Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar:

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Welcome to theNQF Safe Practices for Better

Healthcare 2009 Update

Webinar:Leadership and Leadership Principles

for Safety (Safe Practices 1-4)

Hosted by NQF and TMIT

Attendee dial-in instructions:Toll-free Call-in number (US/Canada): 1-866-764-

6260 (direct number, no code needed)To join the online webinar, go to:

www.safetyleaders.orgOnline Access Password: Webinar1 (case-sensitive)

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Charles Denham, MDChairman, TMIT

Co-chairman, NQF Safe Practices Consensus Committee

Chairman, Leapfrog Safe Practices Program

Safe Practices WebinarJuly 16, 2009

Welcome and Overview of the Culture of Safety

Chapter of the 2009 NQF Safe Practices

Toll-free Call-in number: 1-866-764-6260

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Panelists

Peter Angood, MDCharles Denham, MDJames Conway, MS Dan Ford, MBA


Peter Angood: Important National Highlights Regarding Leadership and Culture

Charles Denham: Leadership and Culture Practices: New Roles for Leaders

James Conway: Bringing Boards on Board: Critical Issues in 2009

Dan Ford: Patient Perspective on Involving Patients in Patient Safety

6Toll-free Call-in number: 1-866-764-6260

Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition- & Site-Specific Practices

Consent & Disclosure

Culture

Workforce

Consent and Disclosure


CHAPTER 7: Hospital-Associated Infections• Hand Hygiene• Influenza Prevention• Central Venous Catheter-Related Blood Stream

Infection Prevention • Surgical-Site Infection Prevention• Care of the Ventilated Patient and VAP • MDRO Prevention• UTI Prevention

Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition-, Site-, and Risk-Specific Practices


Wrong-siteSx Prevention

Press. Ulcer Prevention

DVT/VTE Prevention

Anticoag. Therapy

VAP Prevention

Central V. Cath.BSI Prevention

Sx-Site Inf.Prevention

Contrast Media Use

Hand HygieneInfluenza

Prevention

Pharmacist Systems Leadership:High-Alert, Std. Labeling/Pkg., and Unit-Dose

Med. Recon.

Culture

CPOE

Read-Back & Abbrev.

Discharge System

PatientCare Info.

LabelingStudies

Culture Meas.,FB., and Interv.

Structuresand Systems

ID and Mitigation Risk and Hazards

Team Trainingand Team Interv.

Nursing Workforce

ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care

CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices]

Leadership Structures and Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards

CHAPTER 5: Information Management and Continuity of Care

Patient Care Information Order Read-Back and Abbreviations Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including

CPOE

CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Leadership Role Including: High-Alert

Med. and Unit-Dose Standardized Medication Labeling and Packaging

CHAPTER 8:• Wrong-Site, Wrong-Procedure, Wrong-Person

Surgery Prevention • Pressure Ulcer Prevention• DVT/VTE Prevention• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention• Organ Donation• Glycemic Control• Falls Prevention• Pediatric Imaging

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Informed Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver

Consent and Disclosure

2009 NQF Report

Care of Caregiver

MDROPrevention

UTIPrevention

FallsPrevention

OrganDonation

GlycemicControl

New

MaterialChanges

No MaterialChanges

Legend:

PediatricImaging

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Important National Highlights Regarding

Leadership and Culture

Peter B. Angood, MD, FRCS(C), FACS, FCCMSenior Advisor, Patient Safety

National Quality Forum



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2009 Obama Budget Proposal – 7th of Eight Principles for Healthcare:

“Improve patient safety and quality care. The plan must ensure the implementation of proven patient safety measures and provide incentives for changes in the delivery system to reduce unnecessary variability in patient care. It must support the widespread use of health information technology and the development of data on the effectiveness of medical interventions to improve the quality of care delivered.”



1. Leadership Structures and Systems2. Culture Measurement, Feedback, and

Intervention3. Teamwork Training and Skill Building4. Identification and Mitigation of Risks and

Hazards

Creating and Sustaininga Culture of Safety


This practice outlines and defines the activities that must be undertaken by governance, administrative, and safety leaders with real specificity regarding activities in generating awareness, accountability, ability, and action.

Safe Practice 1:Leadership Structures and Systems


This practice has no substantive changes to the 2006 practice element. Culture measurement is an evolving area and flexibility was built into the original 2006 practice element to accommodate that evolution.

Safe Practice 2:Culture Measurement, Feedback, and Intervention


Safe Practice 3: Teamwork Training and Skill Building

Other than updated references and recognition of the AHRQ-funded TeamSTEPPS program, there are no substantive changes to the practice activities.


Safe Practice 4: Identification and Mitigation of Risks and HazardsThis practice integrates the information flow and actions among Risk Management, Safety, and Performance Improvement Staff and Departments.

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Leadership is pivotal for improvements in all aspects of patient safety, quality, and the general performance of organizations so that the culture of any individual organization continues to grow in its values, beliefs, and daily behaviors, while providing care to the patients and families.


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Leadership and Culture Practices: New Roles for

Leaders

Charles Denham, MDChairman, TMIT

Co-chairman, NQF Safe Practices Consensus Committee

Chairman, Leapfrog Safe Practices Program

Safe Practices WebinarJuly 16, 2009Toll-free Call-in number: 1-866-764-6260

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“If you lose the patient…

Don’t lose the lesson.”

Thomas Hamilton

Director, Survey & Certification Group Center for Medicaid & State Operations

Centers for Medicare & Medicaid Services

IMPROVING PATIENT SAFETY BY CREATINGAND SUSTAINING A CULTURE OF SAFETY

Values

Systems

Structures

Behaviors

Outcomes

Culture Measurement, Feedback, and Intervention

Teamwork Training and Skill Building

Identification and Mitigation of Risks and Hazards

Leadership Structuresand Systems

Patients and Community

NQF 34 Safe Practices

Evolution of Leadership Safe Practices

2003 Safe Practices:

• Culture related activities provided as a list

• Lack of standardization

• Selected reading provided

• Evidence sample provided

2006 Update:

• Harmonized across NQF, AHRQ, Joint Commission, CMS, IHI, Leapfrog Group to line item specification

• Leadership Structures and Systems held firm.

• Care Settings Standardized

• Implementation Guides Added

• Thoroughly Evidence-based and literature cited.

2009 Update:

• Harmonization partners grew from 2006 to include CDC, APIC, and HRSA.

• Leadership Structures and Systems held firm.

• Added Patient Involvement chapter and included in all practices.

• Comprehensive update to Evidence.

• Made care settings standardized to CMS frame.

Coming Soon

--

Coming Soon

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Safe Practice 1: Leadership Structures and Systems Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served.

Safe Practice 2: Culture Measurement, Feedback, and InterventionHealthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk.

Safe Practice 3: Teamwork Training and Skill BuildingHealthcare organizations must establish a proactive, systematic, organization-wide approach to developing team-based care through teamwork training, skill building, and team-led performance improvement interventions that reduce preventable harm to patients.

Safe Practice 4: Identification and Mitigation of Risks and HazardsHealthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm.

Safe Practice 1: Leadership Structures and Systems

Safe Practice 2: Culture Measurement, Feedback and Intervention

Safe Practice 3: Teamwork Training and Skill Building

Safe Practice 4: Identification and Mitigation of Risks and Hazards

Culture


Workforce

Info Management &Continuity of Care

MedicationManagement

Healthcare AssociatedInfections

Condition & SiteSpecific Practices

You need the Safe Practices for Better Healthcare to use the Implementation Toolboxes below. It may be purchased at www.QualityForum.org.

Coming Soon

http://www.qualityforum.org/

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CultureConsent &Disclosure

WorkforceInfo Management &Continuity of Care

MedicationManagement

Healthcare AssociatedInfections

Condition & SiteSpecific Practices

You need the Safe Practices for Better Healthcare to use the Implementation Toolboxes below. It may be purchased at www.QualityForum.org.

Safe Practice 1: Leadership Structures and Systems

Quick Start Pack

SLIDES:Safe Practice 1 Quick Start Guide

VIDEOS:Leadership Structures and SystemsWedding: Commitment eC-T-RLevel 5 Leaders eC-T-R

RESOURCES:Safe Practice 1 Quick Start Guide

Safe Practice Video Articles Slide Sets Collaborations

Practice:Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served.

Applicable Clinical Care Settings:This practice is applicable to Centers for Medicare & Medicaid (CMS) care settings, to include ambulatory, ambulatory surgical center, emergency room, dialysis facility, home care, home health services/agency, hospice, inpatient service/ hospital, outpatient hospital, and skilled nursing facility.

Awareness Structures and Systems:Structures and systems should be in place to provide a continuous flow of information to leaders from multiple sources about the risks, hazards, and performance gaps that contribute to patient safety issues.

DOWNLOAD FULL PACK:Safe Practice 1 Quick Start Pack (ZIP)

Coming Soon

http://www.qualityforum.org/

Leadership Collaborative:

• First Speaker Bill George former CEO of Medtronic

• Practical Issues in Leadership

• Governance, C-Suite, Mid-Level Managers

• Interactive Format with Q & A

• August or September Kick-off Date

Leadership Collaborative

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Bringing Boards On-board: Critical Issues in 2009

James Conway, MSSenior Vice President,

Institute for Healthcare Improvement (IHI)



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• IHI Boards on Board Intervention • NQF Safe Practices:

– Execution of Safe Practices– Publicly Verifiable Results– Example Organizations of Great Leadership

• Concluding Comments• For Further Info• Questions

Outline


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In every way, fully aligned and consistent with NQF Safe Practices 1-4

1. Setting aims2. Getting data and hearing stories 3. Establishing and monitoring system-level

measures4. Changing the environment, policies, and culture5. Learning6. Establishing executive accountability


Boards on Board Plank

5 Million Lives Campaign


• Children’s Hospital, MN– Any sentinel event is reviewed through the Focused Event

Review (FER) process and all reviews are presented to the Board Quality Committee.

– Children’s distributes a monthly Quality Report that includes measures reviewing all aspects of patient safety and creates a quarterly patient safety report. Indicators include infection rates, medication errors, mortality rates, readmission rates, and measures documenting progress towards patient safety goals.

• Virginia Mason Medical Center, Seattle, WA– VMMC has one organizational goal – To ensure the safety of

our patients through the elimination of avoidable death and injury. This has been the only goal since 2005.

• Children’s Hospital, Cincinnati, OH – The Board set aims for each of the two years (FY2007 to

reduce serious safety events by 25% from baseline, and FY2008 to reach an overall reduction in serious safety events of 80% from baseline).

SP1 – Leadership Structures and Systems


• Delnor Community Hospital, Geneva, IL– The Board Quality Committee has developed a global Harm-

Safety Index measurement indicator for its Clinical Dashboard. This serves as a “surrogate” index for harm events and a specific aim is developed based upon internal historical performance.

– A “patient experience” story has been presented at Board meetings since January 2006. Each story is specifically selected and connected to highlight a “Big Dot” or “Driver” measure on the Clinical Dashboard. The story is told by either the patient himself, a medical staff member, and/or senior management.

• Mary Imogene Bassett Hospital, Cooperstown, NY– The Board of Trustees Performance Improvement Committee

developed a clinical quality scorecard to ensure its ongoing oversight of significant quality/safety-related processes such as medication events, adverse drug reactions, patient falls, ventilator-associated pneumonia, compliance with hand hygiene, and MRSA transmission rate, to name a few.

SP1 – Leadership Structures and Systems (cont’d)


SP1 – Leadership Structures and Systems (cont’d)• Dana-Farber Cancer Institute, Boston, MA

– Patient representatives from the adult and pediatric patient and family advisory councils are members of the Board quality committee.

• Henry Ford Health System, Detroit, MI– All executives, including physician executives, are held

accountable for specific, business-unit level quality and safety goals as part of their annual incentive bonus (15% of bonus eligibility, balancing other performance areas such as financial performance, service excellence, employee satisfaction, and individual goals. Employees’ opinions of the culture of safety is one component on each plan.

• Hot Springs Memorial Hospital, Thermopolis, NY– Formal quality report is presented at every board meeting

with the goal of 30% of board time spent on quality. – Patients and families who have suffered medical errors come

to board meetings to tell their story.


• Children’s Hospital, Cincinnati, OH– Through the execution of employee safety surveys

(AHRQ), safety training for all employees, the institution of a safety coach program, and a culture that promotes 200% accountability for safety (for self and others), CCHMC is highly engaged in changing the environment and the culture with particular emphasis on those at the sharp end of error.

• Hot Springs County Memorial Hospital, Thermopolis, NY– We have launched a customer service process that

involves every staff member in quarterly employee satisfaction surveys, monthly leadership rounding, and employee forums.

• Dana-Farber Cancer Institute, Boston, MA– The organization adopted and promulgated a set of fair

and just culture principles in 2003. Demonstrating the organization’s core value of Respect, these principles guide the conduct of root cause analyses and the organization’s response to adverse events and medical errors.

SP2 – Culture


• Henry Ford Health System, Detroit, MI– Our Culture of Safety work plan is system-wide and includes

several tactics on team communications, routine measurement of our employees and physicians to assess their belief in our culture of safety, implementation of “Just Culture” policies and training, Speak Up and Speak Out approaches, and several other initiatives.

• Mary Imogene Bassett Hospital, Cooperstown, NY– For a number of years, Bassett has had a very active

policy/process governing “Evaluation of Accountability Surrounding Errors and Events,” which has facilitated Bassett being recognized as having a “just culture.” On the AHRQ Patient Safety Culture survey, staff responses were above comparison groups in terms of affirming a “non-punitive” culture surrounding errors and events.

SP2 – Culture (cont’d)

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• Contra Costa Regional Medical Center, Martinez, CA– “Tremendous collegiality” … is the result of a conscious effort

from the top down and the bottom up to create a culture of collaboration and teamwork. Through teamwork, Contra Costa has been able to improve care processes and patient outcomes in areas ranging from reducing surgical site infections to reducing heart attacks.

• Dana-Farber Cancer Institute, Boston, MA– Conducted teamwork training with patients and families as

part of the team training• Lucille Packard Children’s Hospital at Stanford, Palo Alto, CA

– Uses actual parents in simulation training exercises• IHI Open School

– Practicing Like A Rock Star: The Need for a Culture Change in Medicine:

• Beth Israel Deaconess, Boston, MA• Virginia Mason Medical Center, Seattle, WA

SP3 – Organization-wide approachto team-based care

http://ihiopenschool.blogspot.com/2009/02/practicing-like-rock-star-need-for.html

http://ihiopenschool.blogspot.com/2009/02/practicing-like-rock-star-need-for.html


SP4 – Identify and mitigate patientsafety risks and hazards

• Virginia Mason Medical Center, Seattle, WA– Each month, all patient safety alert [PSA] data are reviewed

by the board. Specific cases are looked at in detail and all “red” PSAs must come to the board for approval prior to closure. The accountable executive comes to the committee to review case narrative, timeline, value stream map and mistake-proofing of process.

• Owensboro Medical Health System, Owensboro, KY– From the board to the front-line staff, everyone at

Owensboro Medical Health System (OMHS) is focused on quality improvement. Having implemented all the IHI Campaign interventions, OMHS has, among other things, reduced harm from pressure ulcers, patient falls, and medication errors; nearly eliminated ventilator-associated pneumonia; and significantly decreased its mortality rate to well below the national average.

Could It Happen Here? Healthcare

Executive NOV/DEC, 2008



• Thousands of Boards have begun this journey• Accountability/responsibility is growing and

accelerating• Many great organizational journeys to draw from and

on• The depth and pace of change required is only

possible by systematic application of a framework for improvement (aim, foundation, will, ideas, and execution) by:

– Governance and executive leadership– Working closely with all staff across the organization– In partnership with patients and families, and with

communities

In Closing…


• Featured healthcare organizations– http://

www.ihi.org/IHI/Programs/Campaign/mentor_registry_bob.htm

• Board on Board Intervention– http://

www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm

• IHI Leading Systems Improvement Content– http://

www.ihi.org/IHI/Topics/LeadingSystemImprovement/

For Further Information

http://www.ihi.org/IHI/Programs/Campaign/mentor_registry_bob.htm



http://www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm



http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/




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Patient Perspective on Involving Patients in Patient

Safety

Dan Ford, MBA Vice President, FurstGroup

Member, Consumers AdvancingPatient Safety (CAPS)



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Panelists

Peter Angood, MDCharles Denham, MDJames Conway, MS Dan Ford, MBA


Peter Angood: Important National Highlights Regarding Leadership and Culture

Charles Denham: Leadership and Culture Practices: New Roles for Leaders

James Conway: Bringing Boards on Board: Critical Issues in 2009

Dan Ford: Patient Perspective on Involving Patients in Patient Safety

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Upcoming Safe Practices Webinars September 17 – Important Condition and Common

Safety Issues (Safe Practices 26-34) October 22 – Creating Transparency, Openness, and

Improved Safety (Safe Practices 5-8) November 19 – Healthier Communication and Safe

Information Management (Safe Practices 12-16) December 17 – Optimizing a Workforce for Optimal

Safe Care (Safe Practices 9-11)

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• Podcast Ready Downloads • Quick Start Toolboxes• MedMan and Other Collaboratives• Global Patient Safety Award in Nice,

France• Patient Safety Documentary

Summary

Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar:

Documents

Transcript of Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar: