Solutions for Patient Safety:

Anne Lyren, MD, MScClinical Director

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

Who we are

What we aim to do

Mission

Working together to eliminate serious harm across all

children’s hospitals

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

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

Nick LashutkaPresident, SPS

Anne LyrenClinical Director, SPS

Steve MuethingStrategic Advisor, SPS

Missy ShepherdExecutive Director, SPS

SPS Leadership

Develop Ohio Network

Create National Children’s Network

Spread

Scale

(2008-2011)

(2012)

(2013)

(2015 & Onward)

How we approach the work

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”

UN

PLAN

NED

EXT

UBA

TIO

NS

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

READ

MIS

SIO

NS

CLA-

BLO

OD

STRE

AM IN

FECT

ION

S (C

LABS

I)

CA-U

RIN

ARY

TRAC

T IN

FECT

ION

(CAU

TI)

VEN

TILA

TOR-

ASSO

CIAT

ED P

NEU

MO

NIA

(VAP

)

SURG

ICAL

SIT

E IN

FECT

ION

S (S

SI)

ADVE

RSE

DRU

G EV

ENTS

(ADE

)

PRES

SURE

INJU

RIES

(PI)

SERI

OU

S FA

LLS

OBS

TETR

ICAL

ADV

ERSE

EVE

NTS

(OBA

E)

VEN

OU

S TH

ROM

OEM

BOLI

SM (V

TE)

PERI

PHER

AL IN

TRAV

ENO

US

EXTR

AVAS

ATIO

NS

(PIV

IE)

UN

PLAN

NED

EXT

UBA

TIO

NS

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

READ

MIS

SIO

NS

CLA-

BLO

OD

STRE

AM IN

FECT

ION

S (C

LABS

I)

CA-U

RIN

ARY

TRAC

T IN

FECT

ION

(CAU

TI)

VEN

TILA

TOR-

ASSO

CIAT

ED P

NEU

MO

NIA

(VAP

)

SURG

ICAL

SIT

E IN

FECT

ION

S (S

SI)

ADVE

RSE

DRU

G EV

ENTS

(ADE

)

PRES

SURE

INJU

RIES

(PI)

SERI

OU

S FA

LLS

(SF)

OBS

TETR

ICAL

ADV

ERSE

EVE

NTS

(OBA

E)

VEN

OU

S TH

ROM

OEM

BOLI

SM (V

TE)

SAFETY GOVERNANCE (SG) & CAUSE ANALYSIS (CA)

PERI

PHER

AL IN

TRAV

ENO

US

EXTR

AVAS

ATIO

NS

(PIV

IE)

PATIENT and FAMILY ENGAGEMENT (PFE)

LEADERSHIP METHODS (LM)

ERROR PREVENTION (EP)

DISCLOSURE

HIGH RELIABILITY UNITS (HRUs)

JUST CULTURE

16

How we approach the work:Improving safety culture

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)

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

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

20

Children’s Hospitals’ Solutions for Patient

Safety (SPS)

Child Health Patient Safety Organization

(CHA PSO)

21

How we approach the work:Developing Prevention Bundles

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

Nine hospitals implementing this element reliably have a rate 40% less than the

average.

Pressure Ulcer Standard Bundle Element

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

25

SPS Prevention Bundles

• Surgical site infections• Serious falls• Pressure injuries• Central line-associated blood stream infections• Catheter-associated urinary tract infections• Readmissions

26

SPS Recommended Bundles

• Adverse drug events• Venous thromboembolism• Ventilator-associated pneumonia• Obstetric adverse events

27

SPS Bundles Under Development

• Adverse drug events• Venous thromboembolism• Ventilator-associated events (VAE)• Peripheral IV infiltrates/extravasations• Unplanned extubations

PIONEER

AVIATOR

ORBITING

DISCOVERY

EXPLORER

Active Network ImprovementFinding New Breakthroughs

Defining The Standard

ALL IN Reliable Implementation

Sustaining

Sharing WithEveryone

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,

Readmissions, VAP

Cause Analysis;

Error Prevention; Leadership Methods

Serious FallsCAUTI

Operational definitions; Prevention

bundles

THE JOURNEY TOWARD ZERO HARMSPS Design

30

Collaboration

31

All Teach/All Learn

• 130 Aviator Wednesday webinars• 135 HAC workgroup calls• 20 CLABSI Sub-Group calls• 168+ Hospital Workgroup calls• 8 National Learning Sessions• 10 regional meetings

What We Have and Have Not Accomplished

Presented with permissions. © Child Health Patient Safety Organization, Inc. – a component of N.A.C.H.

61% SSER reduction by 22 “goal cohort” hospitals

SHE Stacked Chart

16%

22% 22%

35

5%

7%

22%26%

32%39%

46%

46%

79%

40%10%ReadmissionsVTE

OBAEPUSSI

ADEVAPCAUTI

Falls

13%(2012-2014)

(2015-2016) 0%

CLABSI

Percent Improvement 2012-2016

37 37

Jan-

11 (n

=10)

Mar

-11

(n=1

0)M

ay-1

1 (n

=10)

Jul-1

1 (n

=10)

Sep-

11 (n

=10)

Nov

-11

(n=1

0)Ja

n-12

(n=1

7)M

ar-1

2 (n

=19)

May

-12

(n=1

9)Ju

l-12

(n=1

9)Se

p-12

(n=1

9)N

ov-1

2 (n

=19)

Jan-

13 (n

=19)

Mar

-13

(n=1

9)M

ay-1

3 (n

=19)

Jul-1

3 (n

=19)

Sep-

13 (n

=19)

Nov

-13

(n=1

9)Ja

n-14

(n=1

9)M

ar-1

4 (n

=19)

May

-14

(n=1

9)Ju

l-14

(n=1

9)Se

p-14

(n=1

9)N

ov-1

4 (n

=19)

Jan-

15 (n

=19)

Mar

-15

(n=1

9)M

ay-1

5 (n

=19)

Jul-1

5 (n

=19)

Sep-

15 (n

=18)

Nov

-15

(n=1

9)Ja

n-16

(n=1

8)M

ar-1

6 (n

=18)

May

-16

(n=1

7)

0.0

0.1

0.2

0.3

0.4

0.5

June 2014, Cohort Began Testing Factors

Adverse Drug Events per 1000 Patient Days (Level E-I)Pioneer Cohort vs. Rest of the Network

January 2011 - June 2016

Pioneer Cohort CL (.1738) Rest of the Network CL (.2519)

Num

ber o

f ADE

s per

100

0 pa

tient

day

s

Improvement since June 2014:- Pioneer cohort: 41%- Rest of the Network: 22%

38

668638

3939

4040

4141

4242

43

Condition (Estimated cost per event)

Estimated Harm Prevented

(2012-May 2016)

Cost Savings (2012-May 2016)

ADE ($5,000) 300 $1,500,000

CAUTI ($7,200) 722 $5,198,400

Falls ($13,000) 917 $11,921,000

OBAE ($3,000)* 669 $2,007,000

PI ($19,740) 289 $5,704,860

Readmissions ($9,540) 2054 $19,595,160

SSI ($27,000) 643 $17,361,000

VAP ($51,000) 497 $25,347,000

CLABSI ($55,000) 2012-2014

595 $32,725,000

CLABSI ($55,000) 2015-2016 **

0 0

$121,359,420

Keys to Success

Hospitals that submit process data achieve better results.

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

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

What other characteristics are linked with improved outcomes?

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

-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

LeadershipEngagement

Discovery & Innovation

Process Reliability &

Standardization

High Reliability

Culture

52

What is Left To Do

53

54

Number of Events by HAC for One Month

Condition Number of Events in May 2016

CLABSI 218VTE 89PI 47SSI 28VAP 23

CAUTI 14ADE 11

OBAE 7FALLS 4

441Based on data as of 8/10/2016

Serious HarmAugust, 2015 – July, 2016

CLABSI VTE PIVIE PI SSI CAUTI VAP ADE Falls

56

57

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 Hospital40 bed, Level 3 NICU >700 days without

CLABSI

59

Omaha Children’s

Hospital

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-1

5

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-1

60

1

2

3

4

Serious Safety Events Rolling 12-month average# Children Harmed Rate per 10000 APD

61

Rainbow Babies & Children’s Hospital

62

Serious Safety Events

63

What’s Next for the Network?

• Health Improvement Innovation Network (HIIN) contract– C.diff/Antimicrobial Stewardship, Acute Kidney Injury, Healthcare Disparities,

Employee Safety

• Highly reliable implementation of Prevention Bundles• CLABSI deep dive• Reinvigoration of VAE• Sharing Disclosure best practices• Culture 2.0• Navigator• Regional strategies – reaching beyond

64

65

Thanks.

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