9/26/2017

1

Pamela W. Brown MS, RN

President/ Principal Consultant

Pamela Brown Associates

Or…. How engaging the clinical nurses in reducing harm is the “Secret Sauce.”

Identify that reducing patient harm creates the value of nursing for healthcare organizations

Discuss engaging clinical nurses as safety champions became the secret to reducing patient harm and missed care

Discuss how practice evaluations became the effective detail that resulted in reductions of patient harm

One area of focus for healthcare reform is delivering patient outcomes of high quality and safety at reasonable costs – or deliver value “Value in health care is expressed as the physical health and sense of well-being achieved relative to the cost” (IOM Roundtable on Evidence-

How do we in nursing improve patient outcomes by reducing harm that is sensitive to nursing care?

How do we increase value?

9/26/2017

2

Hospital Acquired Conditions

Falls with Injury Pressure Injuries (Ulcers) Hospital Acquired Infections: CLABSIs

CAUTIs dDiff and others on the way! Peripheral IV Infiltrations and Extravasations

(PIVIES)

Nursing Quality

72 CLABSIs

35 CAUTIs

72 Falls

11 State-Reportable Pressure Ulcers

In just these categories: 190 people were harmed while under our care.

MD

PfP Hospital Acquired Condition

Estimated Additional Cost* per HAC

Estimated Additional Inpatient Mortality per HAC

Adverse Drug Events $5,000 .020

Catheter-Associated Urinary Tract Infections

$1,000 .023

Central Line-Associated Bloodstream Infections

$17,000 .185

Falls $7,234 .055

Obstetric Adverse Events $3,000 .0015

Pressure Ulcers $17,000 .072

Surgical Site Infections $21,000 .028

Ventilator-Associated Pneumonia

$21,000 .144

Postoperative Venous Thromboembolism

$8,000 .104

HAC FY 16 FY 15 Δ

CAUTI 42 35 +7

CLABSI 32 72 -40

SSI 19 24 -5

C-diff 68 67 +1

Falls (with Injury) 53 72 -19

Pressure Ulcers (State Reportable)

8 12 -4

ADE (F-I) 7 7 0

TOTAL 229 289 -60

HAC FY 16 FY 15 Δ

CAUTI $42,000 $35,000 +$7,000

CLABSI $544,000 $1,224,000 -$680,000

SSI $399,000 $504,000 -$105,000

C-diff

Falls (with Injury) $383,402 $520,848 -$137,446

Pressure Ulcers (State Reportable)

$136,000 $204,000 -$68,000

ADE (F-I) $35,000 $35,000 $0

TOTAL $1,539,402 $2,522,848 -$983,446

Reduced avoidable costs by this amount over the last FY

9/26/2017

3

We harmed 60 less people last year

Nearly 1 million dollars in avoidable costs

Improved public image of organization goes up—Viscient Award for Most Improved

Nurses actively engaged in preventing harm

Organizational pride in meeting goals

And….the Value when it is your mother that is not harmed...

Priceless!!!

To Achieve Recommended Clinical Practice Changes for ◦ ADE ◦ CAUTI ◦ CLABSI ◦ Injuries from

Falls/Immobility ◦ OB Adverse Events ◦ Pressure Ulcers ◦ Surgical Site Infections ◦ Venous Thromboembolism ◦ Ventilator Associated

Pneumonia ◦ Readmissions

Implement High Leverage Communication Practice

Changes

Purposeful Rounding

Nurse Knowledge Exchange at Bedside

Interdisciplinary

Rounds/Daily Plan of Care-Goals

Leadership Rounding

FY 14 • An ongoing internal interdisciplinary learning collaborative and Leadership Structure

• Nurse Manager/ Medical Director Accountability for Outcomes

• Learning Sessions And Ongoing Sharing • Targeted Improvement initiatives • Measurement • Vehicle for Implementing a Culture of Safety and High Reliability

9/26/2017

4

Desired Outcomes

Reduced Patient Harm: CLABSI,CAUTI

Pressure Ulcers, Falls Improved

Patient Experience : RN/MD Communization

with Patients Better Staff Engagement

Team Care Year I FY 14

Interventions Nurse Knowledge Exchange at Bedside Purposeful Rounding Posted Plan of Care on White Board Interdisciplinary Rounds

Concepts Interdisciplinary Learning Collaborative

Change Packages-Bundles Small Test of Change Process Measurement Team Care Shares

Relationship Based Care Team Structure and Process Team Communication and Conflict Management

Team Care Year II FY 15

Interventions Continued work on NKE, Hourly PR, IDR, Daily Goals Daily Safety Brief Reliability Measurement: HAC Bundle Tracers HAC Cards Leader Rounding for Influence NM/Med Director Collaborative Job Descriptions New White Boards

Concepts Evolution of a Culture of Safety Principles of High Reliability Psychological Safety Medical Director/Nurse Manager Accountability High Reliability Leadership Methods Celebration and Sharing

Desired Outcomes

Reduced Patient Harm: CLABSI,CAUTI

Pressure Ulcers, Falls Improved

Patient Experience : RN/MD Communication

with Patients Better Staff Engagement

Sensitivity to Operations

Preoccupation with Failure

Reluctance to Simplify

Deference to Expertise

Commitment to Resilience

Anti

cip

ati

on

Conta

inm

ent

State of Mindfulness

High Reliability

Specific Considerations General Orientation Impact

sjc

Introduced Principles High Reliability in Team Care 2014

72 CLABSIs

35 CAUTIs

72 Falls

11 State-Reportable Pressure Ulcers

In just these categories: 190 people were harmed while under our care.

MD

Lots of competing priorities—lost of pressure to improve, but where do we focus?

High variability in practice HAC EBP Measurement Strategy ◦ unreliable, validity questioned

Many novice nurses staffing units Evidence based practice changes not

effectively communicated from Subject Matter Expert Committees to front line staff

Leaders and staff working hard…were they doing the right work?

MD

DH Safety Champions Program

9/26/2017

5

sc

Team Care Year III FY 16

Concepts DH Safety Matrix Triad Leadership High Reliability: Deep Dive into Sensitivity to Operations Leadership Methods Safety Behaviors Training

Interventions Safety Champions Program Safety Champions, Safety Coaches Practice Evaluations Inter-rater Reliability Training Safety Behaviors Training Apparent Cause Analysis Senior Leader Rounding

Desired Outcomes

Reduce Patient Harm by

25%:

CLABSI, CAUTI

Pressure Ulcers, Falls

Improved Patient Experience :

RN/MD Communication with Patient Better Staff Engagement

Safety Champions Program

Nurse Safety Champions

Coaches Faculty

Practice Evaluations Inter-rater Reliability Training

Safety Behaviors Training Senior Leader Rounding

Focus on Sensitivity to Operations

Team Care

Interdisciplinary SME Team

SMEs Safety

Champions Teams

HAIs Prevention Falls Prevention Pressure Injury

Prevention

Falls and Mobility Safety Champions

Infection Prevention Safety

Champions

Pressure Ulcer Prevention Safety

Champions

1. Subject Matter Expert Training

2. Practice Evaluation Training

3. Error Prevention Training

Unit Champions

Coaches to clinical unit

nurses

Practice Evaluations

Champion Teams

Work Training

Focus on prevention of highest priority HACs ◦ HAI, Pressure Injury, Falls

Clinical Nurses ‘Nurse Safety Champions”

Three Standing Champion Groups

Dedicated time learning, practice evaluations, coaching

Specialty Training in HAC Prevention

Evidence Based Practice Evaluation Tools

Inter-rater reliability training Weekly measurement and feedback to all

Monthly education from Subject Matter Experts

Safety Behaviors/Error Prevention training

9/26/2017

6

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PIP SC

Falls SC

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PUP SC

Falls SC

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PUP SC

Falls SC

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PUP SC

Falls SC

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PUP SC

Falls SC

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PUP SC

Falls SC

Nurse

Manager

Clin/

Qual

Specs

Unit

Leader-

ship

Team

Medical

Director

IP SC

PUP SC

Falls SC

Unit 1

Unit 2

Unit 3

Unit 4

Unit 5

Unit 6

IP SC IP

SC IP SC IP

SC IP SC IP

SC

IP Safety Champion Cohort

Led by Infection Prevention SME

Unit Level Structure

PUP SC

PUP SC

PUP SC

PUP SC

PUP SC

PUP SC

PUP Safety Champion Cohort

Led by Pressure Ulcer Prevention SME

Falls

SC Falls

SC Falls

SC Falls

SC Falls

SC Falls

SC

Falls Safety Champion Cohort

Led by Falls Prevention SME

Program Structure

RNs Practicing Clinical Nurses Recognized

RN unit experts and leaders

Who volunteer and are recommended by their managers

Develop and cultivate expertise in infection, falls, pressure ulcer prevention, and others areas as they emerge

Conduct Practice Evaluations and provide feedback to clinical nurses and interdisciplinary team colleagues

Round on patients on unit to identify patients at risk and evaluate care with clinical nurse at bedside

Provide local staff clinical expertise development – coach and teach staff

Attend both Safety Champion Learning Sessions and Error Prevention Training

Contribute actively to Practice Area Council Meetings

Leaders for Safety Champions Teams ◦ Nurse and Physician Team Care Leaders

◦ Subject Matter Experts, and Committees

◦ Quality Specialist-Nursing and Clinical Specialists as coaches

◦ Quality/Nursing Department SWAT Team

Safety Champions Faculty to develop the education and coordinate the experience

Contact Hours for Learning Sessions

Unit Nurse Managers support participation and unit based activity on Safety Champion’s scheduled work time

Recognition and Rewards: Advancement program that recognizes Safety Champions work for advancement

SME Faculty and Coaches for Infection Prevention Safety Champions

9/26/2017

7

Audit Practice Evaluation

• Externally Driven • Their Standards • Used to Judge • Example: IRS, TJC.CMS

• Internally Driven– • Our Standards • Professional

Responsibility • Used to Learn • Examples: Performance Evaluations

ANA Standard: Responsibility of

Professional Nurse to Evaluate their

Practice

“An criterion referenced concurrent electronic data collection and analysis tool that interprets evidence based guidelines and organization Standards of Practice into a set of discrete, single, valid, reliable elements of performance required for effective clinical practice, used to evaluate clinical practice and facilitate rapid improvement of practice.”

First PET developed Pamela W. Brown © 2010

On Art!!

MD

And we have learned that…

Single discrete, observable, measurable, defined elements of practice required for effective practice

Clear directions for determining the presence or absence of the element

Leaves no space for individual interpretation

Has face validity and approval of subject matter experts

Electronic data entry and analysis

Weekly to daily reporting of results

Are tested, elements are refined, and observer have inter-rater reliability

9/26/2017

8

Design /redesign

of Tool

SME Training

of SC on

Prevention/

Guidelines

Inter-rater

reliability

training for

SC

Practice Evaluations

done by SC/ Data

analyzed and

reported weekly

Lack of clarity

detected

/Standard

changed Average number Practice Evaluations Done Weekly

PUP Safety Champions Learning Session

Nov 16, 2016

AO

Falls Prevention Champions Learning Session

Consensus method of inter-rater reliability ◦ the degree to which two or more independent

raters can come to exact agreement about how to assign scores to observations based on a pre-established scoring protocol (or rubric).

Our Rubric or protocol ◦ the practice evaluation tool

HAI Safety Champions Completing

Inter-rater Reliability Testing

All Safety Champions and others who do Practice evaluations must achieve Intra-rater Reliability in use of Practice Evaluation Tools

All or non measure: The number of observations in which the patient received all elements of performance in the tool ◦ 30 observations- 20 met all elements- Score 66%

Composite Measure: The % of elements on tool that were met ◦ 10 elements on tool, 9 met, Score 90%

Element Compliance: The % compliance with each individual element:

Counts: The number of people harmed

Weekly and daily reports to NM, clinical staff and organizational leaders.

9/26/2017

9

AO

Safety Champions Doing Practice Evaluations with PET

Audit Safety Champions make a personal commitment to safety

Safety Coaches are accountable for clear, complete and accurate communication

Safety Champions support a questioning attitude

Building a Culture of Safety and a

High Reliability Organization

Clinical Nurse Safety Champions and PETs are the “Secret Sauce”

MD

Reduced harm by 25% in FY 2016, continued reductions in 2017

Number of Safety Champions in Year One of Program: >100 Year Two

Organization approved new Medication Safety Champions and others in the pipeline

in 2017 Safety Champions find their own

replacements and train clinical nurses on unit Program thriving despite organizational

disruption and change of leadership

9/26/2017

10

First Annual Safety Champions Celebration

Unit Celebration Sharon H. Pappas, PhD, RN, NEA-BC; Value, a Nursing Outcome; Nurs Admin Q, Vol. 37, No. 2, pp. 122–128

DHMC Team Care and Safety Champions Program materials 2013-2107

Thanks to…

DHMC Nurse Safety Champions

SMEs/Coaches-Falls, HAIs. PI

DH Quality Department

DH CNOs, ACNOs and Nurse Managers, Clinical Nurse Specialists and Medical Directors

DH Associate Chief and Chief Quality Officers

Pamela W. Brown. MS, RN President/ Principal Consultant Pamela Brown Associates pambrown@valley.net 603-520-4128

Please contact me to learn more about Safety Champions and Practice Evaluations