High 5s NewsBulletin. News in Brief

Transcription

1 News in Brief High 5s NewsBulletin Two new countries as observers: The Steering Group meeting in Berlin saw the participation of two new countries. Ms Ingrid Allan from the Ministry of Health, Trinidad and Tobago and Ms Ros Gray from the Scottish Patient Safety Programme, attended the meeting to hear 'first hand' the experiences from the implementation of the protocols in hospitals. Trilogy of High 5s papers: A High 5s core publications group lead by WHO is developing three papers for publication in peer review journals. The first paper focusing on the innovative aspects of High5s is now complete and will be submitted to the WHO Bulletin. The other two papers are currently being written and will focus on: the implementation of the Standard Operating Protocols; and the High 5s Evaluation Framework. Steering Group meeting links with ISQua: The next 2011 Steering Group meeting will take place in Hong Kong September Netherlands High 5 s: an abstract on Medication Reconciliation in 11 Dutch hospitals was presented at the Amsterdam IHI meeting in April 2011.The presentation focused on the reduction of medication discrepancies of more than 75% in 6 of the 11 hospitals after 1-5 months SOP implementation in This SOP is now spreading hospital-wide to all transitions in care. For more information: Erica van der Schrieck-de Loos, High 5 s project leader, CBO, a TNO company, the Netherlands, e.vanderschrieck@cbo.nl & Chief of Australian LTA: Professor Chris Baggoley, Chief Executive, Australian Commission on Safety and Quality in Health Care has become Chief Medical Officer of Australia until autumn NO 1, JULY th Semi-annual Steering Group Meeting hosted by the German Federal Ministry of Health & Germany Agency for Quality in Medicine in Berlin By Laura Caisley The biannual Steering Group meeting was held on April 2011at KBV Headquarters (National Association of Statutory Health Insurance Physicians) in Berlin hosted by the German Federal Ministry of Health and the German Agency for Quality in Medicine. 35 individuals from 9 countries, WHO, and the Collaborating Centre participated. Lead Technical Agencies shared SOP implementation experiences and openly discussed lessons learned, opportunities, and challenges during the Steering Group meeting and in SOP-specific breakout sessions. At the end of day one, participants enjoyed a reception hosted by the German Federal Ministry of Health and German Agency for Quality in Medicine at the restaurant located on the Roof of the Bundestag (Reichstag-Building). The evening included a private tour of the German Parliament building and was one of the highlights of a very productive meeting. The next Steering Group meeting will be held in Hong Kong on 12-13/9 prior to the ISQua Conference. This will be the first meeting held in the Pacific region. A summary report of the High5s Steering Group meeting is available at Outcomes from Berlin meeting Evaluation: a) LTAs granted access to de-identified hospital data to the Collaborating Centre to ensure data quality and generate aggregate reports; b) SOP implementation experience data to be collected, reviewed and approved by the LTA, then aggregated by the Collaborating Centre every 6 months. Learning communities: a) plan webinars 4-6 week ahead; b) use additional learning strategies, e.g. LTAs offer visits to hospitals; c) have discussion forums with experts on the Wiki ; d) post footage and films on med safety and safe surgery on the Wiki. Publications: a) Innovation paper to be re-circulated with the Guide for authorship and minutes of Geneva meeting; b) French and Australian LTAs suggested a culture survey paper. Communications proposed the initiation of a NewsBulletin to be issued quarterly. Concentrated Injectables Lead: Germany and Singapore LTAs proposed they could take the lead of this protocol. Netherlands LTA to explore this through the Ministry of Health. 1

2 Host Country Reporting: High 5s implementation in German hospitals By the Agency for Quality in Medicine (AQuMed/ÄZQ) and the German Coalition for Patient Safety. The High 5s Lead Technical Agency for Germany is a collaboration of two organisations dedicated to improving patient safety in the German health care system: the Agency for Quality in Medicine (AQuMed/ÄZQ) and the German Coalition for Patient Safety. In 2009 the Federal Ministry of Health, which has been funding High 5s in Germany since December 2007, mandated these two organisations to execute the High 5s Project together. AQuMed is responsible for overall coordination of the project and implementation of the High 5s SOPs. AQuMed is a non-profit physicians organization based in Berlin. Besides the coordination of patient safety and error prevention measures, AQumed s other major foci are the promotion of the methods of evidence-based medicine and the appraisal and development of clinical practice guidelines, quality indicators and patient information. The German Coalition for Patient Safety is responsible for evaluation activities in the High 5s Project in Germany. The Coalition is a national non-profit expert association for patient safety which includes multiple inter-professional working groups. In January 2009, it established the first research institute in Germany which deals exclusively with patient safety issues the Institute for Patient Safety (IfPS) at the University of Bonn. The IfPS is now conducting the High 5s evaluation activities on behalf of the Coalition. In Germany, the three finalized SOPs are being implemented successively. Correct Site Surgery: The first High 5s SOP to be implemented in German hospitals was Correct Site Surgery. From the end of 2009 to mid-2010, 17 hospitals from across the country were recruited and trained for this SOP. To date, 16 of 17 hospitals have implemented the SOP and the accompanying surgical checklist. Implementation was facilitated byan intense local tailoring process, whereby AQuMed and IfPS worked with hospitals on an individual basis to develop hospital-individualized checklists. Each checklist integrates the mandatory SOP items needed to assure standardization of implementation and data collection, in addition to further items and the format desired by the hospital. Feedback has generally been positive: High 5s hospital coordinators report good acceptance of the checklist by frontline staff, more clarity regarding responsibilities as well as good catches brought to light by the SOP. Allgemeines Krankenhaus Celle Altmark Klinikum Gardelegen Altmark Klinikum Salzwedel Evangelische Elisabeth Klinik, Berlin Evangelische Lungenklinik Berlin Evangelisches Krankenhaus Paul Gerhardt Stift, Lutherstadt Wittenberg Evangelisches Krankenhaus Hubertus, Berlin Evangelisches Waldkrankenhaus Spandau, Berlin Herzogin Elisabeth Hospital, Braunschweig Klinikum Chemnitz Klinikum Coburg Krankenhaus Sinsheim Krankenhaus St. Joseph Stift, Dresden Martin Luther Krankenhaus, Berlin Städtisches Klinikum Solingen Universitätsklinikum Aachen Universitätsklinikum Freiburg The checklists are provided to the hospitals as carbon copies. After the checklists have been completed, the original checklist with the patient data remains in the patient chart and a blinded carbon copy is sent to IfPS. There all copies are scanned and the read out data for the High 5s SOP measures as well as for additional analyses is aggregated automatically. This complex data model was developed in order to relieve hospitals of the additional burden of data aggregation. All 16 hospitals who have implemented the SOP are now regularly sending their data to IfPS. Currently the data algorithms are being programmed and the regular feedback mechanism to the participating hospitals regarding the High 5s SOP measures and data quality analyses will begin shortly. Additional next steps in the context of Correct Site Surgery Protocol implementation include site visits with interviews and the administration of the High 5s implementation experience questionnaire. A German translation of these materials will be finalized in the next weeks. Medication Reconciliation: The second SOP to be implemented in Germany is Medication Reconciliation. This SOP and Getting Started Kit have been translated into German and additional materials such as a short version of the SOP are being produced.

3 The LTA team has been discussing the SOP and nationally tailored implementation strategies and is engaged in a learning exchange with the other High 5s countries implementing Med Rec. At a Sept workshop this SOP and its evaluation framework will be presented to interested hospitals. Recruitment and implementation are to start in the 4th quarter of Other activities: Other High 5s activities have included a two-day training session in Event Analysis methodology for the Correct Site Surgery hospitals in November In addition, the AHRQ Patient Safety Culture Survey was conducted in five hospitals in the summer and fall of A second administration of the Patient Safety Culture Survey in these hospitals is planned for the fall of Another highlight has been hosting the High 5s Steering Group Meeting in Berlin in April Directly after the Steering Group Meeting, a site visit to our High 5s hospital Evangelische Lungenklinik on the outskirts of Berlin was conducted with Steering Group members from Singapore and the USA. Highlights from the Netherlands By Erica van der Schrieck- de Loos and Annemieke van Groenestijn, LTA/High 5's team On 14 & 15 April 2011 site visits were organized to High 5 s hospitals in the Netherlands by the Dutch LTA, which took Steering Group members from Australia, Singapore, USA, Germany and France to two of the 11 participating High 5 s hospitals by minibus. reduced the mean number of unintentional medication discrepancies per patient with 90%. They reduced the percent of patients with at least one unintentional discrepancy with an average of 80%. These results were the reason for the site visits of Steering Group members to the Dutch hospitals. On April 14 and April they visited 2 Dutch High 5's hospitals: the Franciscus Hospital in Roosendaal (southern part) and Antonius Hospital in Sneek (northern part) and Emmeloord. They could see how these hospitals spread the SOP Medication Reconciliation to all transitions in care: emergency and elective admissions, internal transfers and discharges. Thanks to the hospital pharmacists Anneke Groenhuijzen, Joris Arts and Irene Oldenkamp who proudly shared their High 5's experience to the other countries. Due to the great results of the first group of Dutch 11 hospitals a second group of 2 hospitals will start preparing on the implementation of the SOP Medication Reconciliation in June The implementation process and the (inter)national sharing of the High 5 s experiences is lead by the CBO (a TNO company) in the Netherlands. For more information please contact the Dutch LTA: Erica van der Schrieck-de Loos, senior consultant CBO/ project leader High 5 s team the Netherlands, e.vanderschrieck@cbo.nl & Annemieke van Groenestijn MSc, consultant CBO/High 5 s team the Netherlands. CBO (a TNO company) High 5s in Australian hospitals The Netherlands are participating in the WHO High 5 s project and are implementing the Medication Reconciliation SOP. Eleven hospitals implemented within one year this SOP. The project is related to the Dutch guideline medication reconciliation and the Dutch national patient safety programme for the medication safety theme. All hospitals are evaluating the Med. Re. SOP, its implementation process and reduction of medication discrepancies by a worldwide quantitative and qualitative data collection tools. The 11 Dutch hospitals, supported by the Ministry of Health, started implementation of the SOP Medication Reconciliation at the same time (July 2010). Six of the 11 hospitals received their goal in January 2011: at least 50% reduction of medication discrepancies. They By Helen Stark and Margaret Duguid, Australian Commission on Safety and Quality in Health Care Fifteen health services from five Australian states are participating in the High 5s Medication Reconciliation Project which is being led by the Australian Commission on Safety and Quality in Health Care (the Commission). Hospitals involved in the project include large, tertiary referral public hospitals, metropolitan hospitals, rural hospitals and private hospitals. Implementation is proceeding well. So far all hospitals have completed the patient safety culture survey and all but one hospital completed the initial implementation experience survey. Most hospitals have introduced the medication reconciliation 3

4 standard operating protocol (SOP), including training staff and establishing a communication strategy and are collecting performance measurement data. The third national training workshop in May this year was well attended by High 5s Project hospital teams. Topics included: Patient Safety Culture Survey: Australia's High 5s Country Report was presented and a workshop conducted on how to interpret individual hospital survey results in the context of the SOP implementation; High 5s performance measures and data quality issues; Understanding the event analysis (EA) methodology, completing and submitting the EA MDS form. An update was also provided on the pilot being conducted in three Australian health services to identify SOP related adverse events; and Presentations from two hospitals that have strated implementation. The Commission has developed a number of educational resources based on requests from hospitals participating in the High 5s Medication Reconciliation Project. These resources have been made available to all Australian hospitals and are available for downloading from the Commission s website at : /PriorityProgram-06_MedRecon High 5s Senior Project Officer Helen Stark with MATCH UP medicines poster Some multi-media training tools for hospital staff are currently under development. The first of these provides an overview of medication reconciliation and step-by-step instructions on completing the Medication Management Plan (a national form for recording a Best Possible Medication History and reconciliation on admission). Using the MATCH UP medicines tagline and imagery these training presentations will be able to be used for self-directed learning or alternately, presented in small group training sessions. Prince of Wales Hospital Experience Multidisciplinary Med Rec The Prince of Wales Hospital, a 580 bed teaching hospital located in Sydney, is implementing a multidisciplinary approach to medication reconciliation. A core team, including doctors, nurses and pharmacists, have worked together to train all three disciplines in the new process and roll out the initiative across the hospital. Baseline data results and limited pharmacy staffing led to the decision to involve all disciplines. The Director of Clinical Services, the project s executive sponsor, helped identify stakeholders, who then recommended local champions to be involved in an ongoing role. A multidisciplinary core group was formed to ensure key people were involved from the start. Pharmacy, nursing, clinicians, clinical improvement unit, nursing education and research unit and local primary care physicians are all represented. The core group defined the responsibilities of the new process with each discipline deciding what they could do. Training of staff on the process and the use of the national reconciliation tool (the Medication Management Plan) commenced with the pharmacists. Ward pharmacists then used the resources to teach all the nurses and clinicians working on the wards. During these ward based training road shows data relevant to the area was presented including incident reports from the specific department. Training sessions were included in nursing and medical orientation programs to introduce the process to new staff. Continual ward based training occurs to ensure that doctors on rotation are aware of the process. The multidisciplinary core group continues to meet quarterly to monitor progress and to develop strategies to continue to improve the process and increase awareness of the process amongst our community groups. Uptake in clinical areas has varied between units. Major challenges include engaging clinicians, training out-of-hours staff and, sustainability of the initiative and the audit process. A sustainable education program will be required for a consistent process to be introduced hospital wide. Involving patients in medication reconciliation is an important priority and the Commission is currently developing consumer educational materials. These are being designed to increase consumers awareness of the importance of knowing about their medicines and to encourage them to bring an up-to-date medicines list when they are admitted to hospital. The High 5s Project Team at Prince of Wales Hospital 4

5 High 5s in French hospitals Finally, the Medication Reconciliation SOP team is already publishing and publicizing its accomplishments: an abstract on medication reconciliation at hospital admission and the potential clinical impacts of unintentional discrepancies, summarizing a prospective study conducted in the Internal Medicine Department of the Hôpitaux Universitaires de Strasbourg, has been submitted for presentation at the European Society of Clinical Pharmacy conference in Dublin in October By Anne Broyart and Charles Bruneau, Haute Autorité de Santé The French Health Ministry has tasked the Haute Autorité de Santé (HAS) with implementing the High 5s project in France. HAS has partnered with two organizations responsible for promoting and implementing evaluation and quality improvement in their respective regions, one based in Lorraine (EVALOR) and one based in the Rhone-Alpes region (CEPPRAL). Each of these is responsible for follow-up of the implementation and evaluation of one of the two SOPs that France is engaged in, Medication Reconciliation (EVALOR) and Correct Site Surgery (CEPPRAL). Each of these SOPs corresponds to high national priorities in France in the field of patient safety, and implementation teams for both SOPs have been hard at work over the past two years. Medication Reconciliation The nine HCOs involved in the implementation and evaluation of the Medication Reconciliation SOP are collecting baseline data; the collection and transmission of indicator data for all organizations began on July 1, 2011, starting with patients admitted to a few inpatient units, and will ultimately involve all eligible patients. All hospitals have answered the implementation experience questionnaire and teams are currently building expertise in reconciliation, with a training session in May 2010, several wellattended webinars in 2010 and 2011, and meetings of the National Committee for the Medication Reconciliation SOP (comprising all the establishments involved) in December 2010 and May Beyond the SOP itself, several sub-projects are in progress. For example: As a national objective, the hospitals have decided to assess the potential clinical impact of the non-intentional discrepancies identified by the SOP using a standardized scale (NCCMRP, National Coordinating Taxonomy for Medication Error Reporting Prevention), which was the subject of a recent EVALOR-led conference call among all nine hospitals. Soon, all hospitals will participate in a national experiment linking community pharmacies with hospital information systems. Correct Site Surgery Nine more HCOs are involved in the implementation and evaluation of the Safe Surgery SOP. After the conclusion of a pilot phase that took place between July 2010 and December 2010, the evaluation strategy was launched on January 2011; so far, this has included a survey on patient safety culture, completed by seven of the nine hospitals. Surgical site marking and quality data remain issues to be solved, and these topics have been discussed at the third national workshop in May Throughout 2010, the Safe Surgery teams busily continued in their efforts to integrate the High 5s checklist into the WHO Checklist, already required for accreditation in France; with the support of CEPPRAL, each hospital developed an individualized checklist including all mandatory SOP items, yet retaining further items and format of the hospital s choice. At present we are developing a national surgical site marking guide, which includes pictures and an FAQ in order to support the teams and harmonize practices. CEPPRAL will soon begin their second round of site visits, during which they will meet again with the teams and senior management focusing on leadership, training and communication issues. Overall, it is clear that the High 5s initiative addresses national priorities for France, and the presence and support of WHO through webinars and conference calls is motivating hospitals to greater level of participation. Cornouailles Quimper Concarneau Mont de Marsan Moutier Rozeilles Cambrésis Compiègne Paris CHU 3BLM. CHU Toulouse Joseph Ducuing Léon Bérard St Joseph St Luc St Marcellin Lyon CHU Nîmes Lunéville Bourg en Bresse Chambéry CHU Grenoble CHU Nice CHU Strasbourg 5

6 News from Evaluation By Heather Sherman, WHO Collaborating Centre for Patient Safety, The Joint Commission The first quarterly report containing data and information was presented to the Steering Group. Information on implementation experiences indicated that the main challenges to implementation are resources (both funding and time), communication, and knowledge of how existing process actually works (i.e., that what was happening in reality was not what was in the organization's policy & procedure manual). Despite these challenges, the LTAs and participating hospitals are committed to implementing their selected SOPs. LTAs and participating hospitals stressed the importance of continuously communicating the need for the SOP, the impact of the SOP, and the importance of a multidisciplinary approach to implementing the SOP. This communication, education and training must be tailored to the specific audiences. Learning Communities By Carolyn Hoffman, WHO Senior Consultant First High 5s Webinar connects Hospitals and LTAs around the world! Representatives of LTAs and Hospitals from Australia, France, Germany, Netherlands, Singapore and the United States joined speakers from the World Health Organization, The Joint Commission, and the Agency for Healthcare Research & Quality for an important virtual learning event on March 31st. Information on the history and purpose of the initiative was shared as well as recent updates from the hospitals on the implementation and evaluation of the SOPs. This global learning community is a key benefit of the High 5s initiative. Website updates By Scott Williams, The Joint Commission The High 5s Information Management System has been recently updated to provide a more dynamic and informative display of performance measure data. When viewing the performance measure graphs, participating organizations can now toggle between comparison groups (i.e., displaying national and international comparison groups that include all participating hospitals or only those hospitals at full or partial implementation of an SOP). In addition, the graphs now provide an option to include confidence intervals and change the time period displayed. Hospital data will continue to be displayed on the graphs as soon as it is entered by the hospital. LTAs may update the national comparison group at any time. The Collaborating Centre will update the national and international comparison groups quarterly. Comparison groups are also limited to those data records that meet data quality standards and have been approved by the LTA. Focus on Publications By Agnès Leotsakos, WHO Patient Safety Solutions Lead The High 5s paper ' Innovation in Patient Safety, An Introduction to High 5s' was circulated to the Steering Group at the Berlin meeting. Discussion focused on the target audiences of this paper (policymakers) and issues related to authorship. Several ways forward to acknowledging LTA participants included: bringing forward names and LTA Acklowdgements paragraph, writing a similar paper targeting health-care workers to which the names of LTA participants will be included. It was further suggested that the authorship of the first paper remains as I, but that participants names from LTAs are included in the two follow-up papers, one on 'SOP Implementation' and the other on the 'Evaluation Framework'. As a general guide to authorship and for the purpose of the generic High 5s papers, authorship should reflect 'Guidelines for Authorship' agreed by Steering Group at the 2010 meeting. Australian and French LTA proposed that WHO also develops a 'Culture survey' paper to publish the initial data emerging from some hospitals. 6