MHA Keystone Center Overview. Brittany Bogan, FACHE, CPPS Vice President, Patient Safety and Quality

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1 MHA Keystone Center Overview Brittany Bogan, FACHE, CPPS Vice President, Patient Safety and Quality

2 MHA Family of Companies Michigan Health & Hospital Association 501(c)6 Hospital Purchasing Service Michigan nonprofit association MHA Service Corporation For-profit Michigan stock corporation HealthPAC Political action committee formed under state statute MHA Health Foundation 501(c)3 Hospital Councils Nonprofit Michigan corporations (501-c-6 or 3) MHA Unemployment Comp Program Informational IRS return filed by individual participants MHA Keystone Center 501(c)3 A federally certified Patient Safety Organization

3 MHA Keystone Center Our Mission Supporting healthcare providers to achieve excellence in the outcomes desired by the people they serve. Our Vision Achieving the highest quality healthcare outcomes that meet individual values. Our Values Excellence Innovation Compassion Teamwork

4 MHA Keystone Center Board of Directors Robert Welsh, MD, (Chair) Beaumont Hospital-Royal Oak Michelle Schreiber, MD, (Past Chair) Henry Ford Health System Robert Hyzy, MD, (Vice Chair) Michigan Medicine Brian Peters (CEO), MHA Brittany Bogan, FACHE, CPPS, (Board Secretary), MHA Robert H. Connors, MD, Helen DeVos Children s Hospital Spectrum Health Loren Hamel, MD, Lakeland Healthcare Mark Janke, patient advisor Cheryl Knapp, RN, MBA, CPHQ, CPPS, Bronson Battle Creek Hospital Kevin McCarthy, Trillium Staffing Marjorie Mitchell, Michigan Universal Health Care Access Network, patient advisor James E. Richard, DO, Michigan State Medical Society Matthew Rush, FACHE, Hayes Green Beach Memorial Hospital Barbara Smith, MS, NHA, Burcham Hills Retirement Community Shannon Striebich, St. Joseph Mercy Oakland Jonathan So, Detroit Regional Chamber of Commerce

5 MHA Keystone Center Staff Ashley Sandborn Data Services - Keystone

6 MHA Keystone Center History, 15 Years of Safe Care 2003: Received State of Michigan grant for improving care for stroke patients : Agency for Healthcare Research and Quality grant for the ICU project 2006: Launched hospital-associated infection (HAI) collaborative (BCBSM donation): Hand Hygiene and Catheter-associated Urinary Tract Infection (CAUTI) : Keystone Surgery, Emergency Department, Obstetrics, Sepsis, and Organ Donation : National collaborative projects on Central-line-associated Bloodstream Infections (CLABSI), CAUTI, surgery and ventilator-associated pneumonia (47 states, Puerto Rico and D.C.) 2009: Launched one of the first federally certified Patient Safety Organizations (PSO) : Hospital Engagement Network (2 states in HEN 2.0) 2016 present: Great Lakes Partners for Patients (GLPP) Hospital Improvement Innovation Network (HIIN) (3 states)

7 Annual Report

8 Partnerships Agency for Healthcare Research and Quality American Hospital Association Health Research Educational Trust Blue Cross Blue Shield of Michigan Coverys (Insurance company) Duke Center for Patient Safety Johns Hopkins Armstrong Institute Michigan Department of Health and Human Services Sage Oral Care Toolkit Safe and Reliable Healthcare

9 MHA Keystone Center Our Model Why: Person at the Center Patients and Healthcare Workers What: High Reliability Culture is core to work How: Safety, Quality and Data

10 Person & Family Engagement (PFE) 12 recommended policies and practices: Infrastructure, Staffing & Deployment Developed and endorsed by MHA Keystone Center Person & Family Engagement Advisory Council (formerly Patient & Family Engagement) From this list, Michigan hospitals are encouraged to implement two new policies and practices per year.

11 11 Person & Family Engagement March 2018

12 Importance of Leadership Involvement Improvement initiatives succeed when leadership sets the objective of greater safety Reliability Culture Leadership Process Improvement Patient Engagement and then creates the culture that engages both patients and staff 12

13 High Reliability Organization (HRO) An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. Source: Weick KE, Sutcliffe KM. Managing the unexpected: assuring high performance in an age of complexity. San Francisco: Jossey-Bass; 2001.

14 Characteristics of an HRO 1. Sensitivity to operations. Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them. 2. Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure is essential in order to understand the true reasons patients are placed at risk. 3. Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. 4. Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible. 5. Resilience. Leaders and staff need to be trained and prepared to know how to respond when system failures do occur. Source: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders, Agency for Healthcare Research and Quality, Rockville, MD, 2008

15 Cultivating Mindfulness Source: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders, AHRQ Publication No April 2008

16 Value Cultural Maturity Model High Reliability Transformation: Transparency is an accelerant TIPPING POINT GENERATIVE Safety is how we do business around here Constantly Vigilant and Transparent PROACTIVE Anticipating and preventing problems before they occur; Comfort speaking up SYSTEMATIC We have systems in place to manage all hazards REACTIVE Safety is important. We do a lot every time we have an accident UNMINDFUL Who cares as long as we re not caught Chronically Complacent Time *Adapted from Safeskies 2001, Aviation Safety Culture, Patrick Hudson, Centre for Safety Science, Leiden University

17 Quality Improvement and Safety

18 Evolution of the Partnership for Patients Hospital Engagement Network (HEN) Dec Dec CMS contracts MHA 95 Michigan hospitals Hospital Engagement Network (HEN) 2.0 Sept Sept CMS contracts MHA 215 Michigan & Illinois hospitals Hospital Improvement Innovation Network (HIIN) Sept March CMS contracts Integration with QIN- QIO program MHA 316 Michigan, Illinois & Wisconsin hospitals

19 HIIN Scope of Work Adverse drug events (opioid safety, anticoagulation safety, glycemic management) Catheter-associated Urinary Tract Infections (CAUTI) Central-line-associated Bloodstream Infections (CLABSI) C.diff Injury from falls and immobility Pressure ulcers Sepsis and septic shock Surgical-site Infections (SSI) Venous Thromboembolism Ventilator-associated events (VAE) Readmissions Delirium prevention in the ICU MRSA infection

20 Harm Reduction Hospital Engagement Networks (1.0 and 2.0) Number of Network Hospitals Achieving PfP Goal, by measure Reduce Hospital-Acquired Conditions by 40%, Readmissions by 20% Met Goal Reduction (# of network hospitals) Sustained Zero Events (# of network hospitals)

21 Patient Safety Organizations What is a PSO? They serve as a means to collect and learn from adverse events. The MHA Keystone Center PSO captures event information through incident reports, root cause analysis reports and safe tables. What are the benefits of belonging to a PSO? A single organization only may know its own experience, in a PSO a healthcare organization can learn from others, thereby increasing the opportunity to gain from events before they occur locally.

22 MHA Keystone Center PSO The MHA Keystone Center has been listed as a certified Patient Safety Organization (PSO) by the Agency for Healthcare Research and Quality since Hospitals voluntarily report patient safety events for analysis and translation into actionable cultural and safety improvements. As a PSO, the MHA Keystone Center offers opportunities for hospital peers to learn about serious event trends, exchange patient safety experiences, discuss best practices, and learn in an open, uninhibited and legally protected environment.

23 MHA Keystone PSO Membership Benefits Safety e-alerts Quarterly safe table meetings with other PSO member organizations Access to a system that generates comparative reports Root Cause Analysis and Action (RCA 2 ) training Dr. Jim Bagian Integrated biennial culture and engagement survey (SCORE) Integration of learning: PSO + RCA 2 + Culture Survey Michigan and Indiana: 120 hospitals

24 PSO Engagement Report

25 Leadership Support for RCA 2 CEO & Board involvement demonstrates the high priority issues for an organization Review and track the Root Cause Analyses (RCAs) that are performed Review action plan countermeasures to check for appropriate details Approve or disapprove each action recommended by a RCA team (If not the CEO, then another appropriate member of top management) This concur or non-concur exercise demonstrates real responsibility and accountability for the outcomes and risk to the patient Share RCA 2 metrics with the board of directors 25

26 MHA Keystone Center Speak-Up! Award Quarterly award presented to staff from PSO-member organizations Engage staff, recognize and reward patient safety efforts Align organizational reporting with nomination timeline

27 MHA Advancing Safe Care Award The Advancing Safe Care Award honors a team of healthcare professionals within MHA-member hospitals who demonstrate a fierce commitment to providing quality care across diverse socioeconomic populations, lead the charge for quality improvement, promote transparency to improve healthcare, and achieve better outcomes due to a strong culture of safety.

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