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IHI ExpeditionExpedition: Appropriate Use of Blood Products
Session 6: Best Practices: Communication and Awareness Strategies
October 28, 2014
Begins at 3:00 PM EST
Beth Halperin, RN Timothy Hannon, MD, MBADiane Jacobsen, MPH, CPHQ
These presenters have
nothing to disclose
Terina Keller, Project Office Assistant, Institute for Healthcare Improvement (IHI), assists in programming activities for expeditions, maintaining Passport memberships, as well as other projects and collaboratives throughout IHI. Terina is currently in the Co-Operative Education Program at Northeastern University in Boston, MA, where she majors in Sociology with a minor in Health Science. Terina plans to earn her MPH once finished with undergrad and work on issues dealing with social determinants of health around the country and abroad.
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Expedition Director8
Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms. Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C.difficle Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI’s Spread Initiative. She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master’s degree in Public Health- Epidemiology.
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Today’s Agenda9
Ground Rules & Introductions
Debrief: Session 5 Assignment
Best Practices:
Communication and
Awareness Strategies
Action Period Assignment
Ground Rules10
We learn from one another – “All teach, all learn”
Why reinvent the wheel? – Steal shamelessly
This is a transparent learning environment – Share
openly
All ideas/feedback are welcome and encouraged!
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Expedition Objectives
At the end of this Expedition, participants will be able to:
List the quality, economic, and risk management issues
driving the need for safer blood use.
Discuss the pathway required for successful implementation
of evidence-based transfusion guidelines.
Develop three to five key performance indicators for effective
Transfusion Safety Committee oversight
Identify the essential elements of a sustainable Transfusion
Safety Program.
Describe issues of transfusion safety at the bedside and
strategies to improve transfusion administration safety.
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Schedule of Calls
Session 1 – Update on Transfusion Safety
Date: Tuesday, August 19, 3:00-4:30 PM ET
Session 2 – Transfusion Safety Program Infrastructure: Implementing Transfusion GuidelinesDate: Tuesday, September 2, 3:00-4:00 PM ET
Session 3 – Transfusion Safety Program Infrastructure: Measures of Clinical EffectivenessDate: Tuesday, September 16, 3:00-4:00 PM ET
Session 4 – Transfusion Safety Program Infrastructure: Critical Role of Leadership
Date: Tuesday, September 30, 3:00-4:00 PM ET
Session 5 – Nursing at the Bedside: Transfusion Administration SafetyDate: Tuesday, October 14, 3:00-4:00 PM ET
Session 6 – Best Practices: Communication and Awareness StrategiesDate: Tuesday, October 28, 3:00-4:00 PM ET
Session 7 – Putting it All Together: Building a Sustainable Program
Date: Tuesday, November 11, 3:00-4:00 PM ET
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Action Period Assignment Debrief
Audit 10 nursing charts for compliance with dual identification
documentation and vital signs documentation according to your
hospital policy
Design a brief survey tool for nursing to assess awareness of the
current risks of transfusion, to include misidentification,
TRALI,TACO, and TRIM
*test on a small scale
Determine your hospital’s baseline rate of reported transfusion
reactions
What did you learned?
Insights/surprises?
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Faculty14
Timothy Hannon, MD, MBA, is a board certified anesthesiologist with over 20 years experience leading large-scale healthcare change initiatives to improve the safety, quality and efficiency of patient care across the nation. As the visionary founder and CEO of Strategic Healthcare Group, a consulting and informatics company focusing on Blood Management and Transfusion Safety, Dr. Hannon partnered with major healthcare systems to rapidly and sustainably improve transfusion practices, resulting in almost 400,000 blood products saved and total healthcare cost savings approaching $600,000,000. More importantly, by reducing unnecessary transfusions through evidence-based practices and bleeding edge clinical pathways, Dr. Hannon and his team were able to help hospitals avoid 12,700 complications, reduce 476,000 inpatient days, repurpose 700,000 nursing hours, and save 2900 lives.
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Faculty15
Beth Halperin, RN is a graduate of Elmhurst College School of nursing,
a registered nurse and currently the Transfusion Safety Manager for
Advocate Health Care, a ten hospital integrated health system,
headquartered in Oak Brook, Illinois. She has over 20 years of clinical
leadership experience in adult critical care, clinical information systems
projects, and patient safety and quality improvement activities. For the
past seven years, Ms. Halperin has focused her attention on patient
safety issues and concerns, collaborating with Advocate’s physician
leaders on large system patient safety initiatives in obstetrics, root cause
analysis, common cause analysis and safer surgery. In 2007, she was
asked to serve as a member on the Illinois Hospital Association Patient
Safety Task Force. The purpose of this group was to consider
implementation issues with the Illinois Health Care Events Reporting
Law. Since 2011 she has served as Advocate’s Transfusion Safety
Manager, where she works with physician, nursing and blood banking
leaders at Advocate Healthcare to design and deploy patient safety
projects aimed at minimizing each Advocate’s patient’s exposure to blood
product transfusion. As of 2014, as a result of these projects, Advocate
has seen a decline of 46% in the use of blood products.
Beth Halperin, RN
Transfusion Safety Manager
Advocate HealthCare
Downers Grove, Illinois
Communication & Awareness Strategies for
Blood Management ProgramsOctober 28, 2014
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Objectives1. Define the objectives of a communications strategy
2. Describe the importance of early wins in a change management strategy
3. Identify internal and external resources for communications
4. Create communications tactics based on upon successful blood management case studies
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Advocate HealthCare• Largest integrated healthcare system in Illinois:
• 3000 + beds (10 acute care facilities)
• Largest integrated children’s network in Illinois
• Largest emergency and Level I trauma network in the state
• Annual blood budget: $21 million dollars annually
• Physicians on staff: 6000
• Nurses on staff: 8000
• Advocate’s size and diversity make communicating with the clinical team a real challenge
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Why Blood products?• 2011 – Budget at an all time high - $26 Million
• Acuity levels fairly constant
• Significant variation
• Was our transfusion practice evidence based?
• If not, why not?
• If not, what should we do?
• If not, how can we fix it?
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Healthcare’s Elephant…
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• The time gap between a clinical care ‘discovery’ and adoption in practice is real
• Can take up to 17 years*
• What is the impact on patient safety if new evidence isn’t applied in patient care?
*Cabana, et al. JAMA. 1999 Oct 20;282(15):1458-65
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Our Objectives
What is Happening?
We don’t have clinical consensus around safe blood use
No one is really ‘in charge’ of protecting patient safety through the whole transfusion process
We are grossly under-reporting reactions
Why is it Happening?
What should we do about
it?
We need to get the evidence into the hands of the clinicians
Patient Safety is at risk, urgent need to change practice
Everyone needs to hear the message
How will we know if things are changing for the better?
“This is the way I was taught”“Nobody gives just one unit“What exactly is TRALI?”“It’s just a fever, is that a reaction?”
Rules of the Road
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Some things we’ve learned
Everything you do is communication
The way the message begins usually determines the outcome
The way the message is delivered always affects the way it is received
If Doctors went on strike….
Elements of Communications
1. The message must say ‘why’
2. The Messenger really matters
3. Understand the receiver
4. Include person to person channels
5. Make sure your communication is ‘two way’
The Message
The Messenger
Receiver
Channel
Feedback
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Organizational Values Matter • HRO’s perform dangerous, complex tasks every day in unforgiving environments
• Manage to do so safely – almost all the time – without hurting anyone, or failing operationally
• Share five values
• We leveraged these values in our rollout plan
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Sensitivity to operations
Reluctance to simplify
Preoccupation with failure
Deference to expertise
Resilience
Communication Design Principles• Advocate values high reliability
principles
• These ideas are integrated into the communication design and rollout
• Key values:
• Deference to expertise and evidence
• Sensitivity to operations
• Reluctance to simplify
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Sensitivity to operations
Reluctance to simplify
Preoccupation with failure
Deference to expertise
Resilience
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Our Message• That was then….
– “Being liberal with blood is ok”
– “Go big – always give 2 units”
• This is now– Blood is a liquid transplant
– Each transfusion carries risk and benefit
– Change from the old to the new –
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The Messenger• Physicians and nurses
respect two things:
– Excellent patient care
– Expert clinicians
• The messenger should be a clinician who uses blood and understands the evidence
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The MessengerRichard Fantus, MD
Advocate Illinois Masonic Medical Center
“As blood transfusion is a trying, even dangerous procedure to the recipient, the indications for it should be drawn strictly and rather narrowly.”
Bernard Fantus, MD 1937
“Seven is the new ten… one is the new two.” Richard Fantus, MD 2012
Respect your ‘Receivers’• Remember that clinicians are doing
what they think is right
• Always include the rationale for the change
• Do not over-simplify the clinical issues, invite comment
• Endorsements influence listeners
• Tell stories or share examples to illustrate a point
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Examples of early wins…• System chairman was key
– Respected trauma surgeon
– Family history in transfusion medicine
– “I transfuse blood products”
• Medical staff president who spoke up in a system meeting of his peers
– “I am convinced this is the right thing to do, and I intend to start doing it”
Impact of Early Endorsements• Creates legitimacy
• Creates the consensus around ‘what is safe’
• Sets the stage for organizational programs to ensure safe transfusion practice
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Rules for Messengers• Describe the evidence
– Do not expect physicians to change practice before they accept the evidence – it just makes them mad
• Do not over-simplify clinical care
– Promote discussion of actual cases; it helps with integrating new information into future cases
– When they have accepted the evidence, they will tell you what they need to implement the change
Communication Tactics
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Planning Rules • Do not disrupt clinical operations
– Site implementation leaders become decision makers
– What is their priority in improving safety?
– Never turn people with questions away
– Front line providers will design rollout tactics that they can support
– A key job for system leader(s) is to understand what the direct care team needs to adopt the change
Sensitivity to operations
Reluctance to simplify
Preoccupation with failure
Deference to expertise
Resilience
Manage Scope
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Pre-transfusion testing
Medical Decision to Transfuse
Dispense the correct product from the Blood
Bank
Safe Administration at the bedside
For Advocate – the Medical Decision to Transfuse became first priority
Infrastructure created:
– System and site Transfusion Safety Committees to own the transfusion process
– Developed a measurement system to track progress and put it on line for Advocate clinicians to view
Communications were designed to support each element
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Communication Plan Structure• System steering committee
made decisions
– Transfusion guidelines developed and endorsed by each site MEC
– Special projects to support improved care
– Communication plan oversight and tactics approval
System Committee
Site Committee
Site Team Site Team
Strategies: First year• Developing consensus and then communicating ‘sound
practice’ guidelines
• Guidelines compiled by a system task force
• Submitted to each hospital’s medical executive committee for endorsement
• Guidelines-driven CPOE orders
• Site Transfusion Safety Committees
• On-line public measurement system
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Specific Tactics• Step 1: Deference to expertise:
• Team Membership
• Added Public Relations and Physician outreach
• Designed a multi-media campaign that:
• Prioritized high-blood use physicians and nurses – Distilled the guidelines into simple rules
– Explained how the guidelines came into existence and were legitimized by the MEC’s
– Showed physicians how to use the new guidelines-driven CPOE order sets
– Described how the order sets helped them improve patient outcomes
– Developed multiple tools and venues to communicate the message
Details Phase I: Rapid rollout 6 weeks prior to the CPOE go live:
1. Email to the medical staff from our CMO
2. Email from each CNE to the nurses at each site
3. Flyers: Leadership talking points, FAQ’s about our initiative, screenshots with brief explanations
4. Lecture series from SHG team; feedback with Q&A afterwards
5. Unit visits with flyers, stickers, and posters – ‘5 minute inservice’
6. Physicians relations team rounding in MD offices with media kits
7. Intranet web page; slide show for physicians’ lounges
8. Online physician course for CE credit
9. 24-7 Subject matter experts to support CPOE orders go-live; wore our logo as a sticker
10. Posters with our message went up everywhere
11. Physician champion video – link emailed to medical staff & posted on line
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Repeat the Message
Everywhere
Our Results • Since 2011, RBC usage has
declined by:
– 49% at the Level I Trauma sites,
– 44% at all other Advocate sites
• Component use decreased:
• Level I:
–Platelets = 11% Decrease
–Plasma = 42% Decrease
• Level II
–Platelets = 20% Decrease
–Plasma = 27% Decrease
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**Ferraris et al, Arch Surg 2012;147(1)Assumes outcomes for a single unit of RBC, an apheresis unit of platelets or a 3 unit dose of plasma
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3753
31
0
10
20
30
40
50
60
70
80
Jan-11 Jan-12 Jan-13 Jan-14
Level I Level II
RBC Use/1000 Adj Patient Days
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Blood Product Units Saved• RBC’s = 39,642
• Platelets = 3,036
• Plasma = 6,703
• Cryo= 1,918
• Total Resource conservation=57,299 units
Clinical Impact• Health Outcomes for Advocate Patients
– 1,797 complications avoided
– 67,369 inpatient days avoided
– 98,809 Nursing hours repurposed
– 404 Lives saved
Ferraris et al, Arch Surg 2012;147(1)Assumes outcomes for a single unit of RBC, an apheresis unit of platelets or a 3 unit dose of plasma
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Stewardship• In 2011, Advocate spent over $26 million dollars
on blood products
• In 2013, we spent $17.5 million dollars for the same purpose
• The bottom line – we are able to repurpose over $8.5 million dollars into improved patient care
Summary • What worked for Advocate:
• Committed physician and nursing leadership
• Nurses should receive the same educational message as the physicians
• Legitimize your guidelines with the medical staff & nursing leaders through education
• Above all: have a good answer to the question ‘why?’
• Once you can articulate why, work with your media experts to get the word out everywhere to everyone
• Publish your results to your clinical staff
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Questions/Discussion47
Raise your hand
Use the chat
Action Period Assignment
Create a visual aid (poster, screen saver, button) to communicate for
buy-in and encourage behavioral change for better blood use
*test on a small scale
Develop “talking points” for internal and external briefings on your
program
Come prepared to share what you tested/learned
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Expedition Communications
Listserv for session communications:
– To add colleagues, email us at [email protected]
– Pose questions, share resources, discuss barriers or successes
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Final Session
Session 7: Putting it All Together: Building a Sustainable Program
Tuesday, November 11th, 3:00 PM – 4:00 PM ET
Faculty:
Timothy Hannon, MD, MBA
participants share successes, progress, and plans
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