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Raising the Bar On Infusion Therapy Safety: A Patient Safety Program
at Catholic Health Initiatives
Friday, June 24, 2016
AAMI FoundationVision: To drive the safe adoption and safe use of healthcare technology
• National Coalition for Infusion Therapy Safety
• National Coalition to Promote Continuous Monitoring of Patients on Opioids
• NEW Compendium: Opioid Safety & Patient Monitoring
• National Coalition for Alarm Management Safety
• NEW Compendium: AAMI Foundation Management of Clinical Alarm
Please Consider Making a Donation!
Contact Marilyn Flack at mflack@aami.org
Thank You to Our PremiereIndustry Partners
Without the generous support of our industry partners, we would not be able to produce the many tools and deliverables created by the coalition to help you improve infusion therapy safety.
The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.
PlatinumDiamond Gold
LinkedIn Questions
Please post questions on the
AAMI Foundation’s LinkedIn page.
OR
Type a question into the question box on the webinar dashboard.
Nursing Continuing Education Disclosure Statement• This seminar is jointly provided today with our co-provider, the National Association of
Clinical Nurse Specialists (NACNS).
• 1.0 contact hour will be awarded for this seminar. This seminar may be accessed online at the AAMI Foundation website for nursing CE up to two years from today’s date.
• This continuing nursing education activity was approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC).
• Criteria for successful completion includes attendance at the session and submission of a completed evaluation form. You can submit the fee for the CE credit by going to the AAMI store at http://my.aami.org/store/detail.aspx?id=INTRUSIONSEM A link to the evaluation form will be sent to you for completion and a certificate sent to you upon completion of the evaluation.
• The planning committee members have declared no conflict of interest along with our faculty for today’s session.
• Contributions to the AAMI Foundation have been received from the identified sponsors to support program initiatives and projects. However, the program content for today’s seminar has been planned independently by AAMI staff with the seminar presenters.
• Approval of the continuing education activity does not imply endorsement by the provider, ANCC or the Alabama State Nurses Association.
Speaker Introductions
Mary Kane, RN, MS
Vice President
Regional Chief Nursing Informatics Officer
Catholic Health Initiatives
At A Glance: Catholic Health Initiatives
• Operates in 19 states
• 90,000+ employees
• 105 hospitals including:
4 academic health centers and major teaching hospitals
30 critical access hospitals 13 clinically integrated networks10 insurance plans
About 54 million people – or nearly 17% of the U.S. population –live within a 60-mile radius of a CHI hospital.
Financial Highlights
• $21.8 billion in assets
• $13.9 billion in total annual operating revenue
• $910 million in total annual contributions to charity care and community benefit
Mission and Ministry FundMore than $55 million in grants for building healthycommunities
Electronic Record Platforms
• Outpatient
• Allscripts
• Inpatient
• Meditech Magic and 6 x
• Cerner
• Epic
Inpatient platforms used by over 70,000 clinicians and staff within the Catholic Health Care System
9/25/2013 13
Device Strategy
• Three major manufacturers make up 80% of infusion devices within CHI
• CHI has made several acquisitions in the last five years accounting for a number of disparate devices
• Goal is to achieve standardization in both the device strategy as well as software (drug library) content build wherever possible
9/25/2013 14
Build a bridge that can withstand any Tornado/Hurricane we can get.
Worst Hurricane in 200 years. Bridge still standing.
Success!
How We Got Here
2008 Begin implementation
2009 Refine approach
2010 Implement
2011 Implement……etc.
10 year, 60+ Million dollar journey.
Implementation
• Multidisciplinary AND Nationally funded
• National-Local partnership
• CHI-Vendor partnership
• Gap Analysis, Clinical Assessment part of the process
• ~12 week process
• IT, Nursing, Pharmacy, Providers, Informatics, Clinical Engineering, Supply Chain Quality at the table.
Implementations led by Clinical at the National Level. More specifically Clinical Informatics. Stakeholder engagement must include clinical end users of the system.
9/25/2013 19
Library Compliance
“You cannot improve outcomes if you are not accessing the library in the first place.”
2012 64.2%
Root Cause: No one knew how to access their own data.
Library Compliance
“You cannot improve outcomes if you are not accessing the library in the first place.”
2012 64.2%
2013 76.1%
Root Cause: No one thought it mattered
Board of Directors
• Made the target 85% compliance a line item under quality metrics enterprise-wide
• Tied it to executive compensation (bonus)
Result…..compliance now 87.9%
Current State of Library
• Thirty-four different builds.
• No standardized use of Tallman naming convention
• Trade and generic drug names in use
• No consistency in the formatting of common infusion
concentrations
• Inconsistent application of evidence-based infusion rate
recommendations for specific drugs
• Inconsistency in Upper and Lower Soft and Hard Parameters
and in some situations no parameters are set
- Many are ISMP high risk med
Drug LibraryStandardization
Why is Standardization of Drug Libraries Desirable?
• Everyone “talking the same language”
• Allows for truly comparable data between facilities
• Represents opportunity to improve patient safety=improved financial
outcomes
Drug LibraryReview Process
Purpose: Maintaining the Integrity of our Drug LibrariesChange Management process is necessary to assure that our Drug Libraries remain synched, able to address change needs and remain relevant.
Pilot
Roll-Out
Change REQ
Process
Update & Maintain
Creation of
Standard
Override vs. Edit
Overrides are situations where the clinician exceeded an upper or lower soft limit and confirmed their intent to exceed the limit.
• Overrides can only occur with drug library soft limits. • Soft limit overrides indicate variation exists between clinical
practice and drug library parameters. • The source of the variation maybe in physician prescribing or
medication administration practice.
Edits are situations where the clinician indicated intent to change their entry in response to the alerts.
• Edits may occur with soft or hard limits.
Soft LimitSoft limit - like a speed bump requires you to slow down and take an extra step to overcome it
Financial - CHI ROI
Sources
• ADE will cost $8,750 in 2006 Dollars Preventing Medication Errors: Quality Chasm Series. Committee on Identifying and
Preventing Medication Errors. Eds. Aspden P. Wolcott J, et al. Institute of Medicine, 2006
• 7% of ADE’s cause harm based on the Barker Study Barker KN, et al. Arch Int Med. 2002;162:1897-1903
• CHI’s internal cost figure for an ADE is $2,200
Clinical Efficiencies
1. Alerts. System is becoming more responsive2. Overrides. Overridden prone medications have been addressed3. Edits. There is an increased effectiveness of the drug library
in changing clinician programming behavior.
Alert Rates
9/25/2013 37
1. Decreases alert fatigue2. Takes the noise out of the system3. Clinician satisfier
Conclusion
• Performance excellence is the goal
• Increase awareness in your clinicians and leadership
• Joint effort between nursing and pharmacy
• Appropriate change management process
• Educate and informLarge forumsSmall groupsIndividual
Approach
• Report out and remediate system-wide any inconsistencies in alerts, overrides, poor use of limits. Done at the executive leadership level.
Done quarterly
• Report out facility-wide inconsistencies in limits, overrides, alerts
Done monthly
• Provide education both locally and nationally to improve access to local portal
On an as needed basis
Next Steps
• Continue migrations to CHI standard for devices
• Drug library content optimization to be a national initiative
• National governance
• SME work group
• Drive standardization across all platforms
• EMR integration
9/25/2013 40
Lessons Learned• Standardization the rule, but will always be exceptions
• Never discount the wants, needs, desires of individual practices/hospitals/markets
• Governance must include end users to make change permanent
• Partnership for change control of the drug library worked best when nursing and pharmacy was hand in hand
• Change management processes are like numbers…..they just go on and on and on and on…….to infinity and beyond!
9/25/2013 41
Mark Your Calendars!July 18, 2016; 12pm to 1pm
Another in our series: Raising the Bar on Infusion Therapy Safety --A Systematic Approach To Improving Infusion Pump Safety
Molly A. Hicks, RN, MSN
Director of Patient Safety,
Baylor Scott & White Health
Jason Trahan, PharmD
Pharmacy Director – Medication Safety,
Baylor Scott & White Health
Register: https://attendee.gotowebinar.com/register/8325915835043571458
CE credit of 1 hour has been approved for this seminar
Complimentary Resources� Safety Innovations Series
� Alarms Management Patient Safety Seminars • Seminar Recordings
• Webinar Slides
• Key Points Checklists
NEW Opioid Safety & Patient
Monitoring
NEW AAMI FoundationAlarm Compendium
Thank You to Our PremiereIndustry Partners
Without the generous support of our industry partners, we would not be able to produce the many tools and deliverables created by the coalition to help you improve infusion therapy safety.
The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.
PlatinumDiamond Gold
Questions?• Post a question on AAMI
Foundation’s LinkedIn
• Type your question in the “Question” box on your webinar dashboard
• Or you can email your question to: mflack@aami.org.
Consider Making a Donation to the AAMI Foundation Today!
Making Healthcare Technology Safer, Together
Thank you for your support!
http://my.aami.org/store/donation.aspx
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