Patient Safety March 5, 2013

1. Patient SafetyMarch 5, 2013

2. Cumberland (GA) ID/OncologyMarch 5, 2013

3. Our Team Cumberland ID/Oncology

4. Our SMART Goal KP Georgia Cumberland Medical Office Building infectious diseases/oncology department will reduce duplicate medications from a baseline of 46 percent to a goal of 36 percent between August 22, 2011, and November 30, 2011.

5. Our Metrics

6. Process Map-BEFORE

7. Process Map - AFTER

8. Our Successes • Achieved a 67 percent reduction in duplicate medications • The percent of duplicate medications per office visit dropped from 46 percent in July 2011 to 15 percent as of November 2011 • Cost avoidance estimated at $90,000 per three-month period • UBT progressed from a Level 2 to a Level 4 by doing this project

9. Our Challenges • Patients didn’t know/couldn’t accurately describe their medications • Barriers between oncology department and other specialties (such as pharmacy, pain clinic, renal and gastrointestinal) that treat the same patients • Fear of disrupting another specialist’s treatment routine

10. Our Best Practices • Post data in department and analyze in huddles • Build on successful project/workflow from other departments • Encourage patients to use kp.org to monitor their prescription • Involve everyone in the project • Set a goal that stretches your team

11. Our Key Learnings • Increased and improved communication among staff led to more open communication with patients, families • Challenging project strengthened our team

12. Our Rewards & Recognition • Coverage on InsideKP Georgia intranet site • Coverage on LMP website: article, PowerPoint slide, bulletin board poster

13. Questions Questions for the Cumberland ID/oncology team Please use the chat box Send your question to everyone

14. Question #1 Would you like your team to work on a patient safety performance improvement project? Type “yes” or “no” in the chat box

15. Rock Creek (Colorado) GI Team March 5, 2013

16. Our Team

17. Our SMART Goal Implement new patient safety protocol within six months to prevent cross contamination between clean and dirty scopes used on patients by March 30, 2012.

18. Background After hearing a news report about how a patient was exposed to dirty scopes, a team member brought the issue to the UBT. They decided to work on the project together to make sure their patients were not exposed to harm. “Although patient to patient exposure is rare, it has devastating effects,” says William Berry, MD.

19. Background Rock Creek GI performs nearly 200 colonoscopies and upper endoscopies a week Equipment is re-used as many as three times per day

20. Tests of change

21. Sustaining success

22. Our Best Practices • Collaboration of staff and physician working together as a team to ensure patient safety • Innovativeness to hear something out of the regular environment and consider what could happen in your own department • Spread project to Franklin Medical Office. • The practice is now how we do business

23. Our Challenges • Engagement • Providing the right information • Not having tags in inventory

24. Our Successes Value Compass Award

25. Our Key Learnings • It’s imperative that we explain the “why” of new projects • Involve team members • Let people know ahead of time any changes to processes

26. Questions Questions for Rock Creek GI team Please use the chat box Send your question to everyone

27. Question #2 What will your team’s next step be to improve patient safety? Type your short answer in the chat box.

28. South San Francisco (NCAL) Radiology March 5, 2013

29. Our Team Insert team picture here From Bob photos

30. Our SMART Goal South San Francisco Radiology will reduce “significant” event errors from a baseline of 13 in 2011 to a goal of zero through 2012. “Significant” events are defined as any instance where a patient is unnecessarily irradiated, including incorrect body part, incorrect side, wrong patient, etc.

31. Our Timeline

32. Our Timeline

33. Workflow Process Map

34. Stop the Line Form

35. Our Best Practices • Review Stop the Line forms at UBT meetings • Track data to identify opportunities for improvement and measure successes • Perform root-cause analysis if similar issues repeat • Collaborate with Risk/Patient Safety department to resolve issues related to other departments impacting radiology

36. Our Challenges • Solving issues outside of radiology that impact our workflows and patient safety.

37. Our Successes • Reduced “significant” events from 13 in 2011 to 5 in 2012 • Since April 2012, 250 Stop the Line forms have been submitted, averting “significant” events before they reached the patient • Empowered staff members to follow the standardized process and stop to do the right thing for a patient’s safety • Improved working relationships with other departments

38. Our Key Learnings • Collaboration with other departments is vital • Data is a powerful tool to: • identify root causes – within and outside the department • communicate and collaborate with other departments that impact patient safety in Radiology • Understand how departments impact each other in the larger system. • Leverage the UBT to do the groundwork for changes in workflows

39. Questions Questions for South San Francisco radiology team Please use the chat box Send your question to everyone

40. Closing Comments Doug Bonacum Vice President of Quality, Safety and Resource Management Doug.Bonacum@kp.org

41. More Resources • Audio and slides from today will be posted on the LMP website • Check out our patient safety videos at http://lmpartnership.org/stories-videos/life-saving-teams • Visit the Improvement Advisors – Patient Safety group on IdeaBook for more webinars this week • Thank you to co-sponsors LMP Communications and Department of Care and Service Quality • More virtual UBT fairs coming this year