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CMS-QIO Hospital Patient Safety Learning Pilots:

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CMS-QIO Hospital Patient Safety Learning Pilots:

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    1. The AHQA/AHQF 2004 Annual Meeting and Technical Conference March 2004 CMS-QIO Hospital Patient Safety Learning Pilots: Building Patient Safety Partnerships and Practices Welcome to the CMS-QIO Hospital Patient Safety Learning Pilots - or rather PSLP - session. My name is Stormy Sweitzer, I am the PSLP project manager for the Coordinating QIO – HealthInsight, from Utah. I will soon introduce you to my colleagues from the Pilot QIOs.Welcome to the CMS-QIO Hospital Patient Safety Learning Pilots - or rather PSLP - session. My name is Stormy Sweitzer, I am the PSLP project manager for the Coordinating QIO – HealthInsight, from Utah. I will soon introduce you to my colleagues from the Pilot QIOs.

    2. The Patient Safety Learning Pilots prototype includes several components: A reporting system Sensemaking processes. system re-design informed by human factors principles. testing and implementing any recommended system changes – Plan-Do-Study-Act (PDSA). Ongoing monitoring of patient safety improvements. methods for involving hospital leadership, and moving toward status of a high reliability organization or learning organization. WE will talk a little bit more about these in a moment The Patient Safety Learning Pilots prototype includes several components: A reporting system Sensemaking processes. system re-design informed by human factors principles. testing and implementing any recommended system changes – Plan-Do-Study-Act (PDSA). Ongoing monitoring of patient safety improvements. methods for involving hospital leadership, and moving toward status of a high reliability organization or learning organization. WE will talk a little bit more about these in a moment

    3. Participating Microsystems St. Anthony Medical Center, Pharmacy, Crown Point, IN St. Francis Hospital & Health Centers, Ortho/Neuro Nursing Unit, Beech Grove, IN Sunrise Hospital & Medical Center, Oncology Unit, Las Vegas, NV Washoe Medical Center, Adult SICU, Reno, NV St. Joseph’s Hospital, SICU, Marshfield, WI St. Michael’s Hospital, Medical Unit, Stevens Point, WI Although health care is delivered in complex health care systems and organizations, most of the day to day work of health care professionals is actually carried out in smaller work units, or clinical microsystems. Microsystems are small organized groups of providers and staff caring for a defined population of patients. For this project, the microsystem – rather the entire facility - was the focus. As mentioned, six microsystems from three states participated. They are listed on the screen behind me. Each microsystem selected a topic to work on. These included such things as medication safety, falls, pain management, and anticoagulation therapy. The Coordinating QIO – HealthInsight in Utah, worked closely with the CMS government task lead, Dr. Shirley Kellie from the Kansas City Regional Office and a knowledge management expert, Dr. Nancy Dixon of Common Knowledge, to develop interactions, tools, and resources to support - primarily - the pilot QIOs, and as needed, the participating microsystems. The Pilot QIOs from Indiana, Wisconsin, and Nevada, worked directly with participating microsystems to implement the various components and provide assistance and support. So what did we learn from this experience?Although health care is delivered in complex health care systems and organizations, most of the day to day work of health care professionals is actually carried out in smaller work units, or clinical microsystems. Microsystems are small organized groups of providers and staff caring for a defined population of patients. For this project, the microsystem – rather the entire facility - was the focus. As mentioned, six microsystems from three states participated. They are listed on the screen behind me. Each microsystem selected a topic to work on. These included such things as medication safety, falls, pain management, and anticoagulation therapy. The Coordinating QIO – HealthInsight in Utah, worked closely with the CMS government task lead, Dr. Shirley Kellie from the Kansas City Regional Office and a knowledge management expert, Dr. Nancy Dixon of Common Knowledge, to develop interactions, tools, and resources to support - primarily - the pilot QIOs, and as needed, the participating microsystems. The Pilot QIOs from Indiana, Wisconsin, and Nevada, worked directly with participating microsystems to implement the various components and provide assistance and support. So what did we learn from this experience?

    4. Reporting Systems Medical Event Reporting System – Total Healthcare (MERS-TH) Near Miss Event Reporting Just Culture Most of the hospitals participating in the PSLP project had some form of organizational event reporting system in place prior to the start of this project. The effectiveness, scope of events covered, and variety of these systems varied from facility to facility. For this project, each facility was asked to use the Medical Event Reporting System – Total Health (MERS-TH) as the reporting and analysis system for a single microsystem and to ask staff to report near miss events. Additionally, each facility was asked to review an article entitled “Just Culture” by David Marx. To give you a definition: a “just culture” balances the need to have a non-punitive learning environment with the need to hold persons accountable for their actions. The microsystems suggested that there were successes and challenges associated with each of these aspects of the project: MERS-TH provides a very useful framework for assessing risk associated with events – both those that have occurred and those that almost occurred - and allows people to determine which are most worthy of investigation. As well, the event analysis and categorization aspects of MERS-TH aided the microsystems in their attempts to understand events and code them in such a way as to allow for useful trend analysis. Unfortunately, the database developed specifically for use in this project was difficult and time-consuming to use. Microsystems commented that without a more user-friendly system, it was not likely that they would continue using the database. The MERS-TH event report provides a good deal of information, but it takes several minutes to complete – more time than staff wanted to spend on near misses. As well, the report form asks the reporter – the person who discovered the event - to categorize information for later analysis and consistent comparison across events; microsystem team members felt that this categorization did not provide sufficient context about what actually happened. Near misses were seen by microsystems as a highly valuable information source which allows them to be more proactive in their safety and improvement activities. The down side is the frequency of near misses. Many teams have discovered that by focusing on a particular type of event (unique, Oh-my-god) and making reporting of that event very simple and quick, they are better able to sustain reporting activities. Finally, Just Culture has been seen as a useful alternative to a blame-free or non-punitive culture. Instilling this concept in staff has been difficult as they are not sure sometimes if they can trust that their unintentional actions will not be punished or if punishment – when merited - will be fair. Microsystems have found that by involving staff in discussions of events, learning opportunities around safety, and in the analysis and discussion of causes of events, staff are more likely to gain comfort in sharing their stories and experiences.Most of the hospitals participating in the PSLP project had some form of organizational event reporting system in place prior to the start of this project. The effectiveness, scope of events covered, and variety of these systems varied from facility to facility. For this project, each facility was asked to use the Medical Event Reporting System – Total Health (MERS-TH) as the reporting and analysis system for a single microsystem and to ask staff to report near miss events. Additionally, each facility was asked to review an article entitled “Just Culture” by David Marx. To give you a definition: a “just culture” balances the need to have a non-punitive learning environment with the need to hold persons accountable for their actions. The microsystems suggested that there were successes and challenges associated with each of these aspects of the project: MERS-TH provides a very useful framework for assessing risk associated with events – both those that have occurred and those that almost occurred - and allows people to determine which are most worthy of investigation. As well, the event analysis and categorization aspects of MERS-TH aided the microsystems in their attempts to understand events and code them in such a way as to allow for useful trend analysis. Unfortunately, the database developed specifically for use in this project was difficult and time-consuming to use. Microsystems commented that without a more user-friendly system, it was not likely that they would continue using the database. The MERS-TH event report provides a good deal of information, but it takes several minutes to complete – more time than staff wanted to spend on near misses. As well, the report form asks the reporter – the person who discovered the event - to categorize information for later analysis and consistent comparison across events; microsystem team members felt that this categorization did not provide sufficient context about what actually happened. Near misses were seen by microsystems as a highly valuable information source which allows them to be more proactive in their safety and improvement activities. The down side is the frequency of near misses. Many teams have discovered that by focusing on a particular type of event (unique, Oh-my-god) and making reporting of that event very simple and quick, they are better able to sustain reporting activities. Finally, Just Culture has been seen as a useful alternative to a blame-free or non-punitive culture. Instilling this concept in staff has been difficult as they are not sure sometimes if they can trust that their unintentional actions will not be punished or if punishment – when merited - will be fair. Microsystems have found that by involving staff in discussions of events, learning opportunities around safety, and in the analysis and discussion of causes of events, staff are more likely to gain comfort in sharing their stories and experiences.

    5. Learning from Events Sensemaking The power of stories Sensemaking is the act of understanding our experiences – it is a natural occurrence – we do it internally, as well as through informal and formal conversations with others. For purposes of this project, sensemaking was a formalized activity or structure for sharing event-related information, following an investigation, with those that were directly involved in the event. This activity was found to be useful for gaining additional insight into events that might not be collected through the typical investigative process. As well, those involved in the event were able to come together and understand the entire chain of events, not just their own piece of the puzzle. In general, sensemaking was presented in a very specific manner in this project; a more generalized description may aid facilities in identifying sensemaking in natural settings, as well as in creating opportunities for more explicit sensemaking for different purposes. Stories were also seen as a highly valuable means of communicating information about safety and learning from events. Microsystems have learned to use storytelling to draw people in, to share sensitive events in a meaningful way, and to use stories as part of staff meetings and prompting staff to share their safety experiences. Sensemaking is the act of understanding our experiences – it is a natural occurrence – we do it internally, as well as through informal and formal conversations with others. For purposes of this project, sensemaking was a formalized activity or structure for sharing event-related information, following an investigation, with those that were directly involved in the event. This activity was found to be useful for gaining additional insight into events that might not be collected through the typical investigative process. As well, those involved in the event were able to come together and understand the entire chain of events, not just their own piece of the puzzle. In general, sensemaking was presented in a very specific manner in this project; a more generalized description may aid facilities in identifying sensemaking in natural settings, as well as in creating opportunities for more explicit sensemaking for different purposes. Stories were also seen as a highly valuable means of communicating information about safety and learning from events. Microsystems have learned to use storytelling to draw people in, to share sensitive events in a meaningful way, and to use stories as part of staff meetings and prompting staff to share their safety experiences.

    6. Improvement PDSA Change Package Human Factors Rapid Cycle PDSA was promoted as part of this project. Most microsystems were familiar with the concept of PDSA or PDCA, although, the concept of rapid cycles was new or took on new meaning for participants. They can simply test something as opposed to spending months setting up an elaborate plan. The MERS-TH system uses a categorization scheme to code root causes of events according to aspects of human, organizational, or technical root causes. A human–factors based change package was developed for this project to enable participants to link their root cause analysis findings to specific change concepts that are likely to lead to improvement. This was seen as a useful means of guiding Causal analysis teams towards improvement ideas likely to have an impact on the causes of events. Finally, human factors technical assistance was provided to each microsystem. This assistance guided them to new ways of approaching problems that were difficult to understand using traditional quality tools. Principles of safety management, human performance, and design can be considered a useful complement to those of quality improvement.Rapid Cycle PDSA was promoted as part of this project. Most microsystems were familiar with the concept of PDSA or PDCA, although, the concept of rapid cycles was new or took on new meaning for participants. They can simply test something as opposed to spending months setting up an elaborate plan. The MERS-TH system uses a categorization scheme to code root causes of events according to aspects of human, organizational, or technical root causes. A human–factors based change package was developed for this project to enable participants to link their root cause analysis findings to specific change concepts that are likely to lead to improvement. This was seen as a useful means of guiding Causal analysis teams towards improvement ideas likely to have an impact on the causes of events. Finally, human factors technical assistance was provided to each microsystem. This assistance guided them to new ways of approaching problems that were difficult to understand using traditional quality tools. Principles of safety management, human performance, and design can be considered a useful complement to those of quality improvement.

    7. Leadership Local Executive-level Visible leadership engagement and support is an important prerequisite in any project such as this that requires considerable resources. Change itself, though – at least in this project - came from the ground up. Front-line health care teams (or microsystems) tested safety and quality tools and principles that are now being considered for spread throughout their organizations and, in some cases, systems. We do know that leadership at both local and organizational levels will need to continue to work together to sustain resource-intensive aspects of this project. Visible leadership engagement and support is an important prerequisite in any project such as this that requires considerable resources. Change itself, though – at least in this project - came from the ground up. Front-line health care teams (or microsystems) tested safety and quality tools and principles that are now being considered for spread throughout their organizations and, in some cases, systems. We do know that leadership at both local and organizational levels will need to continue to work together to sustain resource-intensive aspects of this project.

    8. Other Key Lessons Relationships Trust Communication Time Some other key lessons: The Pilot QIOs were involved in numerous on-site visits and phone conversations with participating microsystems. They were heavily involved in providing training, technical assistance, and moral support, as well as participated in project activities that the microsystems engaged in. While the intensity and frequency of the interactions varied from state to state and facility to facility, it became apparent that this relationship-building was a key component of the project. Primarily, because these relationships enabled trust, active communication, and learning for all parties involved. Trust was a factor in hospitals and QIOs working together cooperatively with sensitive patient safety data. Communication was necessary to add the building blocks of “Just Culture,” near miss reporting and analysis, sensemaking, and human factors. Communication and trust enabled the hospitals to believe they could use the building blocks to make changes in their system. One other key lesson is that of respect for time. QIO staff believe that many of the providers in this project are just beginning to be facile with some of the tools and processes of patient safety the project entailed. It is likely that the value of the PSLP will best be shown in the changes in patient care that grow from repeated execution of patient safety processes when front line microsystem staff, patient safety professionals, and management all have confidence in the processes and the tools which they have been using. Some other key lessons: The Pilot QIOs were involved in numerous on-site visits and phone conversations with participating microsystems. They were heavily involved in providing training, technical assistance, and moral support, as well as participated in project activities that the microsystems engaged in. While the intensity and frequency of the interactions varied from state to state and facility to facility, it became apparent that this relationship-building was a key component of the project. Primarily, because these relationships enabled trust, active communication, and learning for all parties involved. Trust was a factor in hospitals and QIOs working together cooperatively with sensitive patient safety data. Communication was necessary to add the building blocks of “Just Culture,” near miss reporting and analysis, sensemaking, and human factors. Communication and trust enabled the hospitals to believe they could use the building blocks to make changes in their system. One other key lesson is that of respect for time. QIO staff believe that many of the providers in this project are just beginning to be facile with some of the tools and processes of patient safety the project entailed. It is likely that the value of the PSLP will best be shown in the changes in patient care that grow from repeated execution of patient safety processes when front line microsystem staff, patient safety professionals, and management all have confidence in the processes and the tools which they have been using.

    9. Introductions Jan Miltenberger, RN, MS Health Care Excel, Inc., Indiana Pilot-QIO Deborah Huber, RN, MHSA HealthInsight, Nevada Pilot-QIO Mary Brueggeman, MS, RN, C. MetaStar, Inc., Wisconsin Pilot-QIO Anne Rifleman, BSN St. Michael’s Hospital, Stevens Point, WI For the remainder of the session, you will hear from the project coordinator of each of the three Pilot QIOs, and a member of the microsystem team from St. Michael’s hospital in Wisconsin. They will use a combination of presentation, and live and video-taped reflections from the microsystems to provide you with highlights of the microsystem learning from the activities of the PSLP. I will now turn the time over to Jan Miltenberger, of Health Care Excel, Inc., the Indiana Pilot-QIO. For the remainder of the session, you will hear from the project coordinator of each of the three Pilot QIOs, and a member of the microsystem team from St. Michael’s hospital in Wisconsin. They will use a combination of presentation, and live and video-taped reflections from the microsystems to provide you with highlights of the microsystem learning from the activities of the PSLP. I will now turn the time over to Jan Miltenberger, of Health Care Excel, Inc., the Indiana Pilot-QIO.

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