Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar:

1. Welcome to the • NQF Safe Practices for Better Healthcare • 2009 Update Webinar: • Clear Communication Practices • for Safer Healthcare • (Safe Practices 12-16) • Hosted by NQF and TMIT Attendee dial-in instructions: Toll-free Call-in number (US/Canada): 1-866-764-6260 (direct number, no code needed) To join the online webinar, go to: www.safetyleaders.org Online Access Password: Webinar1 (case-sensitive)

2. Welcome and Safe Practices Overview Hayley Burgess, PharmD Director, Performance Improvement Measures, Standards, and Practices TMIT Safe Practices Webinar November 19, 2009 Toll-free Call-in number: 1-866-764-6260

5. Panelists David W. Bates Kimberly Visconti Peter Angood Hayley Burgess Hayley Burgess: Welcome and Safe Practices Overview David W. Bates: Achieving Success with CPOE Kimberly Visconti: Using RED to Implement NQF SP 15: Discharge • Peter Angood: Practical Implementation Approaches to Patient Care Information, Order Read-Back and Abbreviations, and Labeling of Diagnostic Studies Arlene Salamendra: Roles for the Patient Advocate (Are You Listening?) Arlene Salamendra

6. Culture Consent & Disclosure Consent and Disclosure Workforce Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- and Site-Specific Practices Toll-free Call-in number: 1-866-764-6260

7. Culture CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices] • Leadership Structures and Systems • Culture Measurement, Feedback, and Interventions • Teamwork Training and Team Interventions • Identification and Mitigation of Risks and Hazards Structures and Systems Culture Meas., FB., and Interv. Team Training and Team Interv. ID and Mitigation Risk and Hazards Consent & Disclosure Consent and Disclosure CHAPTER 3: Informed Consent and Disclosure • Informed Consent • Life-Sustaining Treatment • Disclosure • Care of the Caregiver Informed Consent Life-Sustaining Treatment Disclosure Care of Caregiver Workforce CHAPTER 4: Workforce • Nursing Workforce • Direct Caregivers • ICU Care 2009 NQF Report Nursing Workforce Direct Caregivers ICU Care Legend: CHAPTER 5: Information Management and Continuity of Care • Patient Care Information • Order Read-Back and Abbreviations • Labeling Studies • Discharge Systems • Safe Adoption of Integrated Clinical Systems including CPOE Information Management and Continuity of Care No Material Changes Patient Care Info. Read-Back & Abbrev. Material Changes Labeling Studies Discharge System CPOE New Medication Management CHAPTER 6: Medication Management • Medication Reconciliation • Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging Med. Recon. Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose CHAPTER 7: Hospital-Associated Infections • Hand Hygiene • Influenza Prevention • Central Venous Catheter-Related Blood Stream Infection Prevention • Surgical-Site Infection Prevention • Care of the Ventilated Patient and VAP • MDRO Prevention • UTI Prevention Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention VAP Prevention MDRO Prevention UTI Prevention CHAPTER 8: • Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention • Pressure Ulcer Prevention • DVT/VTE Prevention • Anticoagulation Therapy • Contrast Media-Induced Renal Failure Prevention • Organ Donation • Glycemic Control • Falls Prevention • Pediatric Imaging Condition-, Site-, and Risk-Specific Practices Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy Contrast Media Use Organ Donation Glycemic Control Falls Prevention Pediatric Imaging

8. Achieving Success with Computerized Physician Order Entry (CPOE) David W. Bates, MD, MSc • Medical Director of Clinical and Quality Analysis, Partners Healthcare Chief, Division of General Internal Medicine Brigham and Women’s Hospital Safe Practices Webinar November 19, 2009 Toll-free Call-in number: 1-866-764-6260

9. Goals • NQF Safe Practice • CPOE benefits • Drugs • Labs • Other • Meaningful use overview • CPOE risks • University of Pennsylvania (Koppel) • University of Pittsburgh (Han) • Implementing well • CPOE and the big picture • Bar-coding • Conclusions

10. Safe Practice 16: CPOE 2009 Implement a computerized prescriber order entry (CPOE) system built upon the requisite foundation of re-engineered evidence-based care, an assurance of healthcare organization staff and independent practitioner readiness, and an integrated information technology infrastructure. Toll-free Call-in number: 1-866-764-6260

11. CPOE as part of the EHR • Is centrally important because most things that occur in a hospital happen as the result of a physician’s order • Need to get physician to use the computer • Key opportunity to change behavior • Many opportunities to improve performance Toll-free Call-in number: 1-866-764-6260

12. Inpatient Prevention • 55% reduction in serious medication error rate with CPOE • Bates, JAMA, 1998 • 83% reduction in overall medication error rate • Bates, JAMIA, 2000 • Cost of each preventable ADE ~ $6,000 Toll-free Call-in number: 1-866-764-6260

13. Systematic Review of Impact of CPOE on Medication Safety • 5 trials of CPOE • 2 marked decrease in serious medication error rate • 1 improvement in corollary orders • 1 improvement in 5 prescribing behaviors • 1 improvement in nephrotoxic drug dose and frequency • Numerous additional studies since Kaushal, Shojania, Bates, Arch Int Med 2003 Toll-free Call-in number: 1-866-764-6260

14. Other Recent Reviews of CPOE and Medication Safety • CPOE and medication errors—66% reduction in prescribing errors on average • CPOE and ADEs—ten studies, five showed decrease in ADE rates, 4 showed non-significant trends, 1 showed no effect Shamliyan et al., Health Services Res 2008 Wolfstadt et al., J Gen Intern Med 2008 Toll-free Call-in number: 1-866-764-6260

15. Selected Laboratory Interventions • Charge display RCT • No statistically significant effect • BUT $1.7 million lower lab charges in intervention group • Redundant labs • 67% reminders followed • Annual charge savings $31,000, vs. estimate of $376,000 • Only 44% tests performed had computer order • Substantial improvement possible if loop closed with laboratory “back end” Toll-free Call-in number: 1-866-764-6260

16. Order Entry and Critical Paths • Critical paths specify what should happen for a specific day • Essentially sequences of order sets • In place for 25 diagnoses • Have decreased length of stay, costs, improved satisfaction • Require physicians to select diagnosis at admission • Allows prompting about path • Increases likelihood path will be selected Toll-free Call-in number: 1-866-764-6260

17. Summary of Benefits • Benefits are much greater than drug safety benefits alone • Those represent small part of financial benefits • Achieving value depends on building in good decision support • Also on ability to modify, iteratively improve Toll-free Call-in number: 1-866-764-6260

18. How to Prioritize? • ROI of inpatient CPOE evaluated • Cumulative net savings were $16.7 million over 10 years, and net operating $9.5 million • Leading contributors • Renal dosing guidance • Tools to help nurses • Specific drug guidance • Adverse drug event prevention Kaushal, JAMIA 2006 Toll-free Call-in number: 1-866-764-6260

19. Meaningful Use is Being Defined and Will Follow an “Ascension Path” 2009 2011 2013 2015 HIT-Enabled Health Reform HITECH Policies 2011 Meaningful Use Criteria (Capture/share data) 2013 Meaningful Use Criteria (Advanced care processes with decision support) 2015 Meaningful Use Criteria (Improved Outcomes) *Report of sub-committee of Health IT Policy Committee

20. Meaningful Use Matrix andDecision Support: Hospitals 2011 • 10% all orders through CPOE • Drug-drug, drug-allergy, drug-formulary checks • Up-to-date problem list • Generate lists of patients by condition • Implement one clinical decision rule related to a high-priority condition Toll-free Call-in number: 1-866-764-6260

21. Meaningful Use Matrix andDecision Support: Hospitals 2013 • Use CPOE for all order types • Use evidence-based order sets • Conduct closed-loop medication management • Use clinical decision support at the point of care • Retrieve and act on fill data Toll-free Call-in number: 1-866-764-6260

22. University of Pennsylvania: Unintended Consequences • Koppel et al. evaluated on a commercial CPOE application at U Penn and asked users about their impressions about the system • Found many situations in which “a leading CPOE system facilitated medication error risks” • Often took many screens to do things • Needed views not available • Others including Ash have also reported on this Koppel, JAMA, 2005 Toll-free Call-in number: 1-866-764-6260

23. Issues with the Koppel Study • Didn’t actually count errors or adverse events • Said that other studies focused only on advantages—not accurate • CPOE application studied was an old one • Nonetheless, paper stimulated valuable debate and identified key points • Need change systems after implementation • Software alone is insufficient Bates, J Biomed Inform, 2005 Toll-free Call-in number: 1-866-764-6260

24. University of Pittsburgh:Pediatrics Study • Studied children transported in for special care • Mortality rate increased from 2.8% to 6.3% (OR=3.3) after introduction of a commercial CPOE application • Study design was before-after • Other changes were made at same time as CPOE was implemented • Overall mortality wasn’t reported Han, Pediatrics 2005 Toll-free Call-in number: 1-866-764-6260

25. Introduction of CPOE • CPOE was introduced very rapidly—over 6 days! • After implementation, order entry wasn’t allowed until the patient had actually entered hospital and been logged into system • After CPOE implementation, all drugs including vasoactive agents were moved to central pharmacy • Pharmacy couldn’t process medication orders until after they were activated • Many order sets weren’t available initially • Result was substantial delays in care delivery

26. Comments on Han Study • Study was very weak methodologically • Nonetheless, increase in mortality rate was very large and of obvious concern • Introducing substantial delays in this group could easily have caused • Organization broke many of the rules for implementation • Essential for other organizations to handle sociotechnical aspects better Phibbs et al., Pediatrics 2005 Toll-free Call-in number: 1-866-764-6260

27. The Path To Success in Implementing CPOE • Much is the inverse of common pitfalls • But not all • Anyone will have issues that leadership need to deal with • Keep in mind that it will be worth it • Have to pay attention to details to achieve value—doesn’t simply come with successful implementation • Is a much bigger change than anything most organizations have previously attempted on the IT front Toll-free Call-in number: 1-866-764-6260

28. Critical Success Factors in Implementation • Strong leadership and long-term commitment • Creating a culture of innovation • Excellent project management • Attention to clinical processes • A focus on quality Toll-free Call-in number: 1-866-764-6260

29. Getting Benefits—What Does It Take? • Have to have successful implementation • But also need to decide on a core of decision support • Implies having organizational structure enabling group to reach consensus • Will have to make many changes • Need architecture enabling agility • Sufficient resources to keep up • Rule is to have a long queue • Want to start low, go slow—but need to end up with enough Toll-free Call-in number: 1-866-764-6260

30. How to Assess Where You Are Regarding Decision Support • Use the AHRQ/NQF/Leapfrog assessment tool • Gives you a score regarding decision support • Without doing that hard to assess level of implementation of decision support Toll-free Call-in number: 1-866-764-6260

31. The Assessment Methodology Simulations of EHR Use with CPOE The assessment pairs medication orders that would cause a serious adverse drug event with a fictitious patient. A physician enters the order… PatientAB Female 52 years old Weighs 60 kg Allergy to morphine Normal creatinine and observes and records the type of CDS-generated advice that is given (if any). Coumadin (Warfarin) 5 mg po three times a day. Toll-free Call-in number: 1-866-764-6260

32. Hospitallogs on(Password access) Completesample test Obtain patient criteria(Adult or pediatric) Program patient criteria Download and print 30 – 40 test orders(HM if AMB) Enter orders into CPOE application and record results Hospital self-reports results on website Score generated against weighted scheme Report generated Review patient descriptions Review orders and categories Aggregate score to Leapfrog Order category scores viewed by hospital Review scoring The Assessment Tool AHRQ/NQF/Leapfrog Assessment Tool

33. Broader Context • Multiple technologies can improve medication safety • Address different stages of the process • Bar-coding • Smart pumps • Computerized monitoring for ADEs Toll-free Call-in number: 1-866-764-6260

34. Evidence Regarding Bar-coding • Increasingly widely used • About a quarter of hospitals • Very wide use in VA • Published evidence base still modest but growing • Will be included in meaningful use for 2013 • Likely to be put forward as a safe practice soon Toll-free Call-in number: 1-866-764-6260

35. Projections for errors prevented per yearat study hospital: >13,500 medication dispensing errors >6,000 potential ADEs Dispensing Errors and Potential ADEs: Before and After Bar-code Technology Implementation 31% reduction* 63% reduction* * p<0.0001 (Chi-squared test) Poon et al., Annals Internal Medicine, 2006

36. Conclusions • CPOE appears highly beneficial in the aggregate • But can create new problems as well as prevent them • Need to monitor, engineer out • Realizing benefits requires: • Strong implementation • Later implementation of good decision support • Important not just to have but to implement well • Serial refinements in decision support • Easiest things are not highest-yield • Today’s discussion/results very important Toll-free Call-in number: 1-866-764-6260

37. Using the Re-Engineered Discharge (RED) to Implement NQF Safe Practice 15: Discharge Systems Kimberly Visconti, RN Discharge Advocate, Project RED Boston Medical Center Safe Practices Webinar November 19, 2009 Toll-free Call-in number: 1-866-764-6260

38. Background to Current Problem • Hospital discharge is non-standardized and frequently marked with poor quality • Little time spent on discharge teaching • Patients are not prepared at discharge • Poor communication between inpatient and outpatient care • Communication barriers lead to adverse events Toll-free Call-in number: 1-866-764-6260

40. Communication Deficits at Hospital Discharge Are Common • Discharge summary not readily available: • Only available for 12%-34% of first post-discharge appointments • Discharge summary lacking key components: • Hospital course (14.5%) • Discharge medications (21%) • Completed test results (38%) • Pending test results (65%) • Follow-up plans (14%) • Main diagnosis (17.5%) Toll-free Call-in number: 1-866-764-6260

41. Rehospitalizations and Medicare • 20% of Medicare beneficiaries who had been discharged from a hospital were readmitted within 30 days • The cost of unplanned rehospitalizations in 2004 was $17.4 billion Toll-free Call-in number: 1-866-764-6260

42. Major Changes in Hospital Payments • "Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period saving $26 billion over 10 years" • MedPAC recommends reducing payments to hospitals with high readmission rates Obama Administration Budget Document MEDPAC Testimony before Congress March ‘09 Toll-free Call-in number: 1-866-764-6260

43. NQF SP 15 Objective: “Ensure effective transfer of clinical information to the patient and ambulatory clinical providers at the time of discharge." Toll-free Call-in number: 1-866-764-6260

44. RED meets the NQF SP 15 objective using 11 mutually reinforcing components: Patient education 2. Follow-up appointments 3. Outstanding tests 4. Post-discharge services 5. Medication reconciliation 6. Reconcile DC plan with national guidelines 7. What to do if problem arises 8. Assess patient understanding 9. Written discharge plan for patient 10. Timely transmission of DC summary to PCP 11. Post-discharge telephone reinforcement

45. RED Component #1 Educate patient about his/her diagnosis throughout the hospital stay • The RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until discharge SP 15: “preparation for discharge occurring with documentation, throughout the hospitalization”

46. RED Component #2 Make appointments for clinician follow-up and post-discharge testing • Schedule PCP appt within 2 weeks after discharge • Review the provider, location, transportation, and plan to get to appointment • Consult with patient regarding best day and time for appointments • Discuss reason for and importance of all follow-up appointments and testing SP 15: “explicit delineation of roles and responsibilities in the discharge process”

47. RED Component #3 Discuss tests/studies completed and who will follow up on results • Information listed in After Hospital Care Plan (AHCP), which is transmitted to PCP • Patient knows to discuss this with PCP at follow-up appointment and where to find it on his/her AHCP SP 15: “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

48. RED Component #4 Organize post-discharge services • Communicate with case manager and social worker about post-discharge services that they schedule • Provide patient with contact information for these services (phone number, name of company, etc.) Toll-free Call-in number: 1-866-764-6260

49. RED Component #5 Confirm the Medication Plan • Reconcile the patient’s home medication list as close to admission as possible • Review each medication; make sure that the patient knows why s/he takes it • Discuss new medications each day with medical team and with patient SP 15: “completion of discharge plan and discharge summaries before discharge”

50. RED Component #6 Reconcile discharge plan with national guidelines and critical pathways • Communicate with medical team each day about the discharge plan • Recommend actions that should be taken for each patient under a given diagnosis Toll-free Call-in number: 1-866-764-6260