Harm? N.I.M.B.Y.!

Diane M. Wilhite, RHIA, CPHRMDirector, QualityInova Fair Oaks

Inova Fair Oaks Hospital

• Inova Fair Oaks Hospital is a 182-bed advanced acute care community hospital.

• Inova Fair Oaks Hospital is part of Inova Health System, a not-for-profit, community-based, mission-driven healthcare system serving Northern Virginia.• Ranked in the top 10 of the nation’s 100 most integrated health systems

• Inova Health System is governed by a voluntary board of community members.

The numbers game: Harm Happens

44,000 to 98,000 298,865

210,000-440,000

3rd

380,000

1 out of every 25 1 in 7

18%

Harm Happens: But at what cost??

$37.6 billion

$4 billion

$17.1 billion

Call to Action

What is real picture?

Green is good, right?

• This is what green really means? • 147 patients were “harmed” according to our definition• That is an average of 12 patients per month• With a 25% reduction goal, that still means 100+ patients!

What about this?

What it really looks like….

• Gregory F

• Leo D

• Walter K

• Carroll T

• Vergie B

• Alice H

• Rokia Z

• Jane R

• Mary L

• Sediqa F

• Yvonne B

• Laine H

• John D

• Diane A

• Karen M• Alan S• Tamara E• Alexandra• Jeremy C• Patricia C• Kenyon D• Andrew G• Scott F• Alice H• Victoria D• Lawrence P• Mary S• Mercedes M• Santos C• Myung C• Robert R• Patricia G

• Mary Ann B• Sediqa F• Nancy A• Peggy P• Joanne• Guillermo• Hector O• Tran N • Paramjit K• Irene M• Zohar B• John M• Madeline• Ama• Stephen K• Dilia M

• Tarlok A• Harvey H• Mary L• Mercedes M• Shirley W• Jacqueline J• Deborah• Alan• Francis• An D• Carl R• Cleva B• Joan G• Myung C• Carol• Mary Jo• Albert• Alexis

• Shirzad F• Rahimullah E• Barbara C• Khalida• Freda• Floyd D• Barbara C• Einelhayat S• Gregory• Gary

Dead By Mistake

When?

Making it Real for the Staff

Lean Management

System

What is a Lean Management System?

A System by which we:

1) Run our Business based on real time indication of the Value we are delivering to our Customer

2) Continuously Improve our Business and Sustain those Improvements

Foundational Principles:

Respect for People

Elimination of Waste

Sustainment = Standardization + Connected Checking

Why?

Current State Opportunities:

•Inability to sustain improvements

•Competing priorities under each Strategic Priority

•Critical processes are not defined or standardized

•Lack of prioritizing what’s important to the customer

•No visibility to whether we are meeting customer expectations on a real-time basis

•Lagging performance data

How do we Implement this System?

1. Understand what’s important to the Customer

(the value we are delivering)

2. Determine the Processes that are Critical to deliver that Value & Standardize those processes

3. Measure Our Performance Daily• Key Performance Indicators for processes that are critical to

delivering the Value

4. Structured Governance and Report Out• Performance – Target, Actual, Gap

• What we are doing to close the Gap

• Issues that need to be escalated for support

Lean Management Model

IFOHCEO

Directors

Depts Depts Depts Depts

CNO CFO CMO CEO

Directors Directors Directors

Staff

Level 3 KPI’sMonthly Review

Level 2 KPI’sWeekly Review

Level 1 KPI’sDaily Review

Q S A PTrue North KPI’s based on Customer Requirements

Standard Work

Leader Standard Work

Leader Standard Work

Leader Standard Work

Leader Standard Work

Va

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& C

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Re

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w P

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Issu

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Accountability and Engagement

“Hardwiring Accountability at the Front Line”, The Advisory Board, 2012

Medical Unit True North Huddle

Building in Accountability

1. Visual ManagementRun the Business KPI's- Target, Actual, GapLagging Metrics (Press Ganey, etc.)

2. A3 Problem SolvingRoot Cause AnalysisVisualize Cause & EffectFollow Up of Action Items

3. Standard Work for Critical Processes- clear, visual, one page Standard Work where Staff can see it4. Leader Standard Work to Validate Critical Process Standard Work

A. Supervisor -> StaffB. Manager -> Supervisor and StaffC. Director -> ManagerD. Executive -> Director

5. Team Huddle- True North HuddleReview Performance, Discuss Barriers, Review A3/Action Progress, Escalate Issues

6. Staff Engagement in Standard Work, Barriers, and Empowered to Improve

Area:_______________________Inova Fair Oaks

Lean Management SystemScorecard

No activity / large gaps Active but needs improvement Fully active and robustDefinitions:

Standard Work

What is Standard Work?

• The Standard Method for performing a process or task

• The best known approach

• The Expected way to perform a process or task

• The foundation for Process Control, Stability, and Sustainment

Expected Outcome

Not Expected Outcome

Why do we need Standard Work?

Sustainment = Standardization

+ Connected Checking

Staff Satisfaction = Know what is expected

Standard Work Best Practice

Created by those that do the work

Has an “Owner” , who is the point person for keeping the Standard updated

Continuously Improved (PDSA)

Simple, Visual, One-Pager

1-5 Days to Create

Includes any important behaviors

Critical Process Standard Work is checked daily to ensure we are performing to our customer’s expectations

Standard Work Document

Operating Unit Process Name Process Location Target Time Created Reviewed/ Revised

Author

IHS – All Hospitals

Intentional Hourly Rounding (Inpatient Units)

Onsite @ Hospitals 6 – 12 minutes

7/16/14 8/14/14 Christie E. Rust

Purpose: Round on patients with Purpose to actively engage patients and families, build trust, reduce anxiety, prevent harm, and meet their needs

Step Process Step Responsible Time Goal Critical Notes on Step

1 Use AIDET & opening key words to reduce anxiety. Caregiver 20 seconds

Explain what you’re doing during the rounding process. Make sure the patient understands hourly rounding and know why we perform hourly rounding.

2 Perform scheduled tasks. Caregiver Varies

3 Ask the patient about their number one concern and address this concern for him/her. Caregiver 1 – 2 minutes

4

Address the 6 Ps and 2 Qs – “Mind Your Ps &Qs”: 1) Pain: assessment of patient’s pain level 2) Position: check to validate patient’s comfort 3) Potty: ask the patient if he/she needs to use the bathroom 4) Possessions: validate the patient’s belongings are within reach 5) Pump: check the IV bag; if it will empty before the next hourly round, replace the bag now to prevent

beeping of the IV pump 6) Plan of Care: review with the patient their plan of care and update the patient about any changes that

have occurred since the previous review 7) Quiet: ask the patient if it’s quiet enough for them to rest; address noise concerns as appropriate 8) Questions: Ask the patient if he/she has any questions

Caregiver 2 – 5 minutes

5 Assess additional comfort needs. Caregiver

1 – 2 minutes

Additional comfort needs may include blankets, water, food, etc.

6 Conduct an environmental assessment Caregiver 1 minute

Empty trash cans if they’re full Pick up debris from the floor Tidy the room Ensure the bedside table, phone, call bell,

tissues, personal belongings, etc. are within the patient’s reach.

7 Close the conversation. Caregiver 20 seconds 8 Tell the patient when you or a care team member will return. Caregiver 10 seconds

9 Document/update the patient’s activities and plan of care on the communication board using the removable magnetic tool.

Caregiver 1 minute Explain to the patient what you’re documenting and why (ie, “I want you to be informed). Narrate the care!

10 Document/update all other pertinent information on the communication board (ie, pain rating, etc.) Caregiver 1 minute

Explain to the patient what you’re documenting and why (ie, “I want you to be informed). Narrate the care!

Expected Outcome: Process Completed Hourly, Patient Feels Cared For and Understands Plan of Care, Falls Prevented, Call Lights Prevented => Patient Satisfaction Critical Notes on Overall Process N1 Intentional hourly rounding will be completed for each patient every hour between 6 am – 10 pm and every two hours between 10 pm – 6 am.

N2 Intentional hourly rounding is completed by nurses and clin techs. Each unit must identify a process that fits into their workflow for completing hourly rounding (ie, nurses round on even hours, clin techs round on odd hours, etc.).

How do we measure the Value?

•“Key Process Indicator” or “KPI”

•What purpose do KPIs serve?oTo understand if we are delivering customer’s expectationsoMeasure of Performance to TargetoAlign and focus the organization’s effortsoVisibility to trends- improvement or declineoFocus improvement efforts -> Strategic ImprovementoUnderstand if actions are effective

•Outcomes are a product of what you measure and check

Critical Process KPI’s

Basic premise: Any process that is Critical to meeting Customer expectations/needs should be visible in a Daily KPI

Example:Customer: PatientExpectation: Keeping patients free from injury from falls

Critical Processes:

•Falls assessment

•Bed alarms

•Hourly Rounding

Daily KPI: % Always Quality

Medical Unit ServiceDaily Run the Business

Daily KPI Performance

Daily Defect Tracker for Critical Processes

•Hourly Rounding•Falls Assessment•Bed Alarms

Q

A3 Problem Solving

A3 Elements

1. Problem Statement• Impact to

Customer• Measurable

2. Problem Solving Team• Staff Champions• Cross-functional

3. Problem AnalysisA. Pareto of Causes

• Data or Barrier Analysis

B. Root Cause Analysis• 5 Why’s

4. Hypothesis• If we do ___ we

will achieve ___ improvement.

• Tied Directly to Problem Statement

5. Action• 1-2 Actions to remove

Root Cause• Active Small Test of

Change – PDSA• KPI to measure

Action- are we doing it?

• If no Standard Work, start with Standard Work as Action

6. Verification• Test Cause and Effect

• Are we doing Action

• Is it making an impact on the results

• Tied to Problem Statement

Now Back to Harm

What is Harm?

• Criteria used for inclusion:•Confident in data integrity due to multiple verification processes•Familiarity with data set and previously reported •Well defined and readily available

• After several versions, we settled on the following harm definition:•5 Condition Medicare Readmissions•NQF Serious Reportable events•PSI 90•HAIs (CAUTI, CLABSI, C Diff, MRSA, Colon and Abd Hyst SSI)•Falls with Injury

Driving to Zero• Driving to Zero Harm means:

• We had to think in terms of raw numbers. • Rates did not give us the real story• We had to identify our top harm opportunities and the departments that could influence those opportunities• We had to identify and influence the daily processes • We had to engage the front line staff and make it real for them

“Relying on lagging indicators alone is like driving forward while looking out the rearview mirror…”

“How do you know what

you’re doing today will make a

difference in the future…”

Setting the Priorities for All IFOH Departments

• Driving to Zero Harm means:• Top Opportunities:

• Readmissions (specifically CHF and Total Joint)

• C Diff• Falls with Injury

• Strategic A3s developed and progress reported weekly with barriers identified, progress made, selection of real time KPIs and verification with lagging indicators

• All departments have a hand washing KPI requirement

Strategic Priorities

Problem Statement: Perinatal Harm events (PSI 17 Birth trauma, PSI 18 OB trauma with instrumentation, PSI 19 – Birth trauma without instrumentation) measurement has consistently been above targeted benchmarks. Data shows that our biggest opportunity Is with PSI 18 and19. Our current processes need to change to decrease maternal and infant harm during the birth process

Problem Owner: Dr. Lynch, Dr. Pickford

Problem-Solving Team: Members of Perinatal Safety and Peer Review Committee and OB Care

Perinatal Harm Action Plan As of 10/21/2015

Verification: Course Completion ,Monthly Perinatal PSI rates and case review. Develop concurrent tracking methods (ie Safety Always)

Targets: PSI 17=0.0PSI 18=59.14.PSI 19=10.64

Actual:PSI 17=1.69PSI 18=190.48PSI 19=13.04

Gap:PSI 17=1.69PSI 18=131.34PSI 19=2.4

Hypothesis: Mandated Safe Passages course will decrease the number of PSI 18 and 19 patient harm events and may reduce PSI 17 (birth trauma)

What When Who % Comp.

Perinatal Safety and Peer Review committee review of PSI data for 2015 Year to Date. No practitioner trends at this time

July Perinatal Safety Committee meeting

Perinatal Safety Committee

Completed

Recommendation made and approved in OB care for mandated Safe Passages training for Nursing Staff and OB Medical Staff. Dr. Rosen taking recommendation to System OB Medical Directors Group August 6.

August OB Care Committee

Cheri Goll,OB GYN Chair

In progress

Purchase “Peanut Balls” as aids for positioning patients in2nd stage of labor.

Jenn Stroud/ Barbara Markel

Completed

In-services and education for L&D nurses on managing 2nd stage, positioning and perineal techniques to reduce lacerations. (CNM and Doula)

Jenn Stroud/ Barbara Markel

In Progress

Oxytocin case review in progress Perinatal Safety Committee

In Progress

Data reviewed daily for PSI 17,18 & 19 Since January 2015

Jennifer McCaughey

On going

Measures 2014 Result

2015 Goal

2015 Q1

2015 Q2

2015 Q3

2015 Q4

2015 YTD

Birth Trauma injury to Neonate - PSI-17

0.52 0.000.00 1.69 0.86

OB Trauma Vaginal Delivery with Instrumentation - PSI-18

134.97 59.14 157.89 190.48 175.00

OB Trauma Vaginal Delivery without Instrumentation - PSI-19

14.38 10.64 19.54 13.04 16.36

Data through June 2015

What the units are measuring…

Falls:Lagging: Falls with injuryKPIs: Bed alarms on, hourly rounding

Readmissions: Lagging: Number of Medicare 5 condition readmissionsKPIs: CM assessment within 24 hoursHome health referral with LACE > 10, Hospitalist MDRs with CM, Use of STOPLIGHT tool for HF patients, Pharmacist medication education on HF patients

Infections:Lagging: Number of infections, hand hygiene complianceKPIs: Hand hygiene compliance, CLABSI bundle compliance, CHG baths, number of foleys, foley bundle compliance

Harm Events

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Lessons Learned

• Readmissions, while important to track as defects, are not necessarily a good indicator of harm

• The issue is multifactorial and involves our outpatient partners• Our data indicates that readmissions occur at 13 – 15 days post discharge

• Many contributing factors related to readmissions are outside the control of the hospital.

• IFOH focus for 2015 involved improving patient education, especially on medications and for CHF patients

• Unit specific lagging indicators are needed to help demonstrate the impact that the daily KPIs are having

• OB Harm events (PSI 17 – 19) were not included and need to be. • A3 has now been developed and concurrent review of cases and data has

begun.

• Priorities changed. The Quality Status A3 is now tracking 8 different A3s and associated KPIs vs the 3 we started with in January.

Harm Avoidance Measures: 2016

• PSI-90• Pressure Ulcer• Iatrogenic Pneumothorax• CLABSI• Postop Hip Fracture• Postop PE or DVT• Postop Sepsis• Postop Wound Dehiscience• Accidental Puncture or Laceration

• Hospital Acquired Infections• CAUTI• CLABSI• C Diff• MRSA• Surgical Site Infections

• Falls with Injury

• OB Harm• Early Elective Delivery• PSI 18 & 19: OB Trauma Vaginal Delivery with and without instrumentation

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NEW

Final Thought…..

“The names of the patients whose lives we save can never be known.

Our contribution will be what did not happen to them. And, though they

are unknown, we will know that mothers and fathers are at graduations

and weddings they would have missed and that grandchildren

will know grandparents they might never have known, and holidays

will be taken, and work completed, and books read, and symphonies heard,

and gardens tended that, without our work, would never have been.” -Donald M. Berwick, MD, MPP, Former President and CEO, IHI