Innovation, Advocacy, Innovation, Advocacy, and Lessons Learned: and Lessons Learned:

How IHA Implemented a How IHA Implemented a Patient Safety Learning Patient Safety Learning

CollaborativeCollaborative

Cathy Grossi and Becky StewardCathy Grossi and Becky StewardIllinois Hospital AssociationIllinois Hospital Association

The Quality ColloquiumThe Quality ColloquiumHarvard UniversityHarvard University

August 21, 2006August 21, 2006

Illinois Facts:Illinois Facts:

55thth most populous state (12.5 M) most populous state (12.5 M) 2525thth largest (57,918 sq. miles) largest (57,918 sq. miles) AgricultureAgriculture Springfield / ChicagoSpringfield / Chicago 200+ Hospitals200+ Hospitals

Academic Centers (19)Academic Centers (19) S & R (90)S & R (90) CAH (51)CAH (51) Top 3 employer in 48 / 102 countiesTop 3 employer in 48 / 102 counties 1.6 Million inpatients1.6 Million inpatients 4.9 Million ED 4.9 Million ED Medicare (40%) / Med (13%)Medicare (40%) / Med (13%) Uncomp care – $1.2 BUncomp care – $1.2 B

About “Land of Lincoln”About “Land of Lincoln”

Hx - Partners in Quality:Hx - Partners in Quality:

Perinatal: 10 Networks / 148 HospitalsPerinatal: 10 Networks / 148 Hospitals Newborn Hearing Screening: 144 reportNewborn Hearing Screening: 144 report Metabolic Screening: Expanded testing (6-30)Metabolic Screening: Expanded testing (6-30) EMS / Trauma: 11 Regions / 67 HospitalsEMS / Trauma: 11 Regions / 67 Hospitals EMSC: 11 Regions / 206 HospitalsEMSC: 11 Regions / 206 Hospitals Organ / Tissue Donation & TransplantOrgan / Tissue Donation & Transplant Communicable DiseaseCommunicable Disease Cancer RegistryCancer Registry

Illinois HospitalsIllinois Hospitals

Hospitals Harm:Hospitals Harm:

Medical ErrorMedical Error Inadequate StaffingInadequate Staffing Poor Infection Control PracticesPoor Infection Control Practices

Patients at RiskPatients at Risk

2002 Springfield’s “New World” Order:2002 Springfield’s “New World” Order:

Democratic sweep of state governmentDemocratic sweep of state government New Governor, DemocratNew Governor, Democrat Leadership of the General AssemblyLeadership of the General Assembly

Largest turnover of state legislators in 25 yrsLargest turnover of state legislators in 25 yrs 46 new legislators (29 in the House, 17 in the 46 new legislators (29 in the House, 17 in the

Senate)Senate)

Union-friendly environment Union-friendly environment

PoliticalPolitical LandscapeLandscape

Multiple Objectives:Multiple Objectives:

Internal improvementInternal improvement

++

Advocacy & leadershipAdvocacy & leadership

IHA Collective InitiativeIHA Collective Initiative

Slam Dunk:Slam Dunk:

4 Billion prescriptions/yr4 Billion prescriptions/yr 20% of medical errors20% of medical errors 2 to 7 per 100 hospital 2 to 7 per 100 hospital

admissionsadmissions ADE – 1 to 5 day extended LOSADE – 1 to 5 day extended LOS Up to add’l $9000 costUp to add’l $9000 cost

Medication SafetyMedication Safety

Criteria:Criteria: Addresses issue of public concernAddresses issue of public concern Contributes to real improvementContributes to real improvement Reasonable and fair to providers & publicReasonable and fair to providers & public Operationally feasible Operationally feasible W/in provider control & consistent w/accredW/in provider control & consistent w/accred Offers measurement activityOffers measurement activity

Drive results bigger than one organizationDrive results bigger than one organization

Proactive FocusProactive Focus

Develop, adopt and/or support Develop, adopt and/or support efforts for: efforts for:

(1)(1) Pt Safety Organizational FrameworkPt Safety Organizational Framework(2)(2) Hospital Compliance/Consumer Guide Hospital Compliance/Consumer Guide (3)(3) Medication Safety InitiativeMedication Safety Initiative(4)(4) Simulation Training (Team Skills)Simulation Training (Team Skills)(5)(5) Networking RoundtablesNetworking Roundtables

Addressing the IssueAddressing the Issue

From accreditation, gov’t, literature & From accreditation, gov’t, literature & member sourcesmember sources

Approved by IHA Board in May, 2003Approved by IHA Board in May, 2003 IHA web site: Pledge ParticipantsIHA web site: Pledge Participants

Member Pledge: 188/194 Hospitals Member Pledge: 188/194 Hospitals (97%)(97%)

Advocacy: On-going Leadership effortAdvocacy: On-going Leadership effort

Organizational Framework Organizational Framework **

* Available at www.ihatoday.org

Update–In-Progress:Update–In-Progress:

IHA Quality/Patient Safety Data GuideIHA Quality/Patient Safety Data Guide Federal/state/private activityFederal/state/private activity Hard copy/PDF formatHard copy/PDF format Initial distribution: Mid-Quarter 2004Initial distribution: Mid-Quarter 2004 New section - Publicly available hospital New section - Publicly available hospital

infoinfo

IHA Resource Guide IHA Resource Guide **

* Available at www.ihatoday.org

From Medication Safety

To Patient Safety Learning Collaborative

IHA Medication SafetyIHA Medication Safety

Med Safety = Do a Collaborative (2003-2004):Med Safety = Do a Collaborative (2003-2004):

Learning curveLearning curve Business planBusiness plan Internal marketingInternal marketing Job descriptionJob description Recruitment Recruitment Marketing planMarketing plan Project management tool Project management tool

Behind the ScenesBehind the Scenes

Project Development :Project Development :

Phases (Pre-work, learning sessions, video-conferences, site Phases (Pre-work, learning sessions, video-conferences, site visits, showcase conference):visits, showcase conference): MarketingMarketing Budget & ContractsBudget & Contracts SpeakersSpeakers Materials & printingMaterials & printing RegistrationRegistration EvaluationsEvaluations Meeting logistics Meeting logistics RevisionRevision

On-going Focus:On-going Focus: Dedicated managerDedicated manager Faculty advisorsFaculty advisors Online ForumOnline Forum Measurement StrategyMeasurement Strategy Participant Feedback & ReportsParticipant Feedback & Reports PSLC VisibilityPSLC Visibility

Just in TimeJust in Time

Three Aims:Three Aims:

Individual Hospital ImprovementIndividual Hospital Improvement Aggregate Hospital ImprovementAggregate Hospital Improvement IHA ProcessIHA Process

IHA Patient Safety IHA Patient Safety Learning CollaborativeLearning Collaborative

BalanceBalance

The Constant ChallengeThe Constant Challenge

PSLC

Unique Illinois Patient Safety NexusUnique Illinois Patient Safety Nexus

Quality Oversights

Coalitions

Safety Champions

Patients & Families

Regulatory & Legislative

Other States

Illinois Hospitals

Media

Becky Steward, BSNManager, Patient Safety Learning Collaborative

Concept to ImplementationConcept to Implementation

FrameworkFramework

Model for ImprovementModel for Improvement Learning from LeadersLearning from Leaders A tool and a philosophyA tool and a philosophy

Advisors and Advisors and FacilitatorsFacilitators RoleRole InvolvementInvolvement

SpeakersSpeakers CriteriaCriteria From external to internalFrom external to internal

Establish FoundationEstablish Foundation

DevelopDevelop Measures and tools Measures and tools

** Processes Processes

StaffStaff Labor intensiveLabor intensive FTEsFTEs

Build InfrastructureBuild Infrastructure

* Available upon request

PreparationPreparation ContentContent Materials and Materials and

resourcesresources EvaluationsEvaluations

Build InfrastructureBuild Infrastructure

MarketingMarketing AudienceAudience Message Message

pointspoints Non-Non-

competitivecompetitive SizeSize

Build Awareness Build Awareness

Overview 2005Overview 2005

Participants Participants Health SystemHealth System 1 1 HospitalsHospitals 2525

Geographical cross-Geographical cross-sectionsection NorthernNorthern 1010 CentralCentral 7 7 SouthernSouthern 9 9

Staffed bedsStaffed beds Less than 100Less than 100 2 2 101 – 300 101 – 300 1717 301 – 500 301 – 500 4 4 More than 500 More than 500 2 2

Bring Program to Participants Bring Program to Participants

1.1. Pre-workPre-work

2.2. ActionAction

3.3. Sharing Sharing

Three Distinct Phases Three Distinct Phases

Engage ParticipantsEngage Participants Letter Letter Conference call Conference call ** Baseline data Baseline data

collection collection **

Phase One: Pre-workPhase One: Pre-work

* Available upon request

Build RelationshipsBuild Relationships AccessAccess Follow-throughFollow-through

Manage expectationsManage expectations Tracking tool Tracking tool **

Critical ElementsCritical Elements

* Available upon request

Information and Networking Information and Networking Learning SessionsLearning Sessions VideoconferencesVideoconferences Issues and adjustmentsIssues and adjustments On-line ForumOn-line Forum Site visitsSite visits

Phase Two: ActionPhase Two: Action

2005 Pre-WorkLearning Session

Video-conference

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctober

TechniquesTechniques Unlabeled profilesUnlabeled profiles Of cameras and candyOf cameras and candy New ways to use dataNew ways to use data

Unify Diverse Groups Unify Diverse Groups

Each event involves one or more handoffs

• # Patients registered for ED 2.8 / minute

• # Patients registered for Out Pt. 12.4 / minute

• A Patient is admitted to hospital 1 / 64 seconds

• A child is born 1/ 10 minutes, 21 seconds

• A surgery begins 1 / 90 seconds

• A patient is discharged 1/ 60 seconds

• A child is discharged 1/ 6 minutes, 15 seconds•A patient with mental health or 1/ 14 minutes, 39 seconds

substance abuse is discharged

2004 IHA Data, Participants 2006

Imagine the number

of handoffs

Are we lucky?

Or are we safe?

HumoHumor r

Imagery

On-line ForumOn-line Forum Limited to participantsLimited to participants ““Voice from which I Voice from which I

speak”speak” Enable direct contactEnable direct contact

Facilitate CommunicationFacilitate Communication

Monthly reportsMonthly reports SuccinctSuccinct Inherent valueInherent value ChallengesChallenges

Measuring progressMeasuring progress DataData ““Are you done yet?”Are you done yet?”

Assess ProgressAssess Progress

Innovation in Measurement Innovation in Measurement **

Implementation across organization, monitoring data

Expanding use beyond pilot units, collecting / reporting data

Testing tool / process on pilot units, collecting preliminary data

Developing initial tool / process

Having preliminary discussions

Level 1 Level 2 Level 3 Level 4 Level 5

Healthy Hospital in Jan-05 Healthy Hospital in Jun-05 Healthy Hospital in Sep-05

No Process Process Established

Progress over Progress over timetime

* Available upon request

By facilitatorsBy facilitators

Reports to Reports to participantsparticipants IndividualIndividual AggregateAggregate

Provide FeedbackProvide Feedback

Excerpt – 2005 Final Excerpt – 2005 Final ReportReport

Excerpt – 2005 Final ReportExcerpt – 2005 Final Report

Excerpt – 2005 Final ReportExcerpt – 2005 Final Report

Excerpt – 2005 Final ReportExcerpt – 2005 Final Report

Outcomes CongressOutcomes CongressOctober 18, 2006October 18, 2006Bloomington, ILBloomington, IL

Phase Three : SharingPhase Three : Sharing

Highlights:AttendanceEngagement

Challenges

Beyond Illinois

Common ThemesCommon Themes CommitmentCommitment ExpectationsExpectations ResourcesResources CompositionComposition Effective meetingsEffective meetings Small tests of changeSmall tests of change

Elements for Success Elements for Success

Building on 2005Building on 2005 17 of 26 return17 of 26 return ExperienceExperience

Unique Challenges in 2006 Unique Challenges in 2006 Unique Challenges in 2006 Unique Challenges in 2006

Breaking new Breaking new groundground

Participants Participants Health SystemsHealth Systems 4 4 HospitalsHospitals 2121

Geographical cross-Geographical cross-sectionsection Cook CountyCook County 1515 NorthernNorthern 1010 CentralCentral 6 6 SouthernSouthern 1010

Staffed bedsStaffed beds Less than 100Less than 100 4 4 101 – 300 101 – 300 2626 301 – 500 301 – 500 9 9 More than 500 More than 500 2 2

2006 - Handoff 2006 - Handoff CommunicationCommunication

Master calendar / timelineMaster calendar / timeline

Role changesRole changes

Changes to reportingChanges to reporting

SizeSize

Adjustments in 2006 Adjustments in 2006

Save the Date!

IHA Safety IHA Safety Connections:Connections:Relaying the Lessons Relaying the Lessons LearnedLearned

November 14, 2006Hilton HotelLisle / Naperville

Registration limitedwww.ihatoday.org

““It's a job that's never started that takes the longest to finish.”It's a job that's never started that takes the longest to finish.”

J.R.R. TolkienJ.R.R. TolkienBritish scholar & fantasy novelist (1892 - 1973)British scholar & fantasy novelist (1892 - 1973)

Questions? Questions?