This document summarizes the work of Solutions for Patient Safety (SPS) in improving safety outcomes across children's hospitals. SPS aims to reduce hospital acquired conditions and readmissions across its network by providing data, training, and opportunities for hospitals to learn from each other. It discusses accomplishments like reductions in various safety issues. It also identifies areas for continued focus, such as further reducing central line-associated bloodstream infections and ventilator-associated events. Overall, the summary outlines SPS's mission and strategic approach to collaboratively improving safety across its network of children's hospitals.
Discover more about how the West of England AHSN is putting innovation at the heart of healthcare, improving patient outcomes and generating wealth for economic growth.
Learn about the new MedRec rebranding strategy and what it means for patients/consumers, and healthcare professionals
2.What’s new with ‘5 Questions to Ask About Your Medications’
3.Hear how organizations are using ‘5 Questions to Ask About Your Medications’ to engage patients and consumers
This webinar will shift the focus from WHAT you are doing with your improvement efforts, instead shedding light on the importance of HOW you are doing it!
What do the Canadian Patient Safety Institute (CPSI), the Agency for Healthcare Research & Quality (AHRQ) in the United States, and the Michael Garron Hospital in Toronto have in common? All three organizations have seen the benefits to patient safety when implementing the evidence-based teamwork and communication framework, TeamSTEPPS (Team Strategies and Tools for Effective Performance and Patient Safety).
Full details: https://goo.gl/8Y2PHc
Understanding how the Measurement and Monitoring of Safety Framework can form board understanding and help align strategic and operational approach to patient safety.
Full details: https://goo.gl/XyqTQA
Discover more about how the West of England AHSN is putting innovation at the heart of healthcare, improving patient outcomes and generating wealth for economic growth.
Learn about the new MedRec rebranding strategy and what it means for patients/consumers, and healthcare professionals
2.What’s new with ‘5 Questions to Ask About Your Medications’
3.Hear how organizations are using ‘5 Questions to Ask About Your Medications’ to engage patients and consumers
This webinar will shift the focus from WHAT you are doing with your improvement efforts, instead shedding light on the importance of HOW you are doing it!
What do the Canadian Patient Safety Institute (CPSI), the Agency for Healthcare Research & Quality (AHRQ) in the United States, and the Michael Garron Hospital in Toronto have in common? All three organizations have seen the benefits to patient safety when implementing the evidence-based teamwork and communication framework, TeamSTEPPS (Team Strategies and Tools for Effective Performance and Patient Safety).
Full details: https://goo.gl/8Y2PHc
Understanding how the Measurement and Monitoring of Safety Framework can form board understanding and help align strategic and operational approach to patient safety.
Full details: https://goo.gl/XyqTQA
The Nuts & Bolts of Integrating Health Technology Assessment in Care Pathways...Brenda Rehaluk
This MA organizational change project was sponsored by the Alberta Health Services (AHS), Strategic Clinical Network, Health Technology Assessment and Adoption (SCN, HTAA) team. This research project's overarching question was on how can health technology assessment be used effectively in clinical care pathways and clinical practice guideline development.
Findings: Health technology assessment (HTA) creates a common language among health care providers to improve engagement and patient centred care. Optimization of health technology assessment involves the development of relationships, education, and simple technological tools to create a culture of HTA acceptance.
Have you ever struggled to unite a team on an improvement project? Or have you ever been in a situation where lack of communication has hindered your improvement efforts?
Healthcare organizations in Canada are making great strides in promoting safer patient care through engagement and partnership. Now the best of these organizations would like to share their successes and lessons learned with you!
Full details:
https://goo.gl/NukquA
At the end of the session patient/family champions as well as health authorities will understand different approaches to patient engagement in patient safety and quality committees (e.g. dealing with incident reporting, root cause analysis, developing policies and procedures) and how patient engagement impacted patient safety and quality outcomes. The participants and presenters are invited to present examples, tools, and leading practices so the participants will leave with at least one practical idea to implement.
How the CIHI – CPSI collaborative on hospital harm can support patient safety initiatives in your organization
Most patients in Canadian hospitals experience safe care, but when harm happens there is a significant impact on patients, families, the healthcare team, and the health system in general. Until now, there hasn't been a standard approach to measuring and monitoring harm experienced by patients in hospital.
At the end of this 90 minute session patient/ family/ advisors/ champions as well as health providers/ leaders/ authorities will leave with at least one practical idea to apply to patient advisor training as a result of their increased understanding of:
Current training programs and models in use across Canada
Training needs of patient advisors at different system levels
Gaps in training needs and ideas on how to fill them
Available supporting resources and leading practices
Cost-Effectiveness Analysis of RBF in Zimbabwe and ZambiaRBFHealth
Profs. Shepard and Zeng have been leading projects for the Bank to develop methods for performing a cost-effectiveness analysis of Results-Based Financing (RBF) programs and applying them to maternal-child health (MCH) services in Zambia and Zimbabwe. Both countries’ RBF programs proved highly cost-effective. Methods and results should be informative to other RBF and MCH programs.
Lisa Annaly, Head of Provider Analytics at the Care Quality Commission, discusses lessons learned from the CQC as they have worked to monitor care quality over time.
Monitoring quality of care: making the most of dataNuffield Trust
Chris Sherlaw-Johnson, Senior Research Analyst at the Nuffield Trust, introduced the Monitoring quality of care conference and gives an overview of some of the approaches that we've been using at the Trust to identify where care quality has been improving, especially for frail and older people.
Interested in sharing best practices within your organization?
Are you engaged in creating community health status reports? Are you interested in learning about how to improve health equity? The Equity-Integrated Population Health Status Reporting Action Framework can help health professionals at all levels identify and implement manageable steps for integrating equity into existing or new public health status reporting processes. The framework is suitable for use by health/public health staff, community organizations that provide local data, and academic researchers.
This framework was developed collaboratively by the six National Collaborating Centres for Public Health, building upon earlier work by the NCC for Determinants of Health.
To see the summary statement of this tool developed by NCCMT, click here: http://www.nccmt.ca/resources/search/240
The National Collaborating Centre for Methods and Tools is funded by the Public Health Agency of Canada and affiliated with McMaster University. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.
NCCMT is one of six National Collaborating Centres (NCCs) for Public Health. The Centres promote and improve the use of scientific research and other knowledge to strengthen public health practices and policies in Canada.
Ian Blunt & Martin Bardsley: Cause for concernQualityWatch
Ian Blunt and Martin Bardsley of the Nuffield Trust present findings from the QualityWatch 2014 annual statement, and explore how the quality of healthcare in England is changing in response to constrained funding and rising demand.
This presentation was delivered at the QualityWatch annual conference on 28 October 2014. For more information, see: www.qualitywatch.org.uk/QW2014.
QualityWatch is a joint research programme from the Nuffield Trust and the Health Foundation.
Evaluating new models of care: Improvement Analytics UnitNuffield Trust
Martin Caunt, Improvement Analytics Unit Project Director and NHS England and Adam Steventon, Director of Data Analytics at The Health Foundation share insights into how they have approached evaluating new models of care.
Canadian healthcare organizations are taking patient and family engagement to new heights and the best of the best want to share the secrets of their success with you!
Setting a Path for Improved Health Outcomes RBFRBFHealth
Learning is a critical part of the HRITF RBF portfolio, with all programs benefiting from an embedded impact evaluation and in some cases, complemented by qualitative research components such as process evaluation studies. The presentation discusses the following topics:
1. Using RBF at the community-level to address demand side barriers
This presentation elaborates on the early evidence and the rationale for using RBF at the community level. It will share lessons learned from the implementation of community RBF at country level.
2. Using RBF to Strengthen Quality of Care: Early Lessons
This presentation discusses the broader policy implications of using RBF to strengthen the quality of care. It will explore how Measuring and Paying for the Quality of Care has been operationalized and will highlight the experience of Nigeria. Lastly, it will focus on measuring and Analyzing the Quality of Care from the Impact Evaluation perspective.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
Thomas Woodcock, Improvement Science Fellow at Imperial College London, talks about the various measurement approaches and processes when working at large scale to assess care quality improvements.
The Nuts & Bolts of Integrating Health Technology Assessment in Care Pathways...Brenda Rehaluk
This MA organizational change project was sponsored by the Alberta Health Services (AHS), Strategic Clinical Network, Health Technology Assessment and Adoption (SCN, HTAA) team. This research project's overarching question was on how can health technology assessment be used effectively in clinical care pathways and clinical practice guideline development.
Findings: Health technology assessment (HTA) creates a common language among health care providers to improve engagement and patient centred care. Optimization of health technology assessment involves the development of relationships, education, and simple technological tools to create a culture of HTA acceptance.
Have you ever struggled to unite a team on an improvement project? Or have you ever been in a situation where lack of communication has hindered your improvement efforts?
Healthcare organizations in Canada are making great strides in promoting safer patient care through engagement and partnership. Now the best of these organizations would like to share their successes and lessons learned with you!
Full details:
https://goo.gl/NukquA
At the end of the session patient/family champions as well as health authorities will understand different approaches to patient engagement in patient safety and quality committees (e.g. dealing with incident reporting, root cause analysis, developing policies and procedures) and how patient engagement impacted patient safety and quality outcomes. The participants and presenters are invited to present examples, tools, and leading practices so the participants will leave with at least one practical idea to implement.
How the CIHI – CPSI collaborative on hospital harm can support patient safety initiatives in your organization
Most patients in Canadian hospitals experience safe care, but when harm happens there is a significant impact on patients, families, the healthcare team, and the health system in general. Until now, there hasn't been a standard approach to measuring and monitoring harm experienced by patients in hospital.
At the end of this 90 minute session patient/ family/ advisors/ champions as well as health providers/ leaders/ authorities will leave with at least one practical idea to apply to patient advisor training as a result of their increased understanding of:
Current training programs and models in use across Canada
Training needs of patient advisors at different system levels
Gaps in training needs and ideas on how to fill them
Available supporting resources and leading practices
Cost-Effectiveness Analysis of RBF in Zimbabwe and ZambiaRBFHealth
Profs. Shepard and Zeng have been leading projects for the Bank to develop methods for performing a cost-effectiveness analysis of Results-Based Financing (RBF) programs and applying them to maternal-child health (MCH) services in Zambia and Zimbabwe. Both countries’ RBF programs proved highly cost-effective. Methods and results should be informative to other RBF and MCH programs.
Lisa Annaly, Head of Provider Analytics at the Care Quality Commission, discusses lessons learned from the CQC as they have worked to monitor care quality over time.
Monitoring quality of care: making the most of dataNuffield Trust
Chris Sherlaw-Johnson, Senior Research Analyst at the Nuffield Trust, introduced the Monitoring quality of care conference and gives an overview of some of the approaches that we've been using at the Trust to identify where care quality has been improving, especially for frail and older people.
Interested in sharing best practices within your organization?
Are you engaged in creating community health status reports? Are you interested in learning about how to improve health equity? The Equity-Integrated Population Health Status Reporting Action Framework can help health professionals at all levels identify and implement manageable steps for integrating equity into existing or new public health status reporting processes. The framework is suitable for use by health/public health staff, community organizations that provide local data, and academic researchers.
This framework was developed collaboratively by the six National Collaborating Centres for Public Health, building upon earlier work by the NCC for Determinants of Health.
To see the summary statement of this tool developed by NCCMT, click here: http://www.nccmt.ca/resources/search/240
The National Collaborating Centre for Methods and Tools is funded by the Public Health Agency of Canada and affiliated with McMaster University. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.
NCCMT is one of six National Collaborating Centres (NCCs) for Public Health. The Centres promote and improve the use of scientific research and other knowledge to strengthen public health practices and policies in Canada.
Ian Blunt & Martin Bardsley: Cause for concernQualityWatch
Ian Blunt and Martin Bardsley of the Nuffield Trust present findings from the QualityWatch 2014 annual statement, and explore how the quality of healthcare in England is changing in response to constrained funding and rising demand.
This presentation was delivered at the QualityWatch annual conference on 28 October 2014. For more information, see: www.qualitywatch.org.uk/QW2014.
QualityWatch is a joint research programme from the Nuffield Trust and the Health Foundation.
Evaluating new models of care: Improvement Analytics UnitNuffield Trust
Martin Caunt, Improvement Analytics Unit Project Director and NHS England and Adam Steventon, Director of Data Analytics at The Health Foundation share insights into how they have approached evaluating new models of care.
Canadian healthcare organizations are taking patient and family engagement to new heights and the best of the best want to share the secrets of their success with you!
Setting a Path for Improved Health Outcomes RBFRBFHealth
Learning is a critical part of the HRITF RBF portfolio, with all programs benefiting from an embedded impact evaluation and in some cases, complemented by qualitative research components such as process evaluation studies. The presentation discusses the following topics:
1. Using RBF at the community-level to address demand side barriers
This presentation elaborates on the early evidence and the rationale for using RBF at the community level. It will share lessons learned from the implementation of community RBF at country level.
2. Using RBF to Strengthen Quality of Care: Early Lessons
This presentation discusses the broader policy implications of using RBF to strengthen the quality of care. It will explore how Measuring and Paying for the Quality of Care has been operationalized and will highlight the experience of Nigeria. Lastly, it will focus on measuring and Analyzing the Quality of Care from the Impact Evaluation perspective.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
Thomas Woodcock, Improvement Science Fellow at Imperial College London, talks about the various measurement approaches and processes when working at large scale to assess care quality improvements.
Victoria Brazil - Putting the Patient into Patient SafetySMACC Conference
Patients are at risk – from the moment they begin their healthcare journey.
They are at risk of bad outcomes (as defined by us) and of bad experience (as can only be defined by them).
Patient safety experts like James Reason, and groups like the Institute for Healthcare Improvement (IHI) have prompted us to think about systems and complexity as sources of error – and supported strategies to remove predictable human fallibility as far as possible. This is important to make healthcare safer.
Vic Brazil’s talk suggests there is also a human face to patient safety - in the behaviour and attitude of healthcare practitioners and patients themselves......
We think too little of patients. We feel affronted if patient takes a different view of ‘evidence’ or of ‘risk’.
…and they think too much of us....! Every day patients allow nurses (and doctors) to inject drugs into their IV line without asking “whats in that syringe”....
This combination of our subconscious paternalism and patients’ blind faith is a heady mix……but ripe for us to make a difference.
Vic suggests there are are small, human ways we can involve patients in safer healthcare, of better quality and with an improved patient experience.
We can ask them.
We often do involve patient advocates at the ‘strategic end’, but when was the last time you invited a real patient to your departmental teaching or consultant meeting (or smacc conference...!)
Presentations from the patient safety conference held at Teesside University on 1 and 2 September 2014 - Students at the forefront of continuing and improving our culture of safe care
Free book on patient safety by Dr Aniruddha Malpani
Medical errors can be a nightmare – both for patients, and for doctors. However, this is one of those topics which we prefer to sweep under the carpet, because it can be so emotionally charged.
This book provides a holistic overview of medical errors from multiple perspectives. Doctors, nurses, pharmacists, other healthcare providers, pharmaceutical companies, insurers and patients themselves all need to work together to promote patient safety.
Starting with the basics as to why medical errors are still so common, this book highlights what needs to be done to keep patients safe. Reading this book may help to save your life, or that of a loved one. If you are a patient, please read it before you go to the doctor . If you are a doctor, please read it before you see your next patient !
Behavioural change presentation from Mobile World Congress 2016Ross Taylor
How industry and agency needs to collaborate with the best of academia in order to create behavioural change programmes that are rooted in robust, validated techniques as well as creative inspiration.
CDC will provide an overview of their WorkLife Wellness Office services and describe how they used the HealthLead accreditation process to provide a framework to assess the comprehensiveness of their new office and existing programs and processes. Also, how the scoring of framework identified strengths and weaknesses and how the assessment plan of action is used for future strategic planning to drive new connections, data sources, and programmatic gaps as they strive to achieve HealthLead Silver. CDC will share specific examples of what was required and shared as part of the HealthLead audit during the presentation.
Iu Ahrq Hai Assessment Ctr Presentation Feb 22 2010 FinalBrad Doebbeling
75. Healthcare Associated Infections: Assessment Center Findings , Invited Talk, NCQIP, Agency for Healthcare Research and Quality, Bethesda, MD, February 22, 2010.
NHS Improving Quality was invited to take part in a recently held event that celebrated the work that is being done in partnership between the Pennine Acute Hospitals NHS Trust and AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP).
Gillian Phazey, Learning and Organisational Development Manager at Pennine Acute Hospitals NHS Trust explains:
'The Learning and Organisational Development and Governance teams at the Pennine Acute Hospitals NHS Trust have been working collaboratively with AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP) to support staff in developing knowledge and skills in this topic. The programme has been specifically designed to support colleagues wanting to gain an introduction to the fundamentals and concepts of quality improvement. So far, two cohorts of staff, from clinical and non-clinical areas of the Trust have completed the programme, and have completed quality improvement projects in their own work area to apply their knowledge. On 17th July a celebration event was held for cohort 2 where staff presented their work in poster or presentation form, the aim of which is to share and spread learning across the Trust. Projects were wide ranging, from introducing new processes to reduce complaints and drug errors, to improving patient experience by implementing new tools and techniques. The day was a great success with the Chief Executive and Chief Nurse in attendance. The Trust is highly supportive of this approach in equipping staff with these important techniques, and the programme supports not only our internal quality agenda and objectives, but more widely responds to the recommendations of the Berwick report. The next cohort is starting in September this year.'
Fiona Thow, Patient Safety Collaborative Delivery Lead at NHS Improving Quality delivered a keynote speech, (link to presentation slides) providing a national perspective on the plans for improving patient safety and took the opportunity to introduce the national safety collaboratives. She also highlighted the need for organisations and individuals to think differently about safety for both patients and staff.
Susan K. Newbold, PhD, RN-BC, FAAN, FHIMSS
Consultant in Healthcare Informatics working
to advance healthcare information technology
(Friday, 3.45, Keynote)
Harnessing the contribution of the nursing workforce is critical for effective health informatics for present and future endeavors. An overview of the historical efforts of nursing informatics pioneers will lead to a
discussion on how to promote future health informatics to transform healthcare.
Oct 25 CAPHC Concurrent Symposium - Sleep Disorders - Dr. Penny Corkum and ...Glenna Gosewich
CAPHC Concurrent Symposium
Sleep Disorders in Canadian Children: What Can We Do to Ensure Better Nights and Better Days for Children and their Families?
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
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
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
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
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
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
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
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
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
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
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
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.