Guiding a Journey to Safe and Reliable Healthcare · Self-improvement. Dual focus (clinical and...
Transcript of Guiding a Journey to Safe and Reliable Healthcare · Self-improvement. Dual focus (clinical and...
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Guiding a Journey to Safe and Reliable Healthcare
Karen Frush, BSN, MD
Chief Quality Officer
Stanford HealthCare
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Objectives
• Describe a framework for guiding a journey to safe and reliable care
• Discuss the link between teamwork, culture and patient outcomes
• Describe the importance of well-being as an integral component of a comprehensive approach to safety and quality
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Agenda
• The early journey at Duke University Health Systemo A framework to guide the journey
• Insights and lessons learnedo Teamwork and the link to patient outcomes
• Taking the quality journey beyond Duke and into the Community
• Achieving safe and reliable care at Stanford HealthCare
The Journey at Duke Health
Insights & Lessons Learned
Translation to Duke LifePoint
Achieving Safe and Reliable Care at Stanford
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James B. Duke Rebecca Kirkland, MD
U.S. tobacco and electrical power industrialist best known for the introduction of modern cigarette manufacture and marketing
Rebecca Kirkland, MD, MPH, is a Pediatric Endocrinologist and Professor Emerita, Baylor College of Medicine, Houston, TX.
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Dr. W.C. Davison, Founding Dean of
DUSOM
“Culture of Continuous Improvement”
“collaboration and cooperation make
medical care possible”
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Jesica Santillan
December 26, 1985 - February 22, 2003
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Improving Healthcare Safety and quality
• Framework for providing safe and reliable careoLeadership Patient safety and QI leaders at all levels in organization
oPerformance improvement Data driven; improvement science; Lean Six Sigma
oCulture High performing teams and effective communication
Psychological safety and mutual respect
Partnering with patients and families
The Journey at Duke Health
Insights & Lessons Learned
Translation to Duke LifePoint
Achieving Safe and Reliable Care at
Stanford
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CSU Structure
• Patient care services are grouped according to Clinical Service Units (CSUs),which is an operational structure that aligns physicians, staff and administration to DUH priorities.
• Co-lead by Vice-President, Medical Director, & Associate Chief Nursing Officero Hearto Oncologyo Musculoskeletalo Neurosciences and Psychiatryo Transplanto Emergency Serviceso Med/Surg/Critical Care o Perioperative Serviceso Women’s o Children’so Ambulatory Practice
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Organizational Priorities
Balance Scorecard Metrics
Operational Work Plan
How do we decide what is important to the organization?
Mission/Vision/ValuesAdvancing health together
Institute of Medicine’s Six Aims of Quality
Performance Improvement
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Culture: A Major Challenge
• Darrell Kirch: The courage to changeo AAMC 2007 President’s Address
o Traditional Academic Medical Center
Individual Experts → Expert Teams
Hierarchy → Mutual Respect
Punitive → Accountability
• Leading Culture changeo Bryan Sexton, PhD
o Safety Culture Surveys
Measuring, analyzing, understanding and using culture data to drive improvement
Reporting Culture Just Culture
Teamwork Culture
Learning Culture
Informed Culture
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• The clinical environment has evolved beyond the limitations of individual performance, so we have to work as teams
• Teamwork is not the focus of most clinical education efforts, so few staff are well equipped to work as teams
• Good teamwork has been linked to better surgical outcomes; trauma resuscitation and time to OR; hospital acquired infection rates; birth trauma; mortality ratios, operational efficiencies, resilience and well being
• We work in teams, but we train in silo’soNursing School, Medical School
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Teamwork is not Natural, but Critically Important
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Speaking a Different Language
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Paradigm Shift to Team System Approach
Team of Experts
Expert Team
Single focus (clinical skills)
Individual performance
Under-informed decision-making
Loose concept of teamwork
Unbalanced workload
Having information
Self-advocacy
Self-improvement
Dual focus (clinical and team skills)
Team performance
Informed decision-making
Clear understanding of teamwork
Managed workload
Sharing information
Mutual support
Team improvement
Role Clarity
“Achieve a mutual goal through interdependent and adaptive actions”
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Teamwork at Duke
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Changing Culture at Duke
• TeamSTEPPSo National Training Site since 2007
o Patients (PFAC members) as co-faculty
• Duke Patient Safety Center for Training and Researcho Patient Safety Leadership Training
o Physician and Executive Leadership in Patient Safety and Quality
o NPSF Certification as Professional in Patient Safety (CPPS)
o Resilience Courses
o Just Culture - D Marx, JD
o Professionalism - Gerald Hickson, MD
o Beryl Institute and patient partnership, co-design
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Evolution of DUHS Service Line PFACs
DUHS Patient
Advisory Council
Oncology Patient
Advisory Council Peri-operative
services PFAC
Medical school collaboratives
DRaH PAC
groups/ activities
PDC/PRMO CSU PAC groupsDHCH
Patient Advisory Councils
DPC local patient advisory
committees
DRaHOncology
PFAC
Emergency Services
PFAC
DUH Children’s
PFAC
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Overall improvement
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# Med Events > SI 2 (Preventable)
# PSIs
Running 12 Month All Events Rate Per 10K Adj Pt Days
is better
0.99 0.94
0.78 0.74
3.02%3.48%
2.45% 2.29%
0.40%
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FY13 FY14 FY15 FY16
HIP/KNEE LOS INDEX
HIP/KNEE 30 DAY READMISSION RATE
Total Joint LOS and Readmission Trends and Knee LOS and Readmission Trends
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The Duke-LifePointPartnership
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• Founded in 1999; one of largest health care systems in U.S. • More than $6.5 billion in revenues and one of the best balance
sheets in the industry• 71 hospital campuses in 22 states;
approximately 47,000 employees; and more than 6,300 physician relationships
• Leading healthcare provider in its communities and committed to keeping healthcare local
Duke LifePoint HealthcareLifePoint Mission: “Making Communities Healthier”
The Journey at Duke Health
Insights & Lessons Learned
Translation to Duke LifePoint
Achieving Safe and Reliable Care
at Stanford
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DLP Healthcare, LLC (Duke LifePoint) formed in Jan 2011 to improve health care throughout NC & surrounding regions through a network of community hospitals (Duke LifePoint Regional Strategy)
‒ Governing Board oversight with Duke & LifePoint representation‒ Quality Program overseen by joint Duke LifePoint QOC with resources & support provided by DQN
Separate Quality Program Affiliation with LifePoint established to ensure a consistent quality & patient safety platform across LifePoint & Duke LifePoint Hospitals (LifePoint National Quality Program – NQP)
Duke LifePoint Healthcare
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Network of Hospitals, Physicians and Healthcare Services that are Quality Driven, Adaptive to Change, Financially Strong
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2011: CMS Hospital Engagement Network
In December 2011, Duke and LifePoint began a relationship with the CMS Innovation Center as one of 26 organizations designated as a
Hospital Engagement Network.
This was the most widely regarded and most highly anticipated program in the Partnership for Patients.
IMPROVE SAFETY: Reduce preventable harms by 40%
COORDINATE CARE: Reduce readmissions by 20%
ENGAGE PATIENTS AND FAMILIES
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Hospital Board or Patient Advisory Council
Bedside Shift Report At the Point of Care
In Process Improvement
In Governance
Patient Safety and Patient Experience
Patient & Family Engagement
Culture that Supports Safety & Learning
• Environment that fosters teamwork and accountability; psychological safety and speaking up
• Engaging patients & their families
Process Improvement Methods
• Foundational tools and skills
• Technology and data analytics
• Evidence based clinical processes
Leadership• Every level of the
organization• Accountability that is
fair & expected• Engagement of all
stakeholders
Duke-LP HEN Reliable
Framework
Duke LifePoint Framework
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LifePoint Harm Rate for Original HEN Harms(Excludes hip fracture, punctures, pneumothorax, MRSA, sepsis, & wound dehiscence;
excludes data for Central Carolina, Conemaughs, Fleming,& Frye)
Harm Rate 2010 Baseline Original HEN Goal
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HEN Inpatient Harms and Readmissions
64% reduction April 2017 compared to 2010 Baseline
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Improvement in Culture of Safety
Frush K, et al. National Quality Program Achieves Improvements in Safety Culture and Reduction in Preventable Harms in Community Hospitals. Jt Comm J Qual Patient Saf.
2018. Jul:44(7)389-400. doi 10.1016/j.jciq.2018.04.008. Epub 2018 Jun 6
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Achieving Safe and Reliable Care at Stanford
The Journey at Duke Health
Insights & Lessons Learned
Translation to Duke LifePoint
Achieving Safe and Reliable Care at
Stanford
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Safe and Reliable Care: Sociotechnical
• Leadership• Technology, data analytics• Transparency and reliability• Organizational learning
– Psychological Safety– Feedback
• Teamwork and mutual respect– Trust– Inclusion
• Resilience, purpose driven work
Frankel, et al. IHI 2017
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Placeholder - - Stanford Data
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Non-verbal messages
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Effective Leadership
Edgar Scheino Humble Inquiry: The gentle art of asking rather than telling Communication is essential in a healthy organization. But all too often when we interact
with people—especially those who report to us—we simply tell them what we think they need to know. This shuts them down. Humble Inquiry is the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person. It’s an essential art to collaboration, culture, change and leadership.
o Humble Leadership: The power of relationships, openness and trust The more traditional forms of leadership that are based on static hierarchies and
professional distance between leaders and followers are growing increasingly outdated and ineffective. As organizations face more complex interdependent tasks, leadership must become more personal in order to insure open trusting communication that will make more collaborative problem-solving and innovation possible.
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Why is Culture Important?
• At the core, healthcare is about people taking care of people• Culture reflects the behaviors and beliefs of the people within
an organization, “the behavioral norms”oThere are behaviors that create value individually, for the
patient and the organization.oThere are behaviors that create unacceptable risk.
• These attitudes and behaviors are reflected in how people interact with each other both internally and externally with patients and their families
• Culture is the social glue• Culture is linked to outcomes
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Teamwork Climate Scores Across Facility
Patient Satisfaction 9250
Medication Errors per Month 2.06.1
Days between C Diff Infections 12140
Days between Stage 3 Pressure Ulcers 5218
Better Culture: Better Patient Outcomes
Illustrative Data:Extracted fromBlinded Client DataMichael Leonard, MD
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Teamwork Climate Scores Across Facility
Employee Satisfaction 9155
Employee Injury per 1000 days 0.116
Employee Absenteeism per 1000 days 1015
RN Vacancy Rate 19
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Talk about people behind their backs.Intentionally exclude others from the group.
Use a personal phone in ways that interfere with work.Treat new people harshly.
Bully other people.Turn their backs before a conversation is over.
Yell at other people.Fail to respond to phone calls, pages, and/or requests.
Try to publicly humiliate others.Set others up to fail.
Violate HIPPA.Hang up the phone before a conversation is over.
Make comments with sexual, racist, or ethnic slurs.Show physical aggression (e.g., grabbing, throwing,…
Touch people in overtly sexual ways. ≥80 good teamwork
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While you are waiting for us to start, perhaps you could send a quick text to someone important to you, to send a kind thought their way.
Thriving vs. Surviving During Times of Change: Resilience as QualityWith thanks to:J. Bryan Sexton, PhDDirector, Duke Patient Safety Center
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What are the causes??
Work-life imbalancePoor sleep hygiene
LonelinessNegative thoughts
Production pressureLack of control over job
Leadership supportConflicts with colleagues
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Building Personal Resilience: Three good things
Seligman, Steen, Park & Petersen, 2005
• Based on positivity research
• Each night, record 3 positive events in a journal
• As effective as SSRI for 6+ months
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93% would recommend 3 GT to a Friend / 91% Supervisor
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Teamwork Climate Safety Climate Threat Awareness Resilience Work Life Balance
DUHS 20143GT Yes3GT No
Mean
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Resilience
Mean of the clinical area scores
DUHS Safety Culture & Resilience
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Safety Climate, 71
Threat Awareness, 50
Resilience, 40
Work Life Balance, 49
Teamwork Climate, 77
Safety Climate, 80
Threat Awareness, 52
Resilience, 45
Work Life Balance, 51
Teamwork Climate, 64
Safety Climate, 67
Threat Awareness, 50
Resilience, 37
Work Life Balance, 47
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DUHS 2014
3GT Yes
3GT No
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Desired Safety Culture
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Guiding a Journey to Safe and Reliable Healthcare
Safe and Reliable
Healthcare
TechnicalClinical Science and SkillsSystems and Processes
Data AnalyticsTechnology
SocialTeamwork & Communication
Psychological SafetyHumble Leadership
Well-Being
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Thank You!
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Guiding a Journey to � Safe and Reliable Healthcare ObjectivesAgenda James B. Duke Rebecca Kirkland, MDSlide Number 5Slide Number 6Jesica SantillanImproving Healthcare Safety and qualityCSU StructurePerformance ImprovementCulture: A Major ChallengeTeamwork is not Natural, but Critically ImportantSpeaking a Different LanguageParadigm Shift to Team System ApproachSlide Number 15Changing Culture at DukeEvolution of DUHS Service Line PFACsOverall improvementThe Duke-LifePoint �PartnershipSlide Number 20Slide Number 212011: CMS Hospital Engagement NetworkDuke LifePoint FrameworkSlide Number 24Improvement in Culture of SafetyAchieving Safe and Reliable Care �at StanfordSafe and Reliable Care: SociotechnicalPlaceholder - - Stanford DataNon-verbal messages Effective Leadership Why is Culture Important?Better Culture: Better Patient OutcomesBetter Culture: Better Employee OutcomesSlide Number 34�����While you are waiting for us to start, perhaps you could send a quick text to someone important to you, to send a kind thought their way.Slide Number 36What are the causes??Building Personal Resilience: Three good thingsSlide Number 39Slide Number 40Slide Number 41Slide Number 42Desired Safety CultureGuiding a Journey to Safe and Reliable HealthcareSlide Number 45