Turning Quality Upside Down: Using a Perfect Storm to Change the Quality Performance Culture. Centura Health. Centura Health 9/20/2011

Transcription

1 Turning Quality Upside Down: Using a Perfect Storm to Change the Quality Performance Culture 2011 ANCC National Magnet Conference October 4 th, :30 a.m.-12:30 p.m. Session C501 Kathleen Bradley, RN, MSN, NEA-BC Cynthia Oster, PhD, MBA, APRN, CNS-BC, ANP Kathy Bilys, BS Porter Adventist Hospital Denver, Colorado Centura Health A faith-based, nonprofit health care organization formed in 1996 by Catholic Health Initiatives and Adventist Health System Colorado s fourth largest private employer with nearly 13,000 associates The Centura system encompasses 12 hospitals, seven senior living communities, and Centura Health at Home home care, hospice, infusion, home medical equipment and oxygen services Parker Centura Health St. Mary Corwin St. Anthony North St. Anthony Summit Ortho Colorado Avista Penrose/St. Francis St. Thomas More Porter St. Anthony Littleton Mercy 1

2 Porter Adventist Hospital Acute Care Hospital Cancer Care Center Center for Joint Replacement Craniofacial & Skull Base Disorders Complex Medicine Heart Institute Centura Health Transplant Program Robotics Institute Spine Institute Sharon Pappas, RN, PhD, NEA-BC Chief Nursing Officer- Porter Adventist Chief Nursing Executive -Centura 368 licensed beds with 1450 associates Magnet designation January 12, 2009 Objectives Identify vulnerabilities, perfect performance and adherence to regulations and policies across the care continuum. Discuss steps in developing culture, change supporting individual professional accountability and healthcare system performance. What to Expect How Blood changed an organization Background Story Quality Tools Lessons Learned Where We are now 2

3 Evidentiary Background AHRQ (2009) The number of hospital stays for patients who received blood transfusions more than doubled between 1997 and (from 1.1 million to nearly 2.7 million) Blood Administration is a High Risk Procedure. Regulatory Background CMS: A (c)(3): Blood transfusions must be administered in accordance with State law, personnel must have special training. TJC: HR : Define staff qualifications. If blood transfusions are administered by staff other than doctors of medicine staff members must have special training. State of Colorado Licensure Standards Story of a Culture of Assumption Education Audits at a high level (ORR) Good is Good enough Triggers 3

4 A Perfect Storm A perfect storm is a convergence of independent events that form an environment never experienced before. (Fields, 2006) A Culture of Low Expectation Three prevailing winds or barriers to exemplary blood and blood product administration practice, failure to see, failure to move, failure to finish converged to create the perfect storm that threatened our culture of excellence (Black & Gregersen, 2008; Kerfoot, 2010). Perfect Care Implementation Timeline Roving Blood Competency Validations RN Staff Baseline Data Collection See Analyze Failure for System vs. Behavior Consent PDCA & Process Move Change No Fail Environment Wk 18- TAR ongoing Implementation Finish Perfect April- May 2010 June 2010 July 2010 August 2010 September 2010 October 2010 November/ 2010 December 2010 Ongoing Auditing Initiate Audit of 100% Blood Products Just Culture & Peer Review Process Literature Review, EBP (Iowa Model), SOC Evaluation Policy Update, CBT for Blood & Blood Products TAR Competency Validation Analyze Failure for System vs. Behavior Establish ongoing Audit Plan Analyze Failure for System vs. Behavior 4

5 Starting the Transformation Massive Education & Competency Validation 402 Registered Nurses / 6 Weeks Developing the Audit Tool Audits EMR Area Specific Policy Defining Failure Audits 100% Concurrent Inpatient Outpatient Facility RNs Only Nursing Leader Champion Audit Expectations 5

6 Failure to See We do a great job Validating Assumptions Targeted Audits Education Competency Targeted Audits Failure to See Every Unit, Every Blood Product, Every Week Failure to See Failures Identified Weeks Total Blood Units 80 Infused # Misses # Blood Products Infused 20 0 Week Week Week Week Week Week Week Week

7 Vital Signs = 72% of Failures Failure to See Source of Failures Week 1-8 VS - Temp 17% VS - 15 min 27% EMR Screen 7% VS - Stop 28% Consent 7% Stop Time 14% EMR Screen VS - 15 min VS - Temp VS - Stop Consent Stop Time Failure to See We don t do as great a job as we thought Cause and Effect Analysis Vital Signs Policy has specific Temperature 37.5 Policy allows for 30 minute VS (with blood infused under 30 minutes) Vital Signs being delegated to CNA Patient moving to other location before 15 minute VS Failure to See How good do we need to be?... Ongoing Dialogue Identify goal of 100% compliance with policy Communicate expectations to leadership and staff Is perfection achievable?... 7

8 Failure to Move It s time for an overhaul Responding with Action Just-In-Time Training TAR with Competency Validation Update Policy Just Culture Peer Review Taskforces Updated Policy Focus on EBP Our Failure Points Literature Search Professional Organizations Supporting Culture Change Changing the Culture No delegation of Blood Vital Signs No transport of patient before 15 minute Vital Signs Standardize - all Blood has 15 minute Vital Signs Remove specific temperature to allow for nursing judgment 8

9 Trigger for Action Blood Consent Completion Adherence Rate June December Percent Intervention (9/30/10): Blood and blood products released from Blood Bank ONLY with copy of completed informed consent % Adherence Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk n = 2638 units % Adherence Week Monitor for Success Move the Culture Triggers of Failures = PDCA Rapid Decision Making Team September 23rd Change started September 30th Failure to Finish Why can t we get this right?... Analyze Failures System Behavior No Fail Deadline 9

10 Failure to Finish Why can t we get this right?... Just Culture Environment Concurrent Coaching Peer Review All levels Audits Just Culture Algorithm Reason, J. (1997). Managing the risks of organizational accidents. Hants, England: Ashgate Publishing Ltd. Failure to Finish Are these system or behavior?... Failure Tracking Identification June 2010-December 2010 VS - Post, 26% Consent, 8% VS - 15 min, 29% Start/Stop, 16% VS - Pre VS - 15 min VS - Post Consent Start/Stop VS - Pre, 15% 38 Failures in 50,122 data points 10

11 Failure to Finish I think we did it.. Audit Cycle Weekly audits Cause and Effect Just Culture on Every Failure Re-educate as needed Ownership (Patel, 2010) Celebrating Success Bloody Good Job Red Velvet Cakes Perfect Blood Administration Week 18 Sustaining the Gain 11

12 Ongoing Audit Plans Failure to Finish Are these system or behavior?... Failure Tracking Identification January May 2011 VS - Post, 11% VS - Pre VS - 15 min VS - Pre, 11% VS - Post VS - 15 min, 77% 9 Failures in 43,111 data points Sustaining the Gain 12

13 Surviving the Storm Used with Permission: Black, J. & Gregersen, H. (2008). It starts with one. Wharton School Press: Philadelphia, PA. A Closer Look at Quality System Failures PDCAs Recognition of Transfusion Reactions Consents Vitals Signs Non-Facility Associates Act Plan Check Do Data is Key to Changing Practices # of Failures Just Culture identified individual accountability and system issues Data identified improvement opportunities Focused on reducing variability Failures Mean UCL Improvements: Week 1: Just Culture analysis for each failure 2: Enhanced policy distributed 3: Changes to consent process, TAR in EHR 13

14 Key QAPI Lessons Ensure execution throughout PDCA Measure performance (i.e., compliance) at the policy element level Objective approach to change management Agreement on target performance Data on performance Just Culture analysis when there were misses Leadership from Executives to Charge Nurse Translation to Other Indicators Care Plans Critical Values Restraints Cultural Shift Culture of Education and Validation with Verification How are we going to measure this? How will we know if this works? We are not going back to the old way This is about professional accountability for my practice. We are all accountable for patient safety I have a question. 14

15 Where are we Now? A Vision of Excellence practice environment was achieved. A perfect storm environment brought about redesign of leadership roles, performance measures and professional accountability. Utilization of a targeted audit cycle led to a no-fail practice culture. Translation to Other Facilities Independent Auditor Validation Selected as a Best Practice for Quality Process adopted throughout 13 other hospitals within the system Questions? Success is the ability to go from failure to failure with no loss of enthusiasm. Winston S. Churchill (Secretan, 1999) 15

16 References Agency for Healthcare Research and Quality (AHRQ). (2009). Blood transfusions have more than doubled. Research Activities U.S. Department of Health and Human Services No Retrieved from Black, J. & Gregersen, H. (2008). It starts with one. Wharton School Press: Philadelphia, PA. Fields, M. (2006). Perfect storm. BizEd, January/February, Kerfoot, K. (2010). Good is not good enough: the culture of low expectations and the leader's challenge. Pediatric Nursing, 36(4), Retrieved from EBSCOhost. Patel, S. (2010). Achieving quality assurance through clinical audit. Nursing Management - UK, 17(3), Retrieved from EBSCOhost. Reason, J. (1997). Managing the risks of organizational accidents. Hants, England: Ashgate Publishing Ltd. Secretan, L. (1999). Inspirational leadership: Destiny, calling and cause. Toronto, Canada: Macmillan Canada. The Joint Commission. (2011). The Joint Commission E-diction. Accessed from Kathleen Bradley, RN, MSN, NEA-BC Director of Performance, Practice & Innovation Magnet Program Director KathyBradley@Centura.org Cynthia Oster, PhD, MBA, APRN, CNS-BC, ANP Nurse Scientist CynthiaOster@Centura.org Contact Information Kathy Bilys, BS Director of Quality Improvement and Patient Safety KathyBilys@Centura.org Porter Adventist Hospital Denver, Colorado 16