Post on 15-Jan-2016
The Indianapolis Coalition for Patient Safety
It Takes a City
The Indianapolis Coalition For Patient Safety
Opportunities for Research and Partnership
Glenn Bingle, MD, PhDChair, Indianapolis Coalition for Patient Safety
Chief Medical OfficerCommunity Health Network
Kathy Rapala, JD, RN, DNP (c)Executive Director, Indianapolis Coalition for
Patient SafetyVisiting Associate Professor
Purdue School of Nursing
Objectives
• Introduction to the Indianapolis Coalition for Patient Safety
• Overview of Coalition interests and projects
• Opportunities for research and partnership
www.indypatientsafety.orgwww.indypatientsafety.org
Indianapolis Coalition for Patient SafetyEst. 2003
VeteransAdmin
Community
Clarian
St. Vincent
St. Francis
Wishard
Collaboratefor Patient
Safety
Deans of MedicalRN, Pharm Schools
Department of Public Health
Health CareExcel
Health Care Advantage
Marion County Dept of Health
Indiana State Board of Health
Anthem WellPoint
IHIE
RegenstriefInstitutes
Eli Lilly
>>Make Indianapolis safest
For health care
SHAREDVision &
Challenge>> Shared Resources
>> Shared Performance Targets
>> Shared Accountability
>> Shared Funding
>> Shared Learning
Do not compete on safety!
WORKING TOGETHER
>> Outcomes: Accelerated
Improvement
COLLECTIVE ACHIEVEMEN
T
“The Indianapolis Coalition for Patient Safety is a prime example of how collaboration is accelerating change…among very competitive organizations (and) is a national model for community-based process improvement…” --Don Berwick, IHI President and CEO
USA Safety Collaborative View: Where do we fit?USA Safety Collaborative View: Where do we fit?
7
Improved Safety
INDIANA
MINNESSOTA
CALIFORNIA (4)ILLINOISPITTSBURGHWISCONSINTRI CITY (WASHINGTON STATE)
INSTITUTE FOR HEALTH CARE QUALITY IMPROVEMENT
JOINT COMMISSION ON HOSPITAL ACREDITATION
INSTITUTE FOR SAFE MEDICAL PRACTICE
NATIONAL PATIENT SAFETY FOUNDATION
INDIANAPOLIS et al
SAN DIEGO
REGIONAL=8NATIONAL=12
STATEWIDE=31 CITY WIDE=2
Google Search Maryland Coalition Survey
National
Patient Safety
Efforts
Institute for Healthcare
Improvement
Consumer
Groups
Institute for Safe
Medication Practices
Joint
Commission
AHRQ
CMS
National Quality Forum
Partnership for Patient
Safety
LeapfrogGroup
National Patient Safety
Foundation
Ambulatory Quality Alliance
National Committee for
Quality Assurance
National Collaborators on Safety
100K Campaign
Collaboratives
HCUP PSOs
Safety Goals
Data Collection
Hospital Core Safe
Practices
Serious Reportable Events
Nursing Sensitive
Thoracic Surgery
Cancer Care
Safe PracticesSafe practices
Rewards Program
SCIP
8th Scope of Work
ACE
HCAHPS
Sentinel Event Reporting
L Gelinas VHA 07 modified Bingle
2003 2004 2005 2006 2007
Std. UnsafeAbbreviation
Std. SurgicalSafety site; ID; Time out
SafetyRounds &Survey
Accelerate &ImplementAll 100K LivesStrategies
Std.& Improve ReliabilityDelivery to Admin ofAnticoagulants & Insulin
Std singlePlan for EmergencyPreparedness/Avian Flu Response
MRSA collaborativeWith Regenstrief, VA
What activities do city & state collaborations engage in?
• Professional, public, media education• Standardization and implementation of best practice
around safety issues of mutual concern• Coaching; supporting; encouraging best safety practice• Awarding by recognizing excellence• Sharing best practices• Research• Report safety performance • Guideline developing for best practice• Sharing unique resources like simulation labs
• Key milestones include:
– High Alert Drugs • anticoagulants• Insulin
– Surgical Areas
– Root Cause Analysis
– Patient Safety Rounds
– Standardized Abbreviations
– Institute for Healthcare Improvement 100,000 Lives Campaign
Indianapolis Coalition for Patient Safety
Indianapolis Coalition for Patient Safety History
• Officially formed in 2003• 6 Indianapolis healthcare systems—
Clarian, Community, St. Francis, St. Vincent, VA and Wishard--decided to collaborate and not compete on the basis of patient safety.
• Held an first executive session facilitated by the National Patient Safety Foundation in 2003.
Indianapolis Coalition for Patient Safety: Mission & Vision
• Improve the safety of patients receiving healthcare in Indianapolis
• Make Indianapolis (Indiana) the safest city (state) to receive healthcare in the United States.
Initiative Highlights
•Anticoagulation •Lilly/Wishard 6 Sigma Collaboration
•High Risk IV Standardization
Methodist may speed up safety updatesBar-code system is in place at Clarian NorthSeptember 20, 2006
Anticoagulation Initiative
2 babies at Methodist die of overdose4 others also get wrong dosage of anti-clotting drugSeptember 18, 2006
Hospital errors to go public in 2007Indiana identifies 27 mistakes that hospitals will have to reportSeptember 21, 2006
Indianapolis Coalition for Patient Safety
Recognition – Anticoagulant Workgroup
Dan Degnan, PharmD, MS, CPHQ
Jim Fuller, PharmD
Jen Reddan, PharmD
Leann McGinley-Wright, PharmD
Bill Malloy, PharmD
Chris Scott, PharmD
Divya Abraham, PharmD
Mechelle Peck, RN
Tamra Arnold, PharmD
Scott Freeland, PharmD
Jim Eskew, RPh, MBA
Steve Hultgren, RPh, MBA
Susan Brown, RPh, MBA
Anticoagulant Workgroup• Goal: Make the use of anticoagulant
medications in Indianapolis Health-Systems safer
• Partnership identified with the Institute for Safe Medication Practices (ISMP)– Initial model: Collaborative (FMEA, Guided
process)– Final model: Best practice (Self
assessment, commitment to data sharing and comparison)
Core Safe Practice Challenges• Functional drug interaction warnings for CPOE and pharmacy systems• Medication reconciliation for anticoagulants
across the continuum• Majority were “green” across the board
Target Safe Practice Challenges• Pharmacy dispensing for all anticoagulant
doses• Independent double checks• Clinical pharmacy monitoring services for
anticoagulants
Anticoagulant Workgroup – Self Assessment
Universal Metric Identification• Pre-requisite – Minimize chart review, automated
data, meaningful from a safety standpoint, comparable
• ISMP and IHI were starting points• Trial and ErrorHeparin and PTT measures• Protocol (yes or no)• PTT %s in four distinct ranges• Selection rationale
– Protocol effectiveness– Electronic data– Sub therapeutic measurement
Anticoagulant Workgroup – Universal Metric
Anticoagulant Workgroup – Library
Anticoagulant Workgroup – Computer Script
Anticoagulant Workgroup – Computer Script
Research wishes
• Study of the PTTs
• Process/computer studies
• Validation of best practices
• Process measure refinement
Lean Six Sigma
Wishard-Lilly Insulin Safety Project
Coalition for Patient Safety
Executive Leadership Update
Objectives
• Reaffirm the importance and impact of insulin safety in the hospital setting
• Learn how the Lean Six Sigma process and tools were applied to improve the dispensing and administration of insulin at Wishard Health Services
• Share project insights obtained by Wishard and Lilly around patient safety
• Discuss additional opportunities in the hospital setting
Team MembersWishard Health Services Team Lisa Harris, CEO/CMO, Executive SponsorDivya Abraham, Inpatient pharmacyKerri DeNucci, Clinical pharmacyAbby Mortier, Inpatient pharmacy Jim Fuller, Pharmacy DirectorSusan Gallagher, RN Burn UnitCrissy Lough, Quality/Safety Cheryl Young, CNS DMShirley Howell, NP HospitalistTracy Martin, ED DirectorLeeAnn Blue, VP, Nursing Lilly Team
Jim Collins, Exec Director, Devices, SponsorBill Malatestinic, Outcomes Research, SponsorMark Urban, Director B2B, Key StakeholderJana Klopp, PrivacyDoug Whiteman, Outcomes ResearchMatt Thomas, Packaging EngineerJay Yamamoto, Black Belt
• RFP• Pre-determined selection criteria• Targeted opportunity• Mutual Benefit
DMAIC Process and Six Sigma Tool Kit
DefineDefine
MeasureMeasure
AnalyzeAnalyze
ImproveImprove
ControlControl
Charter, Mission statement, SIPOC, Risk analysis, High level process map
Detailed process maps, “Be the vial” hospital tour, Ishikawa fishbone diagram
Baseline data collection
Solutionselection, FMEA
Adherence activities, RACI, Control plan
Unpackage insulinplace in bins
Insulin arrivesat dock
Inventory shipment
Place bins inrefrigerator
Gopher order for insulin comes in
RPh prints orderRPh takes orderand enters in
HMMYES: Label printsif vial charged for
Invento
ry
Tech
RP
hD
esk T
ech
Runner
Tech
Tech pulls labelGoes to refrigeratorto pull appropriate
insulin
Places label and insulin in baggie
Decentral:Set on counter or
on round
Central:Give to RPh tolabel and check
Decentral:Takes baggie to
floor
Decentral:Sets ?? if not
already checked
NO: Vial NOT chargedfor…???
Decentral:Sometimes getschecked here?
Central:Takes baggie to
floor
Central:Sets in “In”basket
*Can sit for minutesto hours here*
Flo
or
Nurs
e
Decentral:Removes from
Inbasket, places inlocked cabinet
Central:Removes from
Inbasket, places in locked cabinet
Insulin sits in refrig until
pulled
Label sits until pulled
Decentral:Tech checks vialsdaily in AM againstcensus for D/C pts
Decentral:Throws away any
open vials
Decentral:Credits any unused
Vials in HMM
Decentral:Removes labels,returns to Dunlap
refrigerator
Sate
llite
RP
h
Decentral:Sets in “In”basketif already checked
Decentral:Stored until
admin topatient
Central:Stored until
admin topatient
Process Maps
Before… After…Unpackage insulin
place in bins
Insulin arrivesat dock
Inventory shipment
Place bins inrefrigerator
Gopher order for insulin comes in
RPh prints orderRPh takes order
and enters in HMM
YES: Label printsif vial charged for
Inve
nto
ry
Te
ch
RP
hD
esk T
ech
Ru
nne
r T
ech
Tech pulls labelGoes to refrigeratorto pull appropriate
insulin
Places label and insulin in baggie
Decentral:Set on counter or
on round
Central:Give to RPh tolabel and check
Decentral:Takes baggie to
floor
Decentral:Sets ?? if not
already checked
NO: Vial NOT chargedfor…???
Decentral:Sometimes getschecked here?
Central:Takes baggie to
floor
Central:Sets in “In”basket
*Can sit for minutesto hours here*
Flo
or
Nu
rse
Decentral:Removes from
Inbasket, places inlocked cabinet
Central:Removes from
Inbasket, places in locked cabinet
Insulin sits in refrig until
pulled
Label sits until pulled
Decentral:Tech checks vials
daily in AM againstcensus for D/C pts
Decentral:Throws away any
open vials
Decentral:Credits any unused
Vials in HMM
Decentral:Removes labels,returns to Dunlap
refrigerator
Sa
tellite
RP
h
Decentral:Sets in “In”basketif already checked
Decentral:Stored until
admin topatient
Central:Stored until
admin topatient
Unpackage insulinplace in bins
Insulin arrivesat dock
Inventory shipment
Place bins inrefrigerator
Gopher order for insulin comes in
RPh prints orderRPh takes order
and enters in HMM
YES: Label printsif vial charged for
Inve
nto
ry
Te
ch
RP
hD
esk T
ech
Ru
nne
r T
ech
Tech pulls labelGoes to refrigeratorto pull appropriate
insulin
Places label and insulin in baggie
Decentral:Set on counter or
on round
Central:Give to RPh tolabel and check
Decentral:Takes baggie to
floor
Decentral:Sets ?? if not
already checked
NO: Vial NOT chargedfor…???
Decentral:Sometimes getschecked here?
Central:Takes baggie to
floor
Central:Sets in “In”basket
*Can sit for minutesto hours here*
Flo
or
Nu
rse
Decentral:Removes from
Inbasket, places inlocked cabinet
Central:Removes from
Inbasket, places in locked cabinet
Insulin sits in refrig until
pulled
Label sits until pulled
Decentral:Tech checks vials
daily in AM againstcensus for D/C pts
Decentral:Throws away any
open vials
Decentral:Credits any unused
Vials in HMM
Decentral:Removes labels,returns to Dunlap
refrigerator
Sa
tellite
RP
h
Decentral:Sets in “In”basketif already checked
Decentral:Stored until
admin topatient
Central:Stored until
admin topatient
Check all meds centrally Quick win, eliminates steps checking @ satellites, delays getting meds to floors
Research wishes
• Process and methodology of Six Sigma for safe insulin administration within facilities; eliminate steps/rework
• Gaps and opportunities analyzing process maps vs. reality• Standard Operating Procedures re: insulin administration• Standard training for physicians, nurses, techs and
pharmacists• Report Card on the progress• Work on other issues identified: meal
times/tests/procedures and relation to our patients on insulin therapy
SPREAD!!!!
Other initiatives
• OR time out/site verification standardization
• Standardization of high risk infusions (collaboration with Purdue PharmaTAP).
• Cardinal grant for IV smart pump comparative data base.
• Severe sepsis initiative
Opportunities for Partnership
• Research opportunities– 6 hospital systems– Suburban Health Organization– Gear toward relevant needs in hospital systems
• Process measurement/validation– Observational research– Process improvement
• Grants, articles, partnerships…many opportunites
How to work with ICPS
• Come to a meeting. We meet the last Tuesday every other month.
• Chat with either of us regarding specific opportunities
• Explore grant opportunties on the subjects we discussed
Thank you!