1. Making Indiana the Safest State: The Challenge and the Opportunity
Betsy Lee, RN, BSN, MSPH
InAHQ Spring Conference
May 9, 2014

2. Conflicts of Interest Disclosures
The speaker has nothing to disclose.

3. Session Objectives
Discuss the status of statewide patient safety improvement in Indiana compared to national benchmarks
 Evaluate potential impact of the Partnership for Patients initiative on patient safety at the local level
 Outline leadership strategies for engaging front line staff in addressing harm across the board

4. Indiana’s Bold Aim
To make Indiana the safest place to receive health care in the United States, if not the world
Inaugural Indiana Patient Safety Summit - March 2010

5. The Challenge: Indiana Performance
How will we know we are the safest state?
Challenge to find comparative data for many safety measures
No publicly available comparative data for ADE’s, Falls, Pressure Ulcers, VTE, VAP, birth-related injuries, early elective deliveries
Infections: CDC HAI Progress report
Nationally, CLABSI dropped 44% from 2008 to 2012
The reduction in Indiana was only 34%
CLABSI SIR increased from 2011 to 2012

6. Indiana 2012 Healthcare Acquired Infections
Comment
Indiana SIR
Nat’l SIR
CLABSI – 102 hospitals
Indiana’s 2012 state CLABSI SIR is significantly
worse than the 2012 national SIR.
0.66
0.56
CAUTI – 104 hospitals
Indiana’s 2012 state CAUTI SIR is similar to the
2012 national SIR.
1.05
1.03
SSI – Colon – 105 hospitals
Indiana’s 2012 state Colon Surgery SSI SIR is significantly worse than the 2012 national SIR.
1.04
0.80
SSI – Abdominal Hysterectomy – 98 hospitals
Indiana’s 2012 state Abdominal Hysterectomy SSI SIR is significantly better than the 2012 national SIR.
0.52
0.89
Source: National and State Healthcare Acquired Infections: Progress Report
Centers for Disease Control and Prevention, March 2014

7. Sepsis Mortality Reductions are Promising
Began sharing
coalition reports

8. Heart Failure 30 Day Readmission Rate
23.79%
Heart Failure 30 day Readmissions
Rank
State
Rate 1 UT
23.11% 27 TX
24.57% 2 OR
23.38% 28 AL
24.68% 3 HI
23.45% 29 AZ
24.73% 4 CO
23.56% KS 5 ID
23.60% 31 MO
24.74% 6 WI
23.63% 32 OH
24.80% 7 DE
23.73% 33 CT
24.81% 8 VT
23.75% 34 VA
24.82% 9 NH
23.79% 35 FL
24.98% 10 MT
23.87% PA 11 IA
23.92% 37 OK
25.05% 12 ND
23.98% 38 MA
25.17% 13 NM
24.05% 39 TN
25.20% 14 WA
24.07% NV 15 IN
24.09% 41 WV
25.31% 16 ME
24.17% 42 IL
25.37% 17 AK
24.23% 43 LA
25.60% 18 WY
24.30% 44 KY
25.61% 19 NC
24.33% 45 RI
25.77% 20 SC
24.43% 46 MS
25.80% MI 47 AR
25.91% 22 GA
24.46% 48 MD
25.99% 23 MN
24.47% 49 NY
26.08% 24 NE
24.50% 50 DC
26.21% 25 SD
24.55% 51 NJ
26.50% CA
18.91%
23.75%
24.17%
23.87%
23.98%
24.47%
23.38%
25.17%
23.60%
23.63%
24.55%
24.30%
25.77%
24.43%
26.08%
25.20%
23.92%
19.67%
24.81%
24.50%
24.80%
23.11%
25.37%
24.09%
25.31%
26.50%
23.56%
24.55%
24.73%
24.82%
24.74%
25.61%
23.73%
24.33%
24.73%
25.05%
25.20%
25.99%
24.09%
25.91%
24.43%
26.21%
Performance Period – CY 2012
25.80%
24.46%
24.57%
24.68%
25.60%
24.98%
24.23%
23.45%
Source: Hospital Compare Release manipulated by WhyNotTheBest.org, , Measure Start – End Dates:7/1/08- 6/30/11

9. Partnership for Patients Aims
40% Reduction in Preventable Hospital Acquired Conditions
1.8 Million Fewer Injuries
60,000 Lives Saved
20% Reduction in 30-Day Readmissions
1.6 Million Patients Recover Without Readmission
Projection: up to $35 Billion dollars will be saved

10. Impact of Partnership for Patients
Large scale funded national initiative
Aims aligned with Indiana priorities
Takes statewide and regional improvement efforts to scale
Encourages local adaptation with the discipline of organized effort and measurement

12. AHA/HRET Hospital Engagement Network
34 states / 1,622 hospitals 12

13. Coalition for Care

14. Partnership for Patients

15. National HEN Targeted Harm Categories
Adverse drug events
Birth-related injuries
Elimination of Early Elective Deliveries
Central line-associated blood stream infections
Catheter-acquired urinary tract infections
Falls with injury
Surgical infections and complications
Venous thromboembolism
Pressure ulcers
Readmissions
Ventilator-associated pneumonia
Here are the ambitious aims and here are the 10 focus areas…

16. Additional Priorities
Leadership Systems
Culture of Safety
Teamwork and Communications
Lean Training
Innovation and Transformation
Preventing Harm Across the Board
Health Care Disparities

17. Expansion to other topics:
2014 CMS Topic Expansion
Expansion to other topics:
Sepsis
MRSA
Acute Renal Failure
- Clostridium difficile
Procedural Harm

18. How Might We Achieve Our Aim?
Focus on initiatives to improve all eleven Partnership for Patients topics
Emphasize measurement, data submission and transparency
Statewide alignment and energy
Engage front-line teams in patient safety efforts
Embrace personal and collective nature of change

19. National Content Development
Change packages for all 10 topic areas are now available at
National HRET conference calls and webinars to share evidence-based practice solutions
National CMS calls sharing ideas for change from hospitals around the country
Indiana learning opportunities for many topics

20. HRET HEN Resources

21. HRET/HPOE Resources

22. Education and Technical Assistance
Improvement Leader Fellowship (HRET)
National Collaborative (HRET HEN Week)
National and Indiana webinars
Regional “Roadshows”
Indiana Patient Safety Summits
IHA Annual Meetings
Lean Six Sigma training Medication Safety Essentials courses (MSE 1.0 and advanced course MSE 2.0) - on-line, on-demand continuing education
Readmissions computerized simulation model
Communities of practice
Site visits and coaching

23. Special Focus: Adverse Drug Events
Significance:
About 1/3 of all hospital adverse events are related to ADEs
LOS is prolonged by days
ADEs affect 1.9 million hospital stays annually
Cost $4.2 billion annually
Responsible for about 100,000 emergent hospitalizations in older Americans, annually4
2/3 result from just four medication classes:
Warfarin, insulin, oral hypoglycemics, and oral antiplatelet agents
2/3 result from unintentional overdoses
1. Classen DC et al. Health Aff (Millwood) 2011;30:581–9.
2. Agency for Healthcare Research and Quality, Rockville, MD, April. HCUP Statistical Brief #109.
3. Classen DC et al. JAMA 997;277:301–6. Bates DW et al. JAMA 1997;277:307–11.
4. Budnitz, DS et al. N Engl J Med 2011:365:

24. ADE Resources

25. Elimination of EED
Policy
Scheduling Form
Consent

26. CMS: Four Calls to Action
Reduce harm across the board. It is a call for hospitals to produce reductions in every type of harm.
Take a systemic approach. It is a call to transform the organization and its practices to eliminate all the causes of harm. “Using every means at our disposal.”
Make your safety transparent to all. It is a call for hospitals to define themselves by their safety performance; define themselves to their employees, doctors, patients and the community.
Make safety personal & compelling. Make every incident of harm a personal patient story that propels the institution to higher levels of performance.

27. Harm Across the Board (HAB):
Monthly Update
Hospital: ________________ State: ______ Month: _________

28. Eleven regional safety coalitions
Members agree not to compete on patient safety
Layered model of regional coalitions and affinity groups supports transformation, learning and spread
Benefits:
Innovate at the front lines
Align with state and national efforts, and standardize when beneficial
Builds local and hospital-specific capacity for improvement and innovation
Encourages safety leadership at all levels across multiple professions

29. Why Regional Efforts Are Important
Focus on improving patient safety and decreasing harm
Identify patient safety issues through data/events
Transparency
Share expertise, resources, and tools
Develop solutions in coalition and collaborative learning
We do not compete on patient safety

30. Leadership and Culture
Staff Engagement
Quality
Improvement on Harm Reduction
Patient/Family Engagement
Regional Patient Safety Coalitions: Scope and Focus
Not Competing on Safety
Culture of Learning
Trusting Relationships
Transparency
Joy in Work, Give
it Meaning, Make it Personal, Board Engagement
Skilled workforce – technical/safety competencies; coaching
Safest
State in
the Nation
Patients and families involved in improving care and reducing harm

32. Regional Coalition Transparency
Hospital Name
ADE
VTE
Pressure Ulcers
EED OB
Falls
VAP
CAUTI
CLABSI
SSI
Readmissions
ABC Hospital 2 4 3 5
General Hospital 1
St. Elsewhere Health System
County Health
Memorial Hospital
Critical Access Hospital Z Z
Hospital does not provide services related to this HAC 3
Demonstrating outstanding improvement
Not engaged in work related to HAC 4
Demonstrating sustained high performance or a national benchmark 1
Engaged in work related to HAC, but not submitting data 5
Potential Mentor Hospital 2
Engaged in work related to HAC and submitting data

33. Partnership for Patients

34. Published in February 2013 Issue of Health Affairs
What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs
Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores’
Enhanced Support for Shared Decision-Making Reduced Costs of Care for Patients with Preference-Sensitive Conditions
Survey Shows That Fewer Than a Third of Patient-Centered Medical Home Practices Engage Patients in Quality Improvement

35. Patient Engagement and Adverse Events
“[T]here was an inverse relationship between [patient] participation [in their care] and adverse events [P]atients with high participation were half as likely to have at least one adverse event during the admission. ”
Source: Weingart SN et al., Hospitalized patients’ participation and its impact on quality of care and patient safety, International Journal for Quality in Health Care 2011; 1-9.

36. Partnership for Patients

37. HSOPS: Agency for Healthcare Research and Quality

38. Indiana HSOPS Results

39. Key Elements of Enhancing Cultures
Teamwork and communication
Leadership engagement in safety strategies
High reliability principles
Eliminating fear
Effective handovers and transitions

40. AHRQ Culture of Safety Survey
Of the 12 dimensions of culture measured in the Hospital Survey on Patient Safety, Handoffs and Transitions has the lowest average percent positive
Subscale questions measure these perceptions:
Things “fall between the cracks”
Important information is lost at the change of shifts
Problems occur with the exchange of information across hospital units
Shift changes are problematic for patients

41. What are hand-offs/handovers?
“The process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver.”
Patterson & Wears, 2010

42. Characteristics of Effective Handovers
Face-to-face, verbal, and interactive
Providers come together and stay in a “zone of readiness and attention” during information sharing
Limit interruptions
Limit initiation of actions
Not just about information exchange, but some type of written, structured tool is employed
Includes time for anticipation and foresight
Receiver does read-back to verify content
Good teamwork as foundation

43. Handover Components Introduction and brief patient history
Overview of current situation
Safety concerns or potential problems
Plan (what’s next?)
Anticipation, reflection, and foresight (what might go wrong?) - provide context
Questions and verification

44. Example: DRAW Diagnosis Recent Changes Anticipated Changes
What to Watch For
Source: Seton Southwest Hospital, Austin, TX

45. Evolution of Culture
Prof. Patrick Hudson, Leiden University, the Netherlands (From Shell E & P)

46. Managing the Unexpected (Weick & Sutcliffe)
“Mindfulness”:
Ability to see the significance of early and weak signals and to take strong decisive action to prevent harm
“Sensemaking”:
Process of transforming experiences into updated views of the system by “taking the time to make sense out of new and changing circumstances”
“Trust is a product of sensemaking.” – J. Morath

47. Tools for Sensemaking (Weick and Battles)
Literally “making sense of events”
Building a systems understanding to eliminate and mitigate risks to patients
True sensemaking is reactive and proactive
Focus of learning organizations – systematically increasing reliability
Provides data-driven framework for sensemaking through tools and joint reflection
Importance of staff engagement and curiosity

48. Characteristics of Mindfulness in High Reliability Organizations (Weick & Sutcliffe)
Preoccupation with failure
Reluctance to simplify interpretations
Sensitivity to operations
Commitment to resilience
Deference to expertise

49. Mindfulness (Weick & Sutcliffe)
“Struggle for alertness”
Trouble starts small and is signaled by weak symptoms that are easy to miss
Small discrepancies can accumulate, enlarge and have disproportionately large consequences

50. Engaging Front-Line Staff in Safety
Focus on the systems of care and on redesigning work processes
Must involve “sharp end” caregivers
Education and training alone will not work – requires increased “mindfulness”
Cultural change requires strong leadership
Must improve reliability through new approaches

51. Leadership for Results
Leverage energy and effort at the front line
Regionalize technical assistance and education
Align measures to mark progress
Concentrate on 11 topic areas
Build capabilities for future challenges
Focus on patients and families
Make it personal

52. Engaging Front Line Teams

53. The Leadership Challenge
Model the Way
Inspire a Shared Vision
Challenge the Process
Enable Others to Act
Encourage the Heart
The Leadership Challenge
Kouzes and Posner, 2002
Paul O’Neil’s quote

54. Contact
Betsy Lee, RN, BSN, MSPH Director, Indiana Patient Safety Center Indiana Hospital Association (317)