Upload
chaka
View
45
Download
2
Tags:
Embed Size (px)
DESCRIPTION
Welcome to the NQF 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 - PowerPoint PPT Presentation
Citation preview
1
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)
2
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
3
Panelists
Peter Angood, MDCharles Denham, MDJames Conway, MS Dan Ford, MBA
Toll-free Call-in number: 1-866-764-6260
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
Toll-free Call-in number: 1-866-764-6260
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
Toll-free Call-in number: 1-866-764-6260
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
Consent & Disclosure
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
99
Important National Highlights Regarding
Leadership and Culture
Peter B. Angood, MD, FRCS(C), FACS, FCCMSenior Advisor, Patient Safety
National Quality Forum
Safe Practices WebinarJuly 16, 2009
Toll-free Call-in number: 1-866-764-6260
1010
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.”
Toll-free Call-in number: 1-866-764-6260
11Toll-free Call-in number: 1-866-764-6260
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
1212Toll-free Call-in number: 1-866-764-6260
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
1313Toll-free Call-in number: 1-866-764-6260
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
1414Toll-free Call-in number: 1-866-764-6260
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.
1515Toll-free Call-in number: 1-866-764-6260
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.
1616
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.
Toll-free Call-in number: 1-866-764-6260
17
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
18
19
“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
24
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
Consent & Disclosure
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
25
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
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
29
Bringing Boards On-board: Critical Issues in 2009
James Conway, MSSenior Vice President,
Institute for Healthcare Improvement (IHI)
Safe Practices WebinarJuly 16, 2009
Toll-free Call-in number: 1-866-764-6260
30
• 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
Toll-free Call-in number: 1-866-764-6260
31
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
Toll-free Call-in number: 1-866-764-6260
Boards on Board Plank
5 Million Lives Campaign
32Toll-free Call-in number: 1-866-764-6260
• 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
33Toll-free Call-in number: 1-866-764-6260
• 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)
34Toll-free Call-in number: 1-866-764-6260
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.
35Toll-free Call-in number: 1-866-764-6260
• 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
36Toll-free Call-in number: 1-866-764-6260
• 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)
37
• 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
38Toll-free Call-in number: 1-866-764-6260
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
Toll-free Call-in number: 1-866-764-6260
40Toll-free Call-in number: 1-866-764-6260
• 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…
41Toll-free Call-in number: 1-866-764-6260
• 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
42
Patient Perspective on Involving Patients in Patient
Safety
Dan Ford, MBA Vice President, FurstGroup
Member, Consumers AdvancingPatient Safety (CAPS)
Safe Practices WebinarJuly 16, 2009
Toll-free Call-in number: 1-866-764-6260
44
Panelists
Peter Angood, MDCharles Denham, MDJames Conway, MS Dan Ford, MBA
Toll-free Call-in number: 1-866-764-6260
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
45
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)
46
• Podcast Ready Downloads • Quick Start Toolboxes• MedMan and Other Collaboratives• Global Patient Safety Award in Nice,
France• Patient Safety Documentary
Summary