Session Code These presenter s have nothing to disclose Using Transparency to Drive Patient Safety Doug Salvador, MD MPH Chief Quality Officer, Baystate Health Chief Medical Officer, Baystate Medical Center Karen Johnson, BSN, RN, CCMSCP Director, Performance Improvement Baystate Medical Center December 12, 2017 #IHIFORUM Mary Beth Collins, BSN, RN Performance Improvement Coordinator Baystate Medical Center
No Conflicts to Disclose
Session Objectives P3 Discuss multiple ways to increase transparency in their organizations to improve patient safety Understand one medical center s program for strategically using transparency Discuss three structures that could be implemented to improve the safety event review and systems improvement process #IHIFORUM
Baystate by the Numbers P4 Safety Reporting System Reports 8,000 per year Peer Reviews 350 per year RCA 50 per year
Patient Safety P5 Proactive Reactive Regulatory Safety Reporting System PI Huddle, Sentinel Event Reviews Education & Training Culture of Safety Failure Mode & Effects Analysis External Requirements & Best Practices Root Cause Analysis Peer Review Communication, Apology & Resolution Peer Support BORM DPH TJC CMS
Background P6
Five Transforming Concepts P7 Transparency Care Integration Patient Engagement Restoring Joy and Meaning in Work Medical Education Reform Leape L, Berwick D, Clancy C et al Transforming Healthcare: a Safety Imperative, Qual Saf Health Care 2009; 18:424-428.
National Patient Safety Foundation s Lucian Leape Institute. Shining a Light: Safer Health Care Through Transparency. Boston, MA: National Patient Safety Foundation; 2015. P8 Transparency Care Integration Patient Engagement Restoring Joy and Meaning in Work Medical Education Reform
IHI Framework for Safe and Reliable Care P9 Psychological Safety Accountability Leadership Teamwork & Communication Transparency Engagement of Patients & Family Negotiation Reliability Improvement & Measurement Continuous Learning
What Did We Want To Improve? P10 Timeliness Getting the Right People to the Case Review Ownership by Operational Teams Follow Through Trends
P11 Baystate s Process for Managing Serious Safety Events: A Patient Story
Patient Story P12 A 47 year old male admitted for a primarily surgical issue. Patient has a history of DM and utilizes an insulin pump. No insulin orders are entered for the patient on admission. No consult to the in-patient diabetes team. Patient s blood sugar is noted to be in the 400 s the day after admission. Patient requires monitoring at a higher level of care.
AN EXERCISE P13
Transparency Exercise P14 Transparency can be used in many small and large ways to drive change. Think of a time when you personally or your organization have attempted to use transparency to make change in patient safety. Was it helpful or not? Why? Pair with a neighbor and share your story, including why it was or was not helpful. Be prepared to share what you heard from your neighbor with the larger workshop group.
Peer Review Filter Tool P15
PI Huddle P16
Performance Improvement Huddle News P17
Compass Huddle P18
P19 Making Changes to Increase Transparency #IHIFORUM
Leader s Harm Report P20 Rolling It Out Making the Case to Leaders Testing Changes Getting Feedback Making it Work Two Grids Real-time documentation Trends Analyze data Revise tool- SharePoint
Leader s Harm Grid P21
New SharePoint Tool P22
Results P23
Analysis of PI Huddle Cases P24 Row Labels Count of Patient Name ED 1 Surgery 1 Hospital Medicine 2 Radiology 3 Women s Services 4 Medicine Specialty 6 Neurosciences 7 Nursing 8 Heart + Vascular 9 Critical Care 10 Children s 11 Other 36 Anesthesia 41 Blank 62 Grand Total 201
Cases by Location P25 Location Case Count ED 85 Surgery 37 Hospital Medicine 25 Radiology 21 Women s Services 21 Medicine Specialty 19 Neurosciences 18 Nursing 16 Heart + Vascular 14 Critical Care 12 Children s 9 Other 8 Anesthesia 6 Blank 5 Trauma 3 Psychiatry 1
Test of Change RCA P26 RCA Case Summary: GAPS: Opportunities Status of Actions: RCA Story:
Next Steps P27 Bring Transparency Down to the Frontline Share learnings widely Compass Huddle Drill down of data to identify trends/patterns in a timely manner RCA issue resolution spread
Acknowledgements P28 Heather Beattie Diane Tillman Judy Richardson Deb Abel Diane Thomas Sean LaValley Brenda Waterman Doug Salvador Mary Ryan-Kusiak Barbara Stoll Maria Pouliot Shannon Dillard
Executive Summary P29 Transparency is a powerful tool to motivate and ensure accountability; over the past 13 months we have seen first-hand the power of this tool. To be successful: Prepare people for transparency and show them you don t want to blame or shame them; Test and improve a repeatable process that can be sustained; Start with a subset of important issues/cases to share; Don t forget to check in and ask whether the process is helping; Always look for opportunities to spread PI News &Compass Huddle.