Innovation, Advocacy, Innovation, Advocacy, and Lessons Learned: and Lessons Learned: How IHA Implemented a Patient How IHA Implemented a Patient Safety Learning Collaborative Safety Learning Collaborative Cathy Grossi and Becky Steward Cathy Grossi and Becky Steward Illinois Hospital Association Illinois Hospital Association The Quality Colloquium The Quality Colloquium Harvard University Harvard University August 21, 2006 August 21, 2006
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Innovation, Advocacy, and Lessons Learned: How IHA Implemented a Patient Safety Learning Collaborative Cathy Grossi and Becky Steward Illinois Hospital.
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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:
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
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:
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
Information and Networking Information and Networking Learning SessionsLearning Sessions VideoconferencesVideoconferences Issues and adjustmentsIssues and adjustments On-line ForumOn-line Forum Site visitsSite visits
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