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Solutions for Patient Safety: Sharing the Journey
- 1. Solutions for Patient Safety: Anne Lyren, MD, MSc Clinical Director
- 3. Sharing the Journey of SPS • Who we are • How we approach the work • What we have and haven’t accomplished • Keys to future network success • Next steps
- 4. Who we are
- 6. What we aim to do
- 7. Mission Working together to eliminate serious harm across all children’s hospitals
- 8. By December 31, 2018: • 40% Reduction in Hospital Acquired Conditions* • 20% Reduction in 7 Day Readmissions* • 50% Reduction in Serious Safety Event Rate By June 30, 2019: • 25% Reduction DART – Days Away Restricted or Transferred by June 2019 *baseline year varies per HAC Network Targets
- 9. What We Provide • Data support, measurement and analysis to identify best practices • Training, sharing and learning opportunities: – Hospital acquired conditions (HACs) and readmissions – Culture transformation activities – Board and leadership engagement – Collaboration with high-performing hospitals
- 10. Nick Lashutka President, SPS Anne Lyren Clinical Director, SPS Steve Muething Strategic Advisor, SPS Missy Shepherd Executive Director, SPS SPS Leadership
- 11. Develop Ohio Network Create National Children’s Network Spread Scale (2008-2011) (2012) (2013) (2015 & Onward)
- 12. How we approach the work
- 13. SPS Strategic Approach Leadership matters Our mission motivates all that we do Network hospitals will NOT compete on safety All Teach, All Learn Network hospitals must commit to building a “culture of safety”
- 14. UNPLANNEDEXTUBATIONS 25% reduction in SSE by 12/31/16 Reduce pediatric HACs by 40% and reduce the readmit rate by 10% across the SPS National Children’s Network by 12/31/16 READMISSIONS CLA-BLOODSTREAMINFECTIONS(CLABSI) CA-URINARYTRACTINFECTION(CAUTI) VENTILATOR-ASSOCIATEDPNEUMONIA(VAP) SURGICALSITEINFECTIONS(SSI) ADVERSEDRUGEVENTS(ADE) PRESSUREINJURIES(PI) SERIOUSFALLS OBSTETRICALADVERSEEVENTS(OBAE) VENOUSTHROMOEMBOLISM(VTE) PERIPHERALINTRAVENOUSEXTRAVASATIONS(PIVIE)
- 15. UNPLANNEDEXTUBATIONS 25% reduction in SSE by 12/31/16 Reduce pediatric HACs by 40% and reduce the readmit rate by 10% across the SPS National Children’s Network by 12/31/16 READMISSIONS CLA-BLOODSTREAMINFECTIONS(CLABSI) CA-URINARYTRACTINFECTION(CAUTI) VENTILATOR-ASSOCIATEDPNEUMONIA(VAP) SURGICALSITEINFECTIONS(SSI) ADVERSEDRUGEVENTS(ADE) PRESSUREINJURIES(PI) SERIOUSFALLS(SF) OBSTETRICALADVERSEEVENTS(OBAE) VENOUSTHROMOEMBOLISM(VTE) SAFETY GOVERNANCE (SG) & CAUSE ANALYSIS (CA) PERIPHERALINTRAVENOUSEXTRAVASATIONS(PIVIE) PATIENT and FAMILY ENGAGEMENT (PFE) LEADERSHIP METHODS (LM) ERROR PREVENTION (EP) DISCLOSURE HIGH RELIABILITY UNITS (HRUs) JUST CULTURE
- 16. 16 How we approach the work: Improving safety culture
- 17. High reliability organizations (HROs) “operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.” Managing the Unexpected (Weick & Sutcliffe)
- 18. Culture Work • Error prevention training for all • Leadership methods training • Root cause analysis training • Board training • Patient/Family engagement • Webinars focused on culture work • PSO – U.S. hospitals
- 19. Culture Work • Wave 6 – 75 hospitals • 70 - Culture Club Thursday webinars • 59 - 1+ patient/family representative on Board • 65 - 1+ patient/family on a Hospital-wide safety committee • 54 - participated in SPS Board Training sessions • 10 in-person culture trainings • 296 peer trainers for Error Prevention and Leadership Methods • 353 peer trainers for Root Cause Analysis Methodology
- 20. 20 Children’s Hospitals’ Solutions for Patient Safety (SPS) Child Health Patient Safety Organization (CHA PSO)
- 21. 21 How we approach the work: Developing Prevention Bundles
- 22. Process data • # of times prevention bundle performed 100% correctly / # of opportunities Outcome data • Number of Events / appropriate denominator (patient days, catheter days) Monthly Data Submission
- 23. Nine hospitals implementing this element reliably have a rate 40% less than the average. Pressure Ulcer Standard Bundle Element
- 24. 24 Factorial Design • Experts identify factors for testing • Hospitals choose 1-2 factors in different combinations • Achieve high reliability with these factors across each hospital • Analyze outcome data with factor data • Determine which factors are associated with best outcomes 24
- 25. 25 SPS Prevention Bundles • Surgical site infections • Serious falls • Pressure injuries • Central line-associated blood stream infections • Catheter-associated urinary tract infections • Readmissions
- 26. 26 SPS Recommended Bundles • Adverse drug events • Venous thromboembolism • Ventilator-associated pneumonia • Obstetric adverse events
- 27. 27 SPS Bundles Under Development • Adverse drug events • Venous thromboembolism • Ventilator-associated events (VAE) • Peripheral IV infiltrates/extravasations • Unplanned extubations
- 28. PIONEER AVIATOR ORBITING DISCOVERY EXPLORER Active Network ImprovementFinding New Breakthroughs Defining The Standard ALL IN Reliable Implementation Sustaining Sharing With Everyone
- 29. PIONEER AVIATOR ORBITING DISCOVERY EXPLORER Active Network Improvement Small group improvemen ts of additional HACs; Grant- funded research; Industry partnerships; State networks 2nd Victim; Employee Safety; Situation Awareness; Topics generated from PSO ADE, VTE, PIVIE, UE Disclosure; Incorporate culture behaviors into HAC work SSI, PI, CLABSI, Readmission s, VAP Cause Analysis; Error Prevention; Leadership Methods Serious Falls CAUTI Operational definitions; Prevention bundles THE JOURNEY TOWARD ZERO HARM SPS Design
- 30. 30 Collaboration
- 31. 31 All Teach/All Learn • 130 Aviator Wednesday webinars • 135 HAC workgroup calls • 20 CLABSI Sub-Group calls • 168+ Hospital Workgroup calls • 8 National Learning Sessions • 10 regional meetings
- 32. What We Have and Have Not Accomplished
- 33. Presented with permissions. © Child Health Patient Safety Organization, Inc. – a component of N.A.C.H. 61% SSER reduction by 22 “goal cohort” hospitals
- 34. SHE Stacked Chart 16% 22% 22%
- 37. 37 37 June 2014, Cohort Began Testing Factors 0.0 0.1 0.2 0.3 0.4 0.5 Jan-11(n=10) Mar-11(n=10) May-11(n=10) Jul-11(n=10) Sep-11(n=10) Nov-11(n=10) Jan-12(n=17) Mar-12(n=19) May-12(n=19) Jul-12(n=19) Sep-12(n=19) Nov-12(n=19) Jan-13(n=19) Mar-13(n=19) May-13(n=19) Jul-13(n=19) Sep-13(n=19) Nov-13(n=19) Jan-14(n=19) Mar-14(n=19) May-14(n=19) Jul-14(n=19) Sep-14(n=19) Nov-14(n=19) Jan-15(n=19) Mar-15(n=19) May-15(n=19) Jul-15(n=19) Sep-15(n=18) Nov-15(n=19) Jan-16(n=18) Mar-16(n=18) May-16(n=17) NumberofADEsper1000patientdays Adverse Drug Events per 1000 Patient Days (Level E-I) Pioneer Cohort vs. Rest of the Network January 2011 - June 2016 Pioneer Cohort CL (.1738) Rest of the Network CL (.2519) Improvement since June 2014: - Pioneer cohort: 41% - Rest of the Network: 22%
- 38. 38 38
- 39. 39 39
- 40. 40 40
- 41. 41 41
- 42. 42 42
- 43. 43 Condition (Estimated cost per event) Estimated Harm Prevented (2012-May 2016) Cost Savings (2012-May 2016) ADE ($5,000) 300 $1,500,000 CAUTI ($7,200) 722 $5,198,400 Falls ($13,000) 917 $11,921,000 OBAE ($3,000)* 669 $2,007,000 PI ($19,740) 289 $5,704,860 Readmissions ($9,540) 2054 $19,595,160 SSI ($27,000) 643 $17,361,000 VAP ($51,000) 497 $25,347,000 CLABSI ($55,000) 2012- 2014 595 $32,725,000 CLABSI ($55,000) 2015- 2016 ** 0 0 $121,359,420
- 44. Keys to Success
- 46. Hospitals that submit process data achieve better results.
- 47. 47 13-24 Months of Process Data Submission HAC # of Hospitals Difference in initial centerlines Difference in current centerlines Difference in % improvement per hospital CAUTI 20 43% -59% 55% SSI 5 -5% -41% 60% CLABSI 24 70% -10% 136% % HAC improvement for hospitals that submit process data vs. hospitals that don’t
- 48. 48 CLABSI Process Data Submission (through 2014) Months of Process Data # of Hospitals Difference in initial centerlines Difference in current centerlines Difference in % improvement per hospital 1-12 15 80% -11% 158% 13-24 24 70% -10% 136% 25-36 19 98% -6% 144% 37-48 10 84% -4% 147% CLABSI Improvement By Length of Process Data Submission: % improvement for submitting vs. non-submitting hospitals
- 49. What other characteristics are linked with improved outcomes?
- 50. Characteristic CAUTI SSI CLABSI Culture Training Completed 60% 7% >300% Implement SPS Prevention Bundles (CAUTI, CLABSI, PI, SSI) House-wide 27% 43% 2% Active Leadership in SPS 13% 19% 52% CEO attended CEO Convening 5% 74% 28% HAC % reduction in hospitals with identified characteristic vs. hospitals without
- 51. -Active Family/Patient Engagement -Active Board Engagement -Active Participation in Learning Events -Active Leadership Role within SPS -CEO/Top Pediatric Leader Engagement -Involvement in Pioneer Work • -Active engagement in Research and Publications -Utilization of SPS Bundles -Exceptional Performance -Consistent and accurate data submission for CAUTI, CLABSI, SSI and Pressure Injuries -Enhanced Transparency within Network -Membership in Child Health PSO for US Hospitals -Participate in Culture Wave Training Recommended Navigator Criteria - 2017 Leadership Engagement Discovery & Innovation Process Reliability & Standardization High Reliability Culture
- 52. 52 What is Left To Do
- 53. 53
- 54. 54 Number of Events by HAC for One Month Condition Number of Events in May 2016 CLABSI 218 VTE 89 PI 47 SSI 28 VAP 23 CAUTI 14 ADE 11 OBAE 7 FALLS 4 441 Based on data as of 8/10/2016
- 55. Serious Harm August, 2015 – July, 2016 CLABSI VTE PIVIE PI SSI CAUTI VAP ADE Falls
- 56. 56
- 57. 57
- 58. 58 East Tennessee Children’s Hospital PICU 5 years without VAP Yale-New Haven Children’s Hospital 20 bed, Level 3 NICU – 3 years without CLABSI 54 bed, Level 4 NICU - 430 days without CLABSI Connecticut Children’s Hospital 40 bed, Level 3 NICU >700 days without CLABSI
- 60. 0 1 2 3 4 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Serious Safety Events Rolling 12-month average # Children Harmed Rate per 10000 APD
- 61. 61 Rainbow Babies & Children’s Hospital
- 63. 63 What’s Next for the Network? • Health Improvement Innovation Network (HIIN) contract – C.diff/Antimicrobial Stewardship, Acute Kidney Injury, Healthcare Disparities, Employee Safety • Highly reliable implementation of Prevention Bundles • CLABSI deep dive • Reinvigoration of VAE • Sharing Disclosure best practices • Culture 2.0 • Navigator • Regional strategies – reaching beyond
- 64. 64
- 65. 65 Thanks. 65
Editor's Notes
- 14 year old three-sport athlete – Jan 2015 tore his ACL playing in an 8th grade basketball game. Underwent some PT then ACL and lateral meniscus repair end of Feb 2015. The surgery went well, and after a month of post-surgical rehab, developed daily fevers then increased swelling and redness of his repaired knee. The doctor in the ER where his mom took him because she couldn’t get anyone from the surgeon’s office to call her back tapped his knee and discovered frank pus in the joint. Admitted in the next 48 hours, underwent two cleanout surgeries. Stayed in the hospital 10 days then went home with PICC line with a plan for long course of antibiotics then another ACL repair since the graft from his first repair had disintegrated in the infection. 5 weeks into his IV antibiotics, developed high spiking fevers. Found to be neutropenic as a side effect of the medication and bacteremic as a result of his infected PICC line. Line was removed, another admission, another long course of antibiotics, more rehab. And finally, this August he had his second ACL repair. Certainly an ACL injury is no small thing. But how about adding on a surgical site infection requiring three additional surgeries, a blood stream infection, and a significant drug side effect – Meanwhile, this previously healthyhappy child had to miss so much school that he is now repeating 8th grade, his parents’ marriage was put to the test, his siblings worried, his mom had to quit her job, and this vibrant, sports-loving boy been physically disabled for over 20 months. This is the face of our mission. We can do better. And we will!
- Over the next few minutes, I’m going to whip you through who we are and what we aim to do, then spend a little more time on what we have and have not accomplished so far. In doing so, I hope to highlight what I believe are the keys to our future and help you anticipate some next steps
- 111 children’s hospitals. Almost 63% are hospitals within hospitals or systems. What is our raison d’etre? (Ray zon DEBT tra)
- We used to say “in the US” but now have welcomed X # of canadian hospitals into our network
- And these are our goals -- There has been a tremendous amount of activity in the network. Of the 111 hospitals 50 hospitals in PSO 72 volunteered to participate in Pioneer HAC work 130,000 data points 6 prevention bundles Successfully identified a prevention bundle for readmissions and are very close on another one 75 hospitals have completed or joined a culture wave in an effort to reduce their serious safety even rate Let me start with those results
- Initial HAC improvement work SSE reduction; efforts to address organizational culture Creation of pediatric patient harm index Expand network to include 25 leading children’s hospitals outside Ohio (Phase I) Active improvement work on 10 HACs Efforts to address organizational culture “All Teach, All Learn” Develop mentor hospitals Begin to publicly disseminate change efforts Add 50 hospitals (Phase II) to data sharing and network learning opportunities (2013). Expand to 80+ children’s hospitals nationwide (2014). Share network best practices with all (2012->) Disseminate at national meetings (2012->) Develop strategies with national organizations (2012->) Establish other regional collaboratives (2013) Komansky joined in summer of 2015 During this time we have had 4 hospitals leave our network, 2 came back the next year. And we have XX on the waiting list to join Of 11 hospitals, 63% are hospitals with hospitals or systems
- Leadership matters: Executive leadership is a critical aspect of successful improvement in pediatric patient safety. The network has designed efforts to inspire and continuously develop the safety leadership skills of the executives who lead our network hospitals. Our mission motivates… We must act with urgency and discipline, focusing on outcomes through a combination of high reliability concepts and quality improvement science methods. We learn through testing and partnering with families and front-line staff. Network hospitals will not compete…. Instead, the SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. All Teach, All Learn SPS network hospitals must humbly share and gratefully learn from others. Accomplishing our goals requires focus on the detailed processes and cultural elements that lead to safer hospitals; guidance and support for hospital teams as they build the capacity for change; and facilitating relationships within the network to broaden and accelerate learning. Network hospitals must commit to building a “culture of safety” Hospitals within the network are employing the cultural transformation strategies of other high reliability industries to significantly reduce harm in their institutions. This emphasis on creating a culture of safety within pediatric institutions is a unique aspect of SPS’s approach.
- Elaine
- Time: 30 secs Key Points: Slide is self explanatory. Key point is we are trying to reduce risk (of nuclear accidents, plane crashes or patient harm events. Risk = Probability x Consequence We can reduce risk by reducing the probability of an event or limiting its consequence. Oftentimes we don’t have a lot of control over the consequence, e.g. plane crashes and people die. We do have control over the probability however. HROs focus on the probability variable in the equation to minimize risk.
- 50+ hospitals Partnered with PSO PSO- institution authorized by federal legislation that allows for the sharing of patient safety details in a way that is protected from discovery by plantiff’s legal discovery. For SPS, provides a number of outstanding benefits – Allows participants to share details of cases Collects data to identify trends
- How do we use data to identify best prevention bundle?
- Want to share with you what one of our classic funnel charts look like. Explain Using this type of information, we have been able to draw conclusions about what elements – comprise to make a bundle.
- Prevention bundles with standard elements introduced at SPS National Learning Session in June 2014 for 5 HACs (CA-UTI, CLA-BSI Falls, PU, SSI) Result of analysis comparing outcome rates of hospitals who implemented the elements reliably versus outcome rates of hospitals who did not At the June learning session, individuals from your hospitals were taught about the bundle elements in detail and instructed to begin the work at their hospitals of increasing reliability with these elements in their own institutions At the Clinical Steering team meeting last week, a sixth bundle was approved for VAP. Over the next several weeks, your hospitals will be similarly introduced to this bundle and begin working on increasing reliability with the bundle’s elements
- Prevention bundles with standard elements introduced at SPS National Learning Session in June 2014 for 5 HACs (CA-UTI, CLA-BSI Falls, PU, SSI) Result of analysis comparing outcome rates of hospitals who implemented the elements reliably versus outcome rates of hospitals who did not At the June learning session, individuals from your hospitals were taught about the bundle elements in detail and instructed to begin the work at their hospitals of increasing reliability with these elements in their own institutions At the Clinical Steering team meeting last week, a sixth bundle was approved for VAP. Over the next several weeks, your hospitals will be similarly introduced to this bundle and begin working on increasing reliability with the bundle’s elements
- Prevention bundles with standard elements introduced at SPS National Learning Session in June 2014 for 5 HACs (CA-UTI, CLA-BSI Falls, PU, SSI) Result of analysis comparing outcome rates of hospitals who implemented the elements reliably versus outcome rates of hospitals who did not At the June learning session, individuals from your hospitals were taught about the bundle elements in detail and instructed to begin the work at their hospitals of increasing reliability with these elements in their own institutions At the Clinical Steering team meeting last week, a sixth bundle was approved for VAP. Over the next several weeks, your hospitals will be similarly introduced to this bundle and begin working on increasing reliability with the bundle’s elements
- Our approach begins in the upper left corner where in the discovery phase, we look to small group collaborations and research to help us identify new problems and new solutions for old problems. When we decide to tackle a harm in the pioneer phase, volunteer hospitals from our network collaborate and test to define new, effective prevention standards. Currently, we have groups here working on VTE, PIV, UE, family disclosure Then in the aviator phase, all SPS hospitals work to hardwire the evidence-based prevention standards throughout their hospitals. As hospitals learn and develop tools to accomplish this, we catalog this work as much as possible so that in the explorer phase we can share these practices with institutions in our midst but outside of our network who incidentally care for the other 50% of children who seek health care.
- We were busy. Our centerline is at 88 participants on an HRO Wednesday ; 48 hospitals per call
- Date of request: 10/19/2016 Approved: 10/21/2016 bjw Presentation/Meeting date: October 24, 2016 Presentation/Meeting: Children’s Hospital CAPHC meeting, Anne Lyrens Requested by: Emily Oehler, Project Manager, SPS, 513-636-206, Emily.Oehler@cchmc.org
- Now onto HACs. I have a love/hate relationship with this chart– the Serious Harm Events by year initial reporting. This chart represents all the HACs – and includes new HACs as well as hospitals as they come on board; what I can tell you is that it only adds things – never takes them away Hate it – because system not stable Love it – attempts to demonstrate the big picture What it can tell you is that in spite of adding new HACs and new hospitals, we are still improving our sum of HACs. Hospitals that began reporting in 2011 have had a 16% decrease, and hospitals that began reporting in 2012 and 2013 both have a 22% decrease.
- Time doesn’t allow me to walk you through all the HAC charts, but I’m dying to show you this one. Look at the adverse drug event rate – a 64% reduction across our network. Now let me show you a large part of what is driving this
- And I want to point out the outstanding work of the 19 hospitals in the pioneer cohort. This group started with a higher rate and with our initial recommended bundle brought their rate down pretty much in line with the rest of the network. Then started their intensive improvement work in June, 2014 and have since then reduced their rate by 41% compared to 22% by the rest of the network. Another benefit of their efforts is that the pioneer cohort has helped us better understand what exactly is driving the improvement. As you can see, our network has shown some improvement, but it wasn’t exactly clear what was driving that. If SPS didn’t exist, and we all just tooled along at our baseline rates, how many more children would have experienced harm?
- That’s the number of children we estimate have been spared harm by our efforts. But what does that mean? How can you get your mind around that number and it’s impact.
- Well, imagine you substituted patients for all the players in the NBA Major league baseball National football league Canadian football league While we’re on the subject of Canadian athletes – the NHL Add in the WNBA Major league soccer Women’s professional soccer Top 100 women’s tennis players Top 100 men Throw in all the major league lacrosse players And all the professional golfers STILL- you won’t have enough people to represent the chlidren spared harm
- So try this- visualize the Burj Khalifa in Dubai, the tallest building in the world. Now imagine yourself walking up the stairs to the top. Every step represents a child spared harm
- You would have to walk up the building more than 2 times to represent those children
- Or perhaps every time you take a breath for next 9 hours and a half, you acknowledge the life of a child not affected by a serious harm. That is what we have accomplished together.
- For those of you interested in the cost savings of our work. We can estimate that by multiplying the estimated cost per event times the number of children spared harm by our work. The grand total through May - $121 million dollars.
- SPS is a little like a conga line at a wedding-- People join the line because it looks like fun or maybe seems like the right thing to do or the peer pressure prevails. The line grows to fill the room, but if the people at the front stop navigating forward, the fun --- and the progress, abruptly end. For this reason, we’ve been considering additional ways to both assist the work that’s happening at the front of the line and also to analyze what differentiates hospitals at the front who are achieving progress toward zero harm faster so we can all emulate it. Our fabulous data team led by Dave Purcell has begun some analysis to better understand the characteristics of highly effective hospitals. And we’ve learned some things…
- Period. Might seem simple. It’s something we’ve encouraged from the beginning because we believed it was important. ”You can’t change what you don’t measure and such like that.” Now we have some data of our own to demonstrate why it’s so important. Let me show you what our network is teaching us.
- This table compares % improvement for hospitals that submit process data compared to hospitals that don’t. For this analysis, we looked at hospitals in their second year of process data submission – figuring that the first year might be a little rocky as hospitals get their processes rolling. We compared the initial centerlines, current centerlines and % improvement of process data submitters as compared to non-submitters. Look what we found using CAUTI as an example– hospitals submitting CAUTI process data started with a higher centerline than their non-submitting peers but ended much lower such that their improvement per hospital was 55% better. Similar results for SSI- and look at CLABSI; hospitals submitting process data in their second year had 136% better improvement than their non- process-data-submitting peers. For CLABSI, this holds true for hospitals no matter how long they’ve been submitting data
- This table compares process data submitters to non-process data submitters at variable lengths of time – so 1-12 months, the 13-24 months I already showed you, etc. All process data submitting groups rock compared to the group that does not submit. Just so you know, the comparison group, the non-submitters, does not consist of brand new hospitals either – they have 2-3 years of outcomes data but no process data Maybe you’re asking yourself, yeah, yeah, Anne. I know. But we submit our data. Why are you emphasizing this point? Because this is the state of process data submission in SPS.
- There’s a long list of characteristics of high-performing hospitals we’d like to study, but we picked some that we had a high degree of confidence would show an association with improved outcomes.
- Here are a couple. Similar to the approach we took with the process data submission analysis, here we’ve considered HAC results of hospitals who have the identified characteristics as compared with hospitals who don’t. For example, hospitals who have completed the culture wave training have a 60% lower CAUTI rate, a 7% lower SSI rate and a >300% lower CLABSI rate. Hospitals who have implemented the SPS prevention bundles of these 4 aviator HACs house wide have a 27, 43, and 2% lower rate for CAUTI, SSI and CLABSI respectively. Similarly you can see positive effects of participating in active leadership roles within SPS and having a CEO who actively participates in network This analysis is new and our first stab at using the data you’ve provided to understand what makes our network tick. It’s not perfect –we have a lot more analysis to do. We don’t know, for example, what combination of interventions is the most effective. We also don’t understand how a hospital’s place on the safety journey may change what are the most effective interventions. I also look forward to hearing from many of you about what would be helpful to you as leaders of this network and leaders of your hospital. In spite of this, we feel confident based on this analysis and our observations of hospitals that achieve results that these interventions are likely to be associated with improved results which helps us advise network hospitals how to focus their resources and energy
- Navigator criteria come in 4 categories Leadership Engagement, Discovery & Innovation, Process Reliability & Standardization, and High Reliability Culture
- Now lest you are tempted to declare victory, pack up your belongings, and head for the airport, let me ground us with some sobering statistics about the work that remains to be done.
- This is the # of events by HAC for one month (SSEs not included) 441 children experience harm – 15 a day. 26 kids while we are attending this learning session
- I’m from Cleveland, remember? Trust me, NOTHING is impossible.
- I have even better examples than that to prove it. [read slide] And there are many other examples of units that demonstrate for all of us that success is possible. Okay, you say, kudos to them, but – well – they are special in some way that I’m not – or maybe lucky. But if you look closely enough, you can also find this success writ large
- Let me tell you the story about this place – Omaha Children’s Hospital 146 bed children’s hospital in Nebraska – You may have never been there but let me tell you that it’s a place ultimately not that different from yours – kids get cancer there, they’re run over by cars, they’re born premature and with complicated hearts, and they have horrible, chronic illnesses from which they sometimes try to die. Joined SPS in 2012 Two years later in the summer of 2014 they found themselves with HAC improvements stalled and culture of safety survey results in the toilet The 4 person team they have allotted to quality and safety efforts were at wit’s end and decided to just GO FOR IT.
- The short story is this. Last month they celebrated 365 days without a SSE giving them an SSER of zero. This was not a miracle. This was hard work and perseverance. When I asked Amber Phipps, one of their quality leaders what the key ingredients were to this recipe, she shared 4: Transparency and honesty with self and board. They met with every single board member and said out loud, “We are two years behind.” And handed each of them a clear, enterprise-wide dashboard demonstrating the lag in their improvement. Used the SPS network – recognized not alone – called hospitals they read about in the SHINE report, visited and invited SPS colleagues visitors to help them improve Passionate and perseverant core team – Amber Phipps, Jill Jensen, Bridget Norton, Mel Hall, Katie Nelson – this group personally engaged the entire hospital and toiled to make safety work fun through their approach to error prevention and leadership method training, videos, town halls, safety minutes, intranet pop-ups, etc., etc. Board and Senior leader engagement – developed a board charter, actively engaged CEO, COO, CMO, CIO and finance team in executive rounding; CEO personally celebrates individuals with great catches by going to thank them in person on their shifts. But maybe right now you’re thinking – that’s great, but we’re different. We’re bigger or we’re a hospital within a system. Our situation is more complicated.
- Let me tell you the story of this place – Rainbow Babies & Children’s hospital 244 bed children’s hospital Hospital within a 1000 bed adult hospital and a system with 12 acute care hospitals
- This is their story. In October, 2010, they had 5 SSEs and reached their jaw-dropping max rate over 2.7 events per 10,000 adjusted patient days. Just going 2 weeks without an SSE was an accomplishment at one point. Then look what happened – error prevention training, root cause analysis, leadership methods, transparency, effort, tears And in March, 2015 they also achieved a zero SSER and in fact sustained it through August 2015. Then in September 2015 they had two painful events in one month. Again they rallied and as of last week, went 12 months without an SSE for the second time. Their keys to success: #1. Far and away, the focus, persistence and authentic engagement of their senior leadership. They didn’t perseverate on the fact that the system leader might not know their names, but they fought the hard fight and put their necks on the line. So when the system leadership rejected their bid to hire more expensive pediatric pharmacists, they tried again. And again, And again. Until they won. And then they battled again for adequate surgical coverage and…. The list goes on #2. Leadership buy-in at the local level – not tolerating eye-rolling, bad behavior, failure to participate. Holding people accountable to very high yield interventions like pediatric early warning scoring and prevention bundles. The leaders themselves are accountable.
- In closing, I would just add a few thoughts about what’s in our near future We cannot stop our relentless efforts to drive high reliability culture and processes – we’ve been working on this a long time but there’s a lot left to be done as I’ll share with you in the next session; We must continue our deep dive into CLABSI– the heme-onc group under the leadership of Jeff Hord has already starting testing new ideas and will be convening at the end of the month; Margie McCaskey is spearheading a group exploring ways to increase bundle reliability, Charlie Huskins- assisting with ongoing dialogue with folks from the CDC, and Holly O’Brien and Mike Gutzeit continue to add their leadership as well. Cincinnati Children’s, King’s Daughter’s, Cook Children’s and Dallas have volunteered to work on a pilot project with Toyota focused on improving reliability to the CLABSI bundle. And many of you are testing and sharing ideas you are developing to help us identify opportunities to reduce this ubiquitous harm. Our progress with VTE is too slow. Char Witmer, Daniela Davis, Julie Jaffray and Brian Branchford have partnered with experts in hematology, intensive care, interventional radiology, nursing, and respiratory therapy to re-organize and re-focus us. I couldn’t be more thrilled about the work that is emerging and think you will be, too. 10 hospitals are contributing time and wisdom to the development of disclosure best practices. The tools they are putting together including some really cool simulation exercises should be ready at the beginning of next year. We launched our critically important employee/staff safety work. Hospitals rallied at the summit at the beginning of the summer and are now preparing to submit DART and TRIR data so we can begin to learn together. The SSI team recently published their work in Pediatrics and the publication which reflects the overall results of our network is in the submission process. Additional publications of our work include ones on CAUTI, CLABSI, pressure injuries, and the pioneer process. Planning for culture 2.0, designed to build on the success of error prevention, leadership methods, and RCA training, is underway, helped by our board and several SPS CEOs as well as leaders from other high reliability industries who believe – as I do – that our future success depends on a new way for leaders to think and act. And, last but not least, a new concept – Navigator – how is it that we can better define those hospitals that are enormously successful? Much more to come on this during our upcoming plenary session.
- I leave you with this – a photo of Ben and his siblings on his first day of school. You can see his bandages and braces protecting his newly constructed knee and his graft site. Let Ben and his family live happily ever after. Let all children avoid this type of harm. We are the leaders who can make it happen. Let’s do it together. Thanks.