21-22 October, 2013 Steering Group Meeting ARS, Aquitaine Bordeaux, France Meeting Summary DAY ONE

Transcription

1 21-22 October, 2013 Steering Group Meeting ARS, Aquitaine Bordeaux, France Meeting Summary Participants: DAY ONE The list of attendees is provided as Attachment 1. Welcome and Introductions: Joint Commission International CEO opened with a welcome to the High 5s Steering Group, WHO and the hosts- the Regional Health Agency, Acquitaine (Agence Regionale de Sante (ARS), Acquitaine.) A brief speech by a representative of ARS-CEO was made to welcome the group. He confirmed ARS commitment to the High 5s Project and to the topics of safe surgery and quality and safety of medication. He also informed the group about ongoing activities related to the topic of Patient Safety: o Obeservatory of Drugs and Medical Devices Therapeutic Innovations (OMEDIT), a sub division of ARS has been working with the Authority for Health (HAS) and has been in charge of implementation of the High 5s Medication Reconciliation- SOP. o Efforts led by OMEDIT have been focused toward patient- centered management pathways by reducing errors at transition of care and to ensure the relevance of medication orders. o The objective for proper medication reconciliation (MR) is to guarantee the most appropriate continuity of medication, and further to involve patients in the MR process. o Involving patients in the MR process provides leverage to increase and improve knowledge about medication, because in France, like in the rest of the world, patients desire to be part of their care process. o To continue and sustain the developments made in Acquitaine, a progressive and prioritized deployment of Medication Reconciliation process at admission and discharge has been contractually agreed to by each hospital and ARS. o At the upcoming National Patient Safety week in November, medication safety will be at the core of numerous actions led by ARS for health care professionals. o ARS and the French teams are acutely aware of the link between information o o o technology capabilities of any hospital and primary care organizations. Acquitaine is the area which gathers the largest amount of data from a system that is now collecting information related to medication, provided through extended access to medical- records (typically in French.) Presently, this system and its viability is being tested and will be evaluated at the national level. One other major priority for the Acquitaine region is the coverage for the elderly in relation to lost autonomy. This topic is addressed by the implementation of a transverse program started in 2012 called- Pathways of Aging People. Pathways of Aging People deals with the elderly who are at risk of losing their autonomy, as well as medication reconciliation. Medication reconciliation is one of 1

2 the most important factors in this pilot as it affects both hospitals and long- term care facilities. Pharmacist Coordinator at ARS and WHO both followed to welcome the group and asked the meeting to commence. LTA and Hospital Updates: PowerPoint presentations from the Lead Technical Agency updates are posted on the High 5s website on the shared resources page under the Learning Committee ( There is progress being made on both interventions in all participating countries. Some highlights were: Australia reported that in lieu of any metrics for hospitals to evaluate their own performance for medication reconciliation, the Australian Commission on Safety and Quality in Healthcare recommends that the hospitals use an indicator that is the same as MR 1 (but extended to all patients). Quality measures are not specified for the accreditation process. However hospitals are encouraged to collect evidence of accurate and complete medication reconciliation at admission and discharge of patients and new indicators are being developed to collect this information at discharge. Australia expressed the desire to work with ISMP Canada to improve the efficiency of the data collection for Med rec quality measures. France informed the group that they have added two new measures and participating hospitals are asked to collect data for these along with the existing MR measures. Though in the past the collection of data has been reportedly burdensome, the hospitals reportedly find the new measures valuable and are comfortable collecting related data. France reported that medication reconciliation has become a more complicated process especially since the scope has been widened to include patients of all ages in France. France also reported that all hospitals are collecting data according the 48 hour criterion, since the number of reconciled patients wasn t much different than when they were reconciling according to the 24 hour criterion. These medication reconciliation efforts have also helped French hospitals develop a clinical pharmacist position. Germany reported they are recruiting further hospitals for MedRec. In addition to the High 5s measures the German hospitals are asked to collect further data on the MedRec process (e.g., who does the BPMH and which sources were used). The student completing her doctoral thesis will be performing some analysis yielding clinical significance reports. Netherlands reported that there was an agreement at the National Patient Safety conference about the need to interview and involve both inpatients and outpatients to get the best history and to have most accurately reconciled patients. There was also an agreement that these interviews are difficult to conduct and can become cumbersome, quickly. USA reported that the last reported unintentional discrepancies of 50% have now been reduced. France suggested asking hospitals to submit positive-outcome data or stories in a voluntary manner and not an imposition. 2

3 The importance of examining the good catches to figure out what lead to the mistake in the first place was emphasized repeatedly. The focus can then be on the process to specifically pin-point where mistakes start happening. Germany has been collecting data on the duration of the team time out in the context of the CSS SOP and presented preliminary results from 3 hospitals. Interim Report Review: A paper-copy of the finished interim report was distributed to all the Steering Group members, a PDF- version of the same was ed to all attendees the night before the meeting as well. A few copies of the annexes for the report were available for review. Steering group members were asked to review the entire report and send any comments to WHO by November 30, WHO informed the group that an Executive Summary will be written and attached to the editable format of the report. Finally, it was decided that upon receipt of any comments on the report and the Executive Summary, final edits will be made at the WHO and the report will be ready to share with LTAs and corresponding hospitals, on various websites (WHO, AHRQ, individual LTA websites.) by January 15, Countdown to the End of High 5s Schedule/ Collaborating Centre Quarterly Milestones: The group discussed timelines for the project. Given that the AHRQ contract ends in September, 2014, CC-activities and support will effectively end in September 2014 as well. Many countries will wrap up project activities in early 2015; the Final Report for the High 5s Project will be released in the spring of Date will be finalized over upcoming calls. SOPs and related documents will also be released at the same time for the general public. The group agreed that all participating countries should submit papers and posters this upcoming year, and represent the High 5s as a group, if possible. The group discussed connecting the spring 2015 global release of High 5s SOPs to conferences such as ISQua, perhaps reserve a plenary session spot for the 2014 meeting. Attending LTAs collectively informed the Steering Group that hospitals would like to apply the SOPs and would like the SOP-related documents and reports to share with them. Additionally, WHO suggested that all countries organize and implement national- level campaigns in preparation for the global release. This activity will be most likely be easier to organize once the Interim Report is released The topic of Ethics approval for the study was discussed. WHO does not have ethics approval for High 5s activities at this time. Many countries reported that they either have a collective approval for project activities (between the LTA and participating hospitals), or individual hospitals have to apply and acquire said approval before engaging in project activities. The importance of shared- stories and lessons learned, including experiential knowledge about which measures are most beneficial was stressed many times during discussions. France mentioned that sharing names of patients and story characters is helpful for readers to relate at a more personal level. WHO suggested using established relationships between countries to spread the word about the High 5s SOPs and the upcoming release of the SOPs. 3

4 CC referred to the Collaborating Centre Quarterly Report Milestones table (Attachment 2) to remind the Steering Group of deliverable dates. IMS Handover: The discussion began with the presumption that CBO of the Netherlands would be willing to accept any IMS-related responsibilities by September The technical transfer of the IMS application is not very complicated or time-consuming. Once the Dutch team identifies their IT- group, the CC can orchestrate the handover. The more complex transition issue relates to the country and hospital data that are stored on the IMS: o Before any transfer of the IMS can take place, the group needs to come to a consensus about the value and the potential use for the data already in the IMS. o Any transfer of the IMS would begin with retaining all content that belongs to the project which currently resides under the Toolkit, Learning Community, and System webs. This would include the SOPs, Measures, Power Point presentations, Meeting Summaries, High 5s reports, and the code that supports user registration, rendering of country and hospital topic pages, and all data collection forms. o Three basic options related to IMS data transfer exist: Option 1: Solicit agreements from each of the participating countries, hospitals and individual users that will allow the Collaborating Centre to transfer all of their information to the CBO. This approach would require the Collaborating Centre to strip out any non-participating country, hospital and individual user content This would be a highly time and labor intensive solution Option 2: Delete ALL data and let the CBO get started afresh. Option 3: Do not limit the transfer of the IMS to the CBO. Rather, make the IMS available to any participating country that wants it and strip out all country webs other than the one that belongs to the receiving country. All individual user topics (except those that belong to country/hospital user groups) would be deleted from the IMS. o Interested countries will still be able to access their own data and collect/ not collect more data, but won t be able to see any cross-country data like they do at present. The group asked how long the CC would store existing data. o The Joint Commission s standard record retention policy is to retain any project related data for three years from the end of the project. o It is important to note, however, that per the Steering Group agreement that was reached following the May 2013 meeting in Washington D.C., all of the individual (blinded) hospital-level data are already made available to Steering Group members. These data are included in the Microsoft Excel workbooks that are distributed to Steering Group members with each new Quarterly Report. General consensus was that Option 3 was likely to be the option preferred by most participating LTAs, but a firm decision was not made. 4

5 Administrative Announcements: Organizing and participating in two versus one Steering Group meeting in 2014 was discussed. The group agreed to have the spring meeting between the months of April and June, Trinidad and Tobago informed the group that they would like to host the meeting, but have only discussed the possibility within their small group, and will need to bring the suggestion to the Ministry s attention and acquire approval before agreeing to the responsibility. Dates for the meeting will be proposed in the upcoming weeks via electronic polling and finalized by mid-january, The group decided that they will hold High 5s promotional events accompanied with meetings such as ISQua in 2014 and perhaps have a smaller meeting in Rio after ISQua activities come to an end. 5

6 DAY TWO SOP Breakout Sessions: See Attachment 3 for detailed summary of the discussions during the SOP- specific breakout sessions, and refer to Attachments 4 and 5 for presentations made by two French hospitals. SOP Release and Dissemination: A matrix (Attachment 6) was developed by the Surgery-expert for discussions within breakout sessions. A summarized version of the discussions was then presented for the SOP release discussion with the Steering Group. This matrix listed assumptions for release of the Correct Site Surgery Standard Operation Protocol (CSS SOP.) Name: According to WHO, High 5s enjoys name recognition internationally. The group agreed we would continue to use the name High 5s beyond the end of the project. Oversight: In countries with oversight bodies (either country wide, regional), the group agreed it made sense to use this oversight body to encourage or mandate use of the SOP. LTA groups or other quality or safety organizations could provide oversight in countries without national or regional oversight bodies. Scope of implementation: It was determined that the CSS SOP would have value in day surgery. Agreed that SOPs should be edited and simplified. Toolkits and links to resources and guidelines to aid in implementation should be included in released documents. Pre-op checklists: The High 5s checklist and the WHO s surgical safety checklist should be harmonized, perhaps a crosswalk or other illustration can show areas of alignment. Integration of protocol into current workload and processes should be highlighted, demonstrate the CSS SOP is not something extra. Surgery-expert will make necessary edits to SOP and other documents, will aim to complete documents by June 1, Evaluation: How should we incorporate evaluation into released SOPs? It was suggested that rather than use the term evaluation we use the term manage the process. If a process is put in place, it must be managed. This term might feel less burdensome or loaded to organizations than evaluation. The group agreed the term manage should be used in lieu of evaluation going forward. Group agreed that we should encourage evaluation (or management ). High 5s tools (surveys, EA materials, etc) should be made available to assist with evaluation. Surgery-expert asked if we could keep only one performance measure, what would it be? Group thought CS-5 Cases proceeding to surgery with unresolved discrepancies was the most valuable. Surgery-expert suggested inserted a new measure CS=-8 which would track good catches. Then it can be determined where and how they occur. 6

7 Information Management System (IMS): CBO will assume responsibility for IMS when AHRQ funding for JCR/JCI ends in September of IMS will not be available beyond 2015 project end (times may be different for different countries.) Please see notes from meeting summary (Day One) for full discussion of issues related to the IMS. All references to IMS need to be deleted from guidance documents. Access to SOPs: The group discussed where the finalized SOPs should reside. The group agreed that the ONE location should be the WHO website, with access provided to this site via links embedded on the other LTA websites. The group also discussed the importance of a warning posted on the material which alerted visitors to the fact that the potential of compromised integrity of the content exists, once it is downloaded from the WHO website, and any edits have been made to the material. MR-expert agreed with the SOP readiness presentation. MR-expert pointed out that there has to be some form of metric included in the final versions to help those implementing the SOPs to know if they are following the process correctly and if they are achieving any kind of success related to implementation. These recommendations will most likely be received and followed in individual organizations depending on resources. Lastly the group agreed that the process of Medication Reconciliation and Correct Site Surgery should be shared with the independent attachment of Process Management process, previously called- Evaluation. Info-Graphics/ Including Key Implementation Experiences Presentation Please see Attachments 7, 8, 9, 10, 11, 12. Scott asked the Steering Group to submit additional comments to him by December 15, 2013 for integration into the finalized version of the info-graphics. Event Analysis: Event Analysis expert provided a report to the Steering Group for discussion. She indicated that a written report had been submitted in the meeting book (Tab 7) and discussed in the SOP specific breakout groups. Her comments would therefore now focus on the following topics: o Summary of Reports YTD in 2013 o Debrief of small group discussions o Recommendations 7

8 1. Year To Date 2013 Correct Site Surgery Event Analysis Reports a. 2 Cluster Analyses (no harm) (128 patients 2 hospitals / one country) b. Hospital follow up actions i. Reinforcement of proper and appropriate documentation of time out ii. Develop a list of agreed upon special equipment and/or implants iii. Rectify system related issues update system so that users cannot proceed with operative procedure until all the items in the checklist have been answered properly c. Hospital follow up evaluation i. Feedback & audit; IT monthly data review and validation together with IT and OR teams; and CSS data validation as well as observational and random audits 2. Year To Date 2013 Medication Reconciliation Event Analysis Reports a. 6 Concise Analyses & 1 Comprehensive Analysis (7 patients all over 72 years of age 2 hospitals / one country) b. Temp Harm (1); Additional Treatment (2); Emotional distress or inconvenience (3) c. Events primarily identified through Pharmacists completing Med Rec but other sources include abnormal INR result, patient/family concern and unexpected need for higher intensity of care (this is consistent with early High 5s prompts d. Reports reflect key contributing factors negatively impacting the ability of the hospital to provide Med Rec within 24 hours of admission e. Key contributing factors include. i. A number of unique provider and site circumstances AND general themes of: ii. Teams rely solely on Pharmacists for Med Rec iii. No after hours clinical pharmacy service iv. no replacement for sick time or vacation v. Doctors and nurses say they cannot perform Med Rec at admission when Pharmacists are not available due to time limitations vi. Physician not asking the patient for their med history (was competent and capable) vii. Lack of collaboration on one common med history and clinical handover f. Hospital follow up actions include i. Training, reallocate / request resources to complete Med Rec within 24 hours ii. Only 1 report clearly stated that Med Rec will occur within 24 hours for applicable pts (and set a timeline) g. Hospital follow up evaluation includes i. Monitor High 5s measures; Feedback & audit; annual quiz; monitor event reports 8

9 3. Are participating hospitals capable / currently performing event analysis? Generally, feedback reflects that hospitals are capable and that some are currently performing event analysis but some support/encouragement would be beneficial as internal and external sharing of findings not always occurring. 4. Do we anticipate additional Event Analysis reports will be submitted before the end of the project? Generally yes! 5. Recommended Next Steps 1. Distribute 3 rd Quarter Event Analysis Report to all hospitals (through each LTA) 2. Use event analysis data received to date and over the coming months to inform revisions to SOPs and evaluation strategy for spread in Consider reframing event analysis within a proposed Review and Manage the Process approach for spreading the SOPs to other hospitals and countries. This process could include a focus on analyzing good catches as well as adverse events thought to be related to the applicable SOP. The presentation concluded by thanking those involved in developing and implementing the High 5s initiative as the Event Analysis evaluation process has contributed to the launch of a new initiative supported by the WHO. Dr. Julius Pham, Johns Hopkins (United States) and Carolyn Hoffman, Alberta Health Services (Canada) are Co-Leading a two phased international project designed to validate an updated Concise Incident Analysis (CIA) methodology. The Canadian Patient Safety Institute is funding the project. The first phase of the CIA project is pilot testing the updated method. Sites in Australia, Hong Kong, Canada and United States are participating in the almost completed pilot test. It will be followed by a validation research project that will be open to countries around the world. Individuals that would like to receive more information regarding the study should contact Carolyn Hoffman. Evaluation: Please refer to Attachment 13 for presentations made at the meeting. 9