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

Welcome to theNQF Safe Practices for Better Healthcare

2009 Update Webinar:Clear Communication Practices

for Safer Healthcare

(Safe Practices 12-16)

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)

Welcome and Safe PracticesOverview

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

Hayley Burgess, PharmDDirector, Performance Improvement Measures, Standards, and Practices

TMIT

Safe Practices WebinarNovember 19, 2009

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Panelists

Peter Angood

Hayley Burgess: Welcome and Safe Practices Overview

David W. Bates: Achieving Success with CPOE

Kimberly Visconti: Using RED to Implement NQF SP 15: Discharge

Peter Angood: Practical Implementation Approaches to Patient Care Information, Order Read-Back and Abbreviations, and Labeling of Diagnostic Studies

Arlene Salamendra: Roles for the Patient Advocate (Are You Listening?)

Arlene Salamendra

Kimberly ViscontiDavid W. BatesHayley Burgess

Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition- and 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

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

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Achieving Successwith Computerized

PhysicianOrder Entry (CPOE)

David W. Bates, MD, MScMedical Director of Clinical and Quality

Analysis, Partners HealthcareChief, Division of General Internal Medicine

Brigham and Women’s Hospital

Safe Practices WebinarNovember 19, 2009Toll-free Call-in number: 1-866-764-6260 8

Goals• NQF Safe Practice• CPOE benefits

Drugs Labs Other

• Meaningful use overview• CPOE risks

University of Pennsylvania (Koppel) University of Pittsburgh (Han)

• Implementing well• CPOE and the big picture

Bar-coding• Conclusions

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Safe Practice 16: CPOE 2009


Implement a computerized prescriber order entry (CPOE) system built upon the requisite foundation of re-engineered evidence-based care, an assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure.

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CPOE as part of the EHR


• Is centrally important because most things that occur in a hospital happen as the result of a physician’s order

Need to get physician to use the computer Key opportunity to change behavior

• Many opportunities to improve performance

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Inpatient Prevention


• 55% reduction in serious medication error rate with CPOE

Bates, JAMA, 1998• 83% reduction in overall medication

error rateBates, JAMIA, 2000

• Cost of each preventable ADE ~ $6,000

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Systematic Review of Impact of CPOE on Medication Safety


• 5 trials of CPOE 2 marked decrease in serious medication error

rate 1 improvement in corollary orders 1 improvement in 5 prescribing behaviors 1 improvement in nephrotoxic drug dose and

frequency• Numerous additional studies sinceKaushal, Shojania, Bates, Arch Int Med 2003

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Other Recent Reviews of CPOE and Medication

Safety


• CPOE and medication errors—66% reduction in prescribing errors on average

• CPOE and ADEs—ten studies, five showed decrease in ADE rates, 4 showed non-significant trends, 1 showed no effect

Wolfstadt et al., J Gen Intern Med 2008

Shamliyan et al., Health Services Res 2008

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Selected Laboratory Interventions


• Charge display RCT No statistically significant effect BUT $1.7 million lower lab charges in

intervention group• Redundant labs

67% reminders followed Annual charge savings $31,000, vs. estimate of

$376,000 Only 44% tests performed had computer order Substantial improvement possible if loop

closed with laboratory “back end”

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Order Entry and Critical Paths


• Critical paths specify what should happen for a specific day

Essentially sequences of order sets In place for 25 diagnoses

• Have decreased length of stay, costs, improved satisfaction

• Require physicians to select diagnosis at admission

Allows prompting about path Increases likelihood path will be selected

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Summary of Benefits


• Benefits are much greater than drug safety benefits alone

Those represent small part of financial benefits• Achieving value depends on building

in good decision support Also on ability to modify, iteratively improve

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How to Prioritize?


• ROI of inpatient CPOE evaluated• Cumulative net savings were $16.7

million over 10 years, and net operating $9.5 million

• Leading contributors Renal dosing guidance Tools to help nurses Specific drug guidance Adverse drug event preventionKaushal, JAMIA 2006

Meaningful Use is Being Defined and Will Follow an

“Ascension Path”2009

2011

2013

2015HIT-Enabled Health Reform

HITECH Policies 2011

Meaningful Use

Criteria (Capture/sh

are data)

2013 Meaningful Use

Criteria(Advanced care processes with

decision support)

2015 Meaningful Use Criteria (Improved Outcomes)

*Report of sub-committee of Health IT Policy Committee 19

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Meaningful Use Matrix andDecision Support: Hospitals

2011


• 10% all orders through CPOE• Drug-drug, drug-allergy, drug-

formulary checks• Up-to-date problem list• Generate lists of patients by

condition• Implement one clinical decision rule

related to a high-priority condition

21Toll-free Call-in number: 1-866-764-6260

• Use CPOE for all order types• Use evidence-based order sets• Conduct closed-loop medication

management• Use clinical decision support at the

point of care• Retrieve and act on fill data

Meaningful Use Matrix andDecision Support: Hospitals

2013

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University of Pennsylvania: Unintended Consequences


• Koppel et al. evaluated on a commercial CPOE application at U Penn and asked users about their impressions about the system

Found many situations in which “a leading CPOE system facilitated medication error risks”

Often took many screens to do things Needed views not available

• Others including Ash have also reported on this

Koppel, JAMA, 2005

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Issues with the Koppel Study


• Didn’t actually count errors or adverse events

• Said that other studies focused only on advantages—not accurate

• CPOE application studied was an old one

• Nonetheless, paper stimulated valuable debate and identified key points

Need change systems after implementation Software alone is insufficient

Bates, J Biomed Inform, 2005

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University of Pittsburgh:Pediatrics Study


• Studied children transported in for special care

• Mortality rate increased from 2.8% to 6.3% (OR=3.3) after introduction of a commercial CPOE application

• Study design was before-after Other changes were made at same time as

CPOE was implemented Overall mortality wasn’t reported

Han, Pediatrics 2005

Introduction of CPOE• CPOE was introduced very rapidly—

over 6 days!• After implementation, order entry

wasn’t allowed until the patient had actually entered hospital and been logged into system

• After CPOE implementation, all drugs including vasoactive agents were moved to central pharmacy

• Pharmacy couldn’t process medication orders until after they were activated

• Many order sets weren’t available initially

• Result was substantial delays in care delivery

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Comments on Han Study


• Study was very weak methodologically

• Nonetheless, increase in mortality rate was very large and of obvious concern

Introducing substantial delays in this group could easily have caused

• Organization broke many of the rules for implementation

• Essential for other organizations to handle sociotechnical aspects better

Phibbs et al., Pediatrics 2005

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The Path To Success in Implementing CPOE


• Much is the inverse of common pitfalls

But not all• Anyone will have issues that

leadership need to deal with• Keep in mind that it will be worth it

Have to pay attention to details to achieve value—doesn’t simply come with successful implementation

• Is a much bigger change than anything most organizations have previously attempted on the IT front


• Strong leadership and long-term commitment

• Creating a culture of innovation• Excellent project management• Attention to clinical processes• A focus on quality

Critical Success Factors in Implementation

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Getting Benefits—What Does It Take?


• Have to have successful implementation

• But also need to decide on a core of decision support

Implies having organizational structure enabling group to reach consensus

• Will have to make many changes Need architecture enabling agility Sufficient resources to keep up Rule is to have a long queue Want to start low, go slow—but need to end up

with enough


• Use the AHRQ/NQF/Leapfrog assessment tool

• Gives you a score regarding decision support

• Without doing that hard to assess level of implementation of decision support

How to Assess Where You Are Regarding Decision

Support

Simulations of EHR Use with CPOE

The Assessment Methodology

The assessment pairs medication orders that would cause a serious adverse drug event with a fictitious patient.

PatientAB

Female52 years oldWeighs 60 kgAllergy to morphineNormal creatinine

A physician enters the order…

and observes and records the type of CDS-generated advice that is given (if any).

Coumadin (Warfarin) 5 mg po three times a day.

Toll-free Call-in number: 1-866-764-6260 31

Hospitallogs on

(Password access)

Complete sample

test

Obtain patient criteria(Adult or pediatric)

Program patient criteria

Download and print 30 – 40

test orders (HM if AMB)

Enter orders into

CPOE application and record

results

Hospital self-reports

results on website

Score generated

against weighted scheme

Report generated

Aggregate score to Leapfrog

Order category scores viewed

by hospital

Review patient

descriptions

Review orders and categories

Review scoring

The Assessment Tool

AHRQ/NQF/Leapfrog Assessment Tool

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Broader Context


• Multiple technologies can improve medication safety

Address different stages of the process• Bar-coding• Smart pumps • Computerized monitoring for ADEs

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Evidence Regarding Bar-coding


• Increasingly widely used About a quarter of hospitals

• Very wide use in VA• Published evidence base still

modest but growing• Will be included in meaningful use

for 2013• Likely to be put forward as a safe

practice soon

0.19%

0.61%

0.88%

0.07%

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

Dispensing Error Rate Potential ADE Rate

Before Period (115164doses observed)After Period (253984doses observed)

31% reductio

n*

63% reductio

n*

* p<0.0001 (Chi-squared test) Poon et al., Annals Internal Medicine, 2006

Dispensing Errors and Potential ADEs: Before and After Bar-code

Technology Implementation

Projections for errors Projections for errors prevented per yearprevented per year at study hospitalat study hospital::

• >13,500 medication >13,500 medication dispensing errorsdispensing errors

• >6,000 potential >6,000 potential ADEsADEs

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Conclusions


• CPOE appears highly beneficial in the aggregate

But can create new problems as well as prevent them

• Need to monitor, engineer out• Realizing benefits requires:

Strong implementation Later implementation of good decision support

• Important not just to have but to implement well

Serial refinements in decision support• Easiest things are not highest-yield

Today’s discussion/results very important

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Using the Re-Engineered Discharge (RED) to

Implement NQF Safe Practice 15:

Discharge SystemsKimberly Visconti, RN

Discharge Advocate, Project REDBoston Medical Center



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Background to Current Problem


• Hospital discharge is non-standardized and frequently marked with poor quality

• Little time spent on discharge teaching

• Patients are not prepared at discharge

• Poor communication between inpatient and outpatient care

• Communication barriers lead to adverse events

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Communication Deficits at Hospital Discharge Are

Common


• Discharge summary not readily available:

Only available for 12%-34% of first post-discharge appointments

• Discharge summary lacking key components:

Hospital course (14.5%) Discharge medications (21%) Completed test results (38%) Pending test results (65%) Follow-up plans (14%) Main diagnosis (17.5%)

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Rehospitalizations and Medicare


• 20% of Medicare beneficiaries who had been discharged from a hospital were readmitted within 30 days

• The cost of unplanned rehospitalizations in 2004 was $17.4 billion

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Major Changes in Hospital Payments


• "Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period saving $26 billion over 10 years"

• MedPAC recommends reducing payments to hospitals with high readmission rates

MEDPAC Testimony before Congress March ‘09

Obama Administration Budget Document

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NQF SP 15 Objective:


“Ensure effective transfer of clinical information to the patient and ambulatory clinical providers at the time of discharge."

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1. Patient education2. Follow-up appointments3. Outstanding tests 4. Post-discharge services5. Medication reconciliation 6. Reconcile DC plan with national guidelines 7. What to do if problem arises8. Assess patient understanding9. Written discharge plan for patient10. Timely transmission of DC summary to PCP11. Post-discharge telephone reinforcement

RED meets the NQF SP 15 objective using 11 mutually reinforcing

components:

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• The RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until discharge

RED Component #1Educate patient about his/her

diagnosis throughout the hospital stay

SP 15: “preparation for discharge occurring with documentation, throughout the hospitalization”

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• Schedule PCP appt within 2 weeks after discharge

• Review the provider, location, transportation, and plan to get to appointment

• Consult with patient regarding best day and time for appointments

• Discuss reason for and importance of all follow-up appointments and testing

RED Component #2Make appointments for clinician

follow-up and post-discharge testing

SP 15: “explicit delineation of roles and responsibilities in the discharge process”

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• Information listed in After Hospital Care Plan (AHCP), which is transmitted to PCP

• Patient knows to discuss this with PCP at follow-up appointment and where to find it on his/her AHCP

RED Component #3Discuss tests/studies completed and who will follow up on results

SP 15: “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

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• Communicate with case manager and social worker about post-discharge services that they schedule

• Provide patient with contact information for these services (phone number, name of company, etc.)

RED Component #4Organize post-discharge services


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• Reconcile the patient’s home medication list as close to admission as possible

• Review each medication; make sure that the patient knows why s/he takes it

• Discuss new medications each day with medical team and with patient

RED Component #5Confirm the Medication Plan

SP 15: “completion of discharge plan and discharge summaries before discharge”

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• Communicate with medical team each day about the discharge plan

• Recommend actions that should be taken for each patient under a given diagnosis

RED Component #6Reconcile discharge plan with national guidelines and critical

pathways


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• What constitutes an emergency• What to do if a non-emergent problem arises• Where to find contact information for the

discharge advocate and PCP on the After Hospital Care Plan

RED Component #7Review appropriate steps for what

to doif a problem arises

SP 15: “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.”

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• Fax the discharge summary and After Hospital Care Plan to PCP within 24 hours after discharge

RED Component #8Expedite transmission of the

discharge summary to the PCP

SP 15: “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”

“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”

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• Deliver information to reach those with low health literacy level

• Include caregivers when appropriate• Utilize professional interpreters as needed

RED Component #9Assess degree of understanding by

asking patient to explain the details of the plan

SP 15: "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled. This information must also be communicated to the accepting physician.”

"Use the 'teach-back process' to ensure pt understands transition-of-care planning."

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• After Hospital Care Plan includes:1) Principal discharge diagnosis2) Discharge medication instructions3) Follow-up appointments with contact

information4) Pending test results 5) Tests that require follow-up

RED Component #10Give the patient a written

discharge plan at time of discharge

SP 15: “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

David Smith

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David Broitman

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Pharmacist to call you

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• Call patient within 72 hours after discharge• Assess patient status• Review medication plan• Review follow-up appointments• Take appropriate actions to resolve problems

RED Component #11Provide telephone reinforcement of the discharge plan after discharge

SP 15: “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post-discharge adverse events and unnecessary rehospitalizations"

Can Health IT assist with providing a comprehensive

discharge?

Toll-free Call-in number: 1-866-764-6260 60

Embodied Conversational Agents• Enhance patient education before discharge • Emulate face-to-face communication• Develop therapeutic alliance• Determines competency

• ECA is currently being tested at BUMC

New Horizons Using Health IT

Characters: Louise (L) and Elizabeth (R)Toll-free Call-in number: 1-866-764-6260

Automated Discharge WorkflowSP 15: “the development of IT systems to collect discharge information and create discharge plans from existing hospital databases could enable components of the plan to be easily collected”

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Patient interacting with ECA

Thank you!

• For general information about Project RED, please refer to our website:http://www.bu.edu/fammed/projectred/

• For information about implementing RED or obtaining RED software, please contact:[email protected]


http://www.bu.edu/fammed/projectred/

mailto:[email protected]

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Practical Implementation Approaches to Patient Care

Information, Order Read-Back and

Abbreviations, and Labeling of Diagnostic Studies

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

National Quality Forum



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Safe Practice 12: Patient Care Information

Safe Practice 13: Order Read-Back and Abbreviations Safe Practice 14:Labeling of Diagnostic Studies


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Ensure that care information is transmitted and appropriately documented in a timely manner and in a clearly understandable form to patients and to all of the patient’s healthcare providers/professionals, within and between care settings, who need that information to provide continued care.

SP 12: Patient Care Information


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SP 12:•The fragmentation of care across many providers, and an inability to access key care information for patients, results in very dangerous, yet preventable, scenarios.

•One study reported that only 51% of potentially "life-threatening" critical test results received appropriate attention ... audit of patient charts revealed that 15% contained no documentation that clinicians were ever aware of the critical test result or that any corrective action was taken.

•Patient care information, for the purposes of 2009, is defined as “critical information regarding medical history, diagnostic test results, medications, treatment, and procedures.”

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SP 12:•This practice instructs organizations how to ensure that care information is appropriately documented in a timely manner and clearly communicated to patients and all of the patient's health care professionals who need that information to provide continuity of care.

•This practice now includes establishing a process to communicate critical test results that are completed after the patient has been discharged from the organization.


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Incorporate within your organization a safe, effective communication strategy, structures, and systems to include the following:

•For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person who is receiving the information record and “read-back” the complete order or test result.

•Standardize a list of “Do Not Use” abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization.

SP 13: Order Read-Back and Abbreviations

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SP 13: •Combined into one 2009 Safe Practice, the activities defined were merged from 2 separate 2006 Practices … combination addresses ineffective communication, which is most frequently cited category of root causes for sentinel events.•Implementing safeguards to relay accurate patient information, such as a verbal or telephone order, includes having the person receiving the information record and read back the complete order or test result.


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SP 13: •Organizations are instructed to standardize a list of "do not use" abbreviations and dose designations that should not be used.•Though now a combined practice, it does not have substantive changes to the 2006 practice elements.


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Implement standardized policies, processes, and systems to ensure accurate labeling of radiographs, laboratory specimens, or other diagnostic studies, so that the right study is labeled for the right patient at the right time.

SP 14: Labeling of Diagnostic Studies


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SP 14: • The potential exists for radiographs, laboratory

samples, and pathology specimens to be mislabeled, or incompletely labeled, and consequently misinterpreted across all care settings.

• This practice defines implementation of standardized processes to ensure accurate labeling of diagnostic studies.

• No substantive changes from 2006 practice.


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Roles for the Patient Advocate

(Are You Listening?)

Arlene Salamendra Patient Advocate Leader

Former Board Member and Staff Coordinator,Families Advocating Injury Reduction (FAIR)



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Upcoming Safe Practices Webinar December 17 – Optimizing a Workforce for Optimal

Safe Care (Safe Practices 9-11)

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

Documents

direct number

thenqf safe practices

medication errors66

safe practices overview

safe practicesoverview

recent reviews of cpoe

cpoe kimberly visconti

showed decrease