportunities
• We had to identify and influence the daily processes
• We had to engage the front line staff and make it real for them
Setting the Priorities for All IFOH
Departments
• Driving to Zero Harm means:
• Top Opportunities:
• Readmissions (specifically CHF
and Total Joint)
• C Diff
• Falls with Injury
• Strategic A3s developed and progress
reported weekly with barriers identified,
progress made, selection of real time
KPIs and verification with lagging
indicators
• All departments have a hand washing
KPI requirement
Strategic Priorities
Problem Statement: Perinatal Harm events (PSI 17 Birth trauma, PSI 18 OB trauma
with instrumentation, PSI 19 – Birth trauma without instrumentation)
measurement has consistently been above targeted benchmarks. Data shows that
our biggest opportunity Is with PSI 18 and19. Our current processes need to
change to decrease maternal and infant harm during the birth process
Perinatal Harm Action Plan As
of 10/21/2015
What
When
Targets:
PSI 17=0.0
PSI 18=59.14.
PSI 19=10.64
Perinatal Safety and Peer Review committee review of
PSI data for 2015 Year to Date. No practitioner trends
at this time
July Perinatal
Safety
Committee
meeting
Perinatal Safety
Committee
Completed
Recommendation made and approved in OB care for
mandated Safe Passages training for Nursing Staff and
OB Medical Staff. Dr. Rosen taking recommendation to
System OB Medical Directors Group August 6.
August OB
Care
Committee
Cheri Goll,
OB GYN Chair
In progress
Purchase “Peanut Balls” as aids for positioning
patients in2nd stage of labor.
Jenn Stroud/
Barbara Markel
Completed
In-services and education for L&D nurses on managing
2nd stage, positioning and perineal techniques to
reduce lacerations. (CNM and Doula)
Jenn Stroud/
Barbara Markel
In Progress
Oxytocin case review in progress
Perinatal Safety
Committee
In Progress
Jennifer
McCaughey
On going
Actual:
PSI 17=1.69
PSI 18=190.48
PSI 19=13.04
Gap:
PSI 17=1.69
PSI 18=131.34
PSI 19=2.4
Data reviewed daily for PSI 17,18 & 19
Problem Owner: Dr. Lynch, Dr.
Pickford
Problem-Solving Team: Members of
Perinatal Safety and Peer Review
Committee and OB Care
Hypothesis: Mandated Safe Passages course will decrease the number
of PSI 18 and 19 patient harm events and may reduce PSI 17 (birth
trauma)
Verification: Course Completion ,Monthly Perinatal PSI rates and case review.
Develop concurrent tracking methods (ie Safety Always)
Since January
2015
Who
%
Comp.
Data through June 2015
2014
Result
2015
Goal
Birth Trauma injury to Neonate PSI-17
0.52
0.00
OB Trauma Vaginal Delivery with
Instrumentation - PSI-18
134.97
OB Trauma Vaginal Delivery
without Instrumentation - PSI-19
14.38
Measures
2015
Q1
2015
Q2
2015
Q3
2015
Q4
2015
YTD
0.00
1.69
0.86
59.14
157.89
190.48
175.00
10.64
19.54
13.04
16.36
What the units are measuring…
Falls:
Lagging: Falls with injury
KPIs: Bed alarms on, hourly rounding
Readmissions:
Lagging: Number of Medicare 5 condition
readmissions
KPIs: CM assessment within 24 hours
Home health referral with LACE > 10, Hospitalist MDRs
with CM, Use of STOPLIGHT tool for HF patients,
Pharmacist medication education on HF patients
Infections:
Lagging: Number of infections, hand hygiene
compliance
KPIs: Hand hygiene compliance, CLABSI bundle
compliance, CHG baths, number of foleys, foley bundle
compliance
Harm Events
37
Lessons Learned
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Readmissions, while important to track as defects, are not necessarily a
good indicator of harm
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The issue is multifactorial and involves our outpatient partners
• Our data indicates that readmissions occur at 13 – 15 days post discharge
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Unit specific lagging indicators are needed to help demonstrate the
impact that the daily KPIs are having
OB Harm events (PSI 17 – 19) were not included and need to be.
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Many contributing factors related to readmissions are outside the control of
the hospital.
IFOH focus for 2015 involved improving patient education, especially on
medications and for CHF patients
A3 has now been developed and concurrent review of cases and data has
begun.
Priorities changed. The Quality Status A3 is now tracking 8 different
A3s and associated KPIs vs the 3 we started with in January.
Harm Avoidance Measures: 2016
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PSI-90
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Hospital Acquired Infections
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NEW
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Pressure Ulcer
Iatrogenic Pneumothorax
CLABSI
Postop Hip Fracture
Postop PE or DVT
Postop Sepsis
Postop Wound Dehiscience
Accidental Puncture or Laceration
CAUTI
CLABSI
C Diff
MRSA
Surgical Site Infections
Falls with Injury
OB Harm
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Early Elective Delivery
PSI 18 & 19: OB Trauma Vaginal Delivery with and without instrumentation
Final Thought…..
“The names of the patients whose lives we save can never be known.
Our contribution will be what did not happen to them. And, though they
are unknown, we will know that mothers and fathers are at graduations
and weddings they would have missed and that grandchildren
will know grandparents they might never have known, and holidays
will be taken, and work completed, and books read, and symphonies heard,
and gardens tended that, without our work, would never have been.”
-Donald M. Berwick, MD, MPP, Former President and CEO, IHI