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 [email protected] 603-520-4128
Please contact me to learn more about Safety Champions and Practice Evaluations