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): (direct number, no code needed) To join the online webinar, go to: Online Access Password: Webinar1 (case-sensitive)

2 Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program Safe Practices Webinar August 25, 2009 Welcome and Review of Specifications for Safe Practice 1, Leadership Structures and Systems Toll-free Call-in number:

3 Panelists Charles Denham 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 (Featured Speaker) Peter Angood: National Perspective on Leadership Issues and Closing Remarks Peter Angood Hayley BurgessBill GeorgeJennifer Dingman

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6 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 Toll-free Call-in number:

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NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness Toll-free Call-in number:

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10 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 Changes of 2006 Version to 2009 Update

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12 Harmonization – The Quality Choir Toll-free Call-in number:

13 The Patient – Our Conductor Toll-free Call-in number:

14 Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices Consent & Disclosure Culture Workforce Consent and Disclosure Toll-free Call-in number:

15 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 Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition-, Site-, and Risk-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy VAP Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge System Patient Care Info. Labeling Studies Culture Meas., FB., and Interv. Structures and Systems ID and Mitigation Risk and Hazards Team Training and Team Interv. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care 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 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 CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging 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 Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Informed Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure 2009 NQF Report Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control New Material Changes No Material Changes Legend: Pediatric Imaging

16 LEADERSHIP STRUCTURES and SYSTEMS Values Systems Structures Behaviors Outcomes Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Identification and Mitigation of Risks and Hazards Leadership Structures and Systems Patients and Community NQF 34 Safe Practices

17 AwarenessAccountabilityAbilityAction 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. Toll-free Call-in number:

18 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 AwarenessAccountabilityAbilityAction Toll-free Call-in number:

19 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 AwarenessAccountabilityAbilityAction Toll-free Call-in number:

20 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 AwarenessAccountabilityAbilityAction Toll-free Call-in number:

21 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 AwarenessAccountabilityAbilityAction Toll-free Call-in number:

22 Review of Specifications for Safe Practice 18, Pharmacist Leadership Structures and Systems Hayley Burgess, PharmD, BCPP Director, Performance Improvement Measures, Standards, and Practices TMIT Safe Practices Webinar August 25, 2009 Toll-free Call-in number:

23 Cornish PL, et al. Arch Intern Med. 2005;165: Bates D, et al. Massachusetts Technology Collaborative Feb. Forster AJ, et al. Ann Intern Med. 2003;138: 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.

24 Reasons for Pharmacy Leaders to be Quality Focused Toll-free Call-in number: ) 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

25 Standards and Measures Relating to Medication Use Toll-free Call-in number:

26 Standards and Measures Relating to Medication Use NQF Endorsed Measures 34 Safe Practices 28 Serious Reportable Events IOM 20 Priority Areas; Preventing Med. Errors and Overuse of Antibiotics AHRQ 32 Quality Indicators 27 Patient Safety Indicators view.htm view.htm CMS Core Measures 27 HCAHPS Joint Commission National Patient Safety Goals Med. Management Standards NationalPatientSafetyGoals/09_hap_npsgs.htm Leapfrog Leaps Survey, CPOE Simulator NPP National Priority Partnership

27 NQF Safe Practices Specifically Related to Medication Process or Use Safe Practice 12Communication of Patient Care Information Safe Practice 13Order Read-back and Abbreviations Safe Practice 15Discharge Systems Safe Practice 16Safe Adoption of Computerized Prescriber Order Entry Safe Practice 17Medication Reconciliation Safe Practice 18Pharmacist Leadership Structures/Systems (Includes SPs 1-4 framework) Safe Practice 20Influenza Prevention Safe Practice 22Surgical-Site Infection Prevention Safe Practice 23Care of the Ventilated Patient Safe Practice 24Multidrug-Resistant Organism Prevention Safe Practice 28Venous Thromboembolism (VTE) Safe Practice 29Anticoagulation Therapy Safe Practice 30Contrast Media-Induced Renal Failure Prevention Safe Practice 32Glycemic Control Safe Practice 33Falls Prevention 15/34 Safe Practices

28 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—Infection25 of 28 SCIP—Cardiac1 of 1 SCIP—VTE2 of 2 Pregnancy and Related Conditions (PRC)0 of 3 Children’s Asthma Care (CAC)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, Imaging4 of 11 CMS Outcome Measures (Claims-Based) 30-day Mortality for AMI, HF, PN; 30-day Readmission AMI, HF, PNimmeasurable 66 of 98 Core Measures

29 Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' Perception of Hospital Care in the United States. NEJM Oct;339(18): 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

30 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? Toll-free Call-in number:

31 (“Hospitals–Inpatient” →”Specifications Manual” →”Version 3.0b” →”Alphabetical Data Dictionary” → then review sections related to various medication contraindications 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 Toll-free Call-in number:

32 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. Care Coordination Overuse This priority focuses on eliminating overuse while ensuring the delivery of appropriate care. Overuse Palliative and End-of-Life Care This priority focuses on guaranteeing appropriate and compassionate care for patients with life-limiting illnesses. Palliative and End-of-Life Care Patient and Family Engagement This priority focuses on engaging patients and families in managing their health and making decisions about their care. Patient and Family Engagement Population Health This priority focuses on improving the health of the overall population. Population Health Safety This priority focuses on improving the safety and reliability of America’s healthcare system. Safety

33 Safe Practice 18 Pharmacy Leadership Structures and Systems [Combined 2006 SPs ] Toll-free Call-in number:

34 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. Toll-free Call-in number:

35 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. Toll-free Call-in number:

36 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. Toll-free Call-in number:

37 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 to senior leadership

38 Additional Specifications: Leadership Structures and Systems Sections Selection and Procurement Storage Ordering and Transcribing Preparing and Dispensing Medication Administration Monitoring High Alert Medications Evaluation

39 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. Toll-free Call-in number:

40 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! Toll-free Call-in number:

41 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 “) asp 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. Toll-free Call-in number:

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43 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 Toll-free Call-in number:

44 Overview of “7 LESSONS” Lessons 1-4 Q & A Lessons 5-7 Q & A Conclusion Agenda Toll-free Call-in number:

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46 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” 7 Lessons for Leading in Crisis Toll-free Call-in number:

47 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 Global Economic Crisis of Toll-free Call-in number:

48 #1Face reality, starting with yourself #2Don’t be Atlas: get the world off your shoulders #3Dig deep for the root cause #4Get ready for the long haul #5Never waste a good crisis #6You’re in the spotlight: follow True North #7Go on offense: focus on winning now The 7 Lessons Toll-free Call-in number:

49 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 Lesson #1: Face Reality, Starting with Yourself Toll-free Call-in number:

50 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 Lesson #2: Don’t Be Atlas – Get World off your Shoulders Toll-free Call-in number:

51 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 Lesson #3: Dig Deep for Root Cause Toll-free Call-in number:

52 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 Lesson #4: Get Ready for Long Haul Toll-free Call-in number:

53 Pharmacy and Nursing Leadership Issues General Administrative Issues Q & A Toll-free Call-in number:

54 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 Lesson #5: Never Waste a Good Crisis Toll-free Call-in number:

55 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 Lesson #6: You’re in the Spotlight: Follow True North Toll-free Call-in number:

56 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 Lesson #7: Go on Offense, Focus on Winning Now Toll-free Call-in number:

57 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 7 Steps to Focus on Winning Toll-free Call-in number:

58 Pharmacy and Nursing Leadership Issues General Administrative Issues Q & A Toll-free Call-in number:

59 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 Conclusion

60 More Information on 7 LESSONS. Go to To purchase 7 Lessons, go to: To receive your free copy of Study Guide to 7 Lessons,

61 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

62 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

63 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)