Indiana Action Coalition: Patient Safety Indiana Nursing Summit January 11, 2013 IOM: Future of Nursing Recommendation #2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Health care organizations should support and help nurses in taking the lead in developing and adopting innovative, patient-centered care models. Focus on engaging nurses in interprofessional teams to redesign care 2012 Subcommittee Membership Co-Chairs: Betsy Lee, RN, BSN, MSPH, Indiana Hospital Association Kyle Hultgren, PharmD, Purdue University College of Pharmacy, Center for Medication Safety Advancement Members: Jonell Allen, RNC, MSN, CNS-BC, Community Health Network Rebecca Bartle, RN, MSB, HFA, Hoosier Owners and Providers for the Elderly James Bien, MD, FAAP, Indiana University Health Arnett Mary Browning, DNP, RN, NE-BC, Community Health Network Yvonne Culpepper, DNP, RN, Hendricks Regional Hospital Lynn Devich, MSN, MBA, RN, ACNS-BC, Hendricks Regional Health Bridget Dolohanty-Johnson, MSN, RN, Parkview Whitley Hospital Laurie Fish, RN, BSN, CIC, Indiana University Health Marcy Grandstaff, RN, MSN, CCRN, CWCN, Community Health Network 1
2012 Subcommittee Membership Members (continued): Kerra Heggen, RN, BS, MSN, Elkhart General Hospital Lisa Hopp, PhD, Purdue University Calumet Denise Kaetzel, RN, MSN, Memorial Hospital and Health Care Center Vicky Kirton, RN, MA, Goshen College Denise Lakin, RN, St. Vincent Clay Hospital Paula McAfee, RN, MS, Larue Carter Hospitals Sara McComb, PhD, Purdue University Schools of Industrial Engineering and Nursing Belle McCool, DNP, RN, NE-BC, Deaconess Hospital Keith Reissaus, Goodwill Industries Mary Sitterding, PhDc, RN, MS, Indiana University Health Marijane Smallwood, RN, MSN, NE-BC, Hendricks Regional Hospital Colleen Walker, RN, BSN, Franciscan St. Francis Health Linda Webb, RN, Pulaski Memorial Hospital Vision All healthcare facilities and providers will adopt or create a culture of patient safety to promote positive patient and family experiences and/or outcomes. Mission To create statewide awareness of the importance of leadership, teamwork, communication/transparency, research/evidence based practice, standardized just and patient-centered cultures that promote safe and trustworthy patient care delivery at all levels of healthcare. 2
Goals Engage front line nurses with interprofessional teams with a focus on patient safety and preventing harm Build capacity and competencies to support patient safety and quality across the continuum of care, particularly with care transitions Connect to current Indiana patient safety efforts related to the national Partnership for Patients initiative Strategies to facilitate collaborative efforts to transform care 1. Support the efforts of regional patient safety coalitions that promote front-line improvements in care delivery 2. Align the Future of Nursing goals into the priorities of the national Partnership for Patients initiative 3. Integrate Future of Nursing message for nursing leadership for safety into educational programs and other activities 4. Support the work of Hospital Engagement Networks in implementing strategies to improve quality of care across care settings in Indiana 5. Expand involvement by other disciplines in the practice and education settings 2012 Activities Leveraged current safety efforts through the Indiana Patient Safety Center and the regional patient safety coalitions Recruited representatives from various settings of care and disciplines Discussed research connections Added clinical nurse specialists who teach and work directly with front-line staff around patient safety issues 3
Work Groups 1) Charter development 2) Research, including safety metrics 3) Safety competencies, including dissemination National Context: Partnership for Patients Bold National Aims by 2013: 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 Up to $35 Billion Dollars Saved Ten Priority Areas of Focus Hospital Engagement Networks are required to address ten areas of focus: Adverse Drug Events Catheter-Associated Urinary Tract Infections Central Line Associated Blood Stream Infections Injuries from Falls and Immobility Obstetrical Adverse Events Pressure Ulcers Surgical Site Infections Venous Thromboembolism Ventilator-Associated Pneumonia Reducing Readmissions 4
CMS Call to Action for All Hospitals 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. CMS Call to Action for All Hospitals (continued) 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. Current Statewide Capacity Building Leveraging dialogue and learning through the eleven (11) regional patient safety coalitions to advance collaboration and drive harm to zero, including notable reductions in deaths from sepsis statewide Technical assistance and educational activities across multiple Hospital Engagement Networks, including IHA/HRET, Ascension, VHA, UHC, Children s Hospital Safety Network, JCR, LifePoint, NAPH 5
Current Statewide Capacity Building Numerous collaborative education efforts to focus on enhancing patient and family engagement (HENs, safety coalitions, Health Care Excel, and other stakeholders) IHA Coalition for Care is conducting broad-scale Lean/Six Sigma training/certification: 235 Green Belts 109 Black Belts Purdue University Medication Safety Essentials CE course Medication Safety Alliance 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 hospitalspecific capacity for improvement and innovation Encourages safety leadership at all levels across multiple professions Indiana Hospital Association Indiana Patient Safety Coalitions Northwest Indiana North Central Indiana Northeast Indiana West Central Indiana Eastern Indiana Central Southwest Indiana Indianapolis Suburban Health Organization Southeastern Indiana South Central Indiana Community Patient Safety Coalition (Southwest) 6
Team Indiana: Working Together to Make Indiana the Safest State IHA launched a video series aimed at encouraging hospitals to elevate leadership for safety, engage in regional coalitions and target all harm topics. Indiana Medication Safety Alliance Future Activities Focus on disseminating patient safety knowledge across the state Build capacity across the continuum of care for patient handovers Examine possible metrics to measure progress Facilitate patient and family engagement across the continuum of care 7
Challenges and Opportunities How to continue capacity building after HEN funding runs out How to disseminate common patient safety knowledge and competencies across Indiana, across multiple disciplines How to spread broad-based improvement knowledge and skills to front-line providers to apply to new challenges and topics Summary The Indiana Action Coalition s Patient Safety Subcommittee aligns with the Future of Nursing recommendations that 1) nurses should be full partners in redesigning health care and 2) that we should embrace opportunities for nurses to lead. Nurses are in a unique position to lead patient safety transformation within their own organizations, but often lack the education and competencies needed to lead system level change to reduce patient harm. Discussion Questions What are some specific ways in which health care organizations and schools of nursing can advance leadership and improvement competencies in front line nurses? What suggestions do you have for including patients and families in patient safety improvement efforts across the state? 8
Contacts Betsy Lee Director, Indiana Indiana Hospital Association blee@ihaconnect.org (317) 423-7795 Kyle Hultgren, Pharm.D. Managing Director - Center for Medication Safety Advancement Adjunct Assistant Professor of Pharmacy Practice Purdue University College of Pharmacy khultgre@purdue.edu (317) 275-6081 25 9