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Patient SafetyMarch 5, 2013
Cumberland (GA) ID/OncologyMarch 5, 2013
Our Team
Cumberland ID/OncologyName Title/Classification
Terry Portis, RN Management co-lead
Latasha Dixon, MA Labor co-lead, UFCW Local 1996
Angela Peeples, NP Clinician co-lead
Sonya Jones LPN
Kellye Aschmeyer PharmD
Pierson Gladney, Bindu Lingam, Harvey Hamrick
MDs
Linda Turner, Gwendolyn Brown, Janine Feliciano
RNs
Darlene Cokley, Julia Siler MAs
Bianca Cooper PA
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.
Our Metrics
Measure Data Source
Duplicate medications per office visit KP HealthConnect Medications Activity tab
Use of discontinue button in HealthConnect
Use of reorder button in HealthConnect
National Medication Utilization Data Report (weekly)
Process Map-BEFORE
Patient Registers/Checks In
RN/LPN/MA Reviews Medication List with
Patient
MD Reviews List in KPHC with Patient
RN/LPN/MA Updates List in KPHC via
marking ‘Taking’ or “Not Taking’
Start
Exit WorkflowMD Reconciles List in
KPHC MD/RN/MA Reviews
AVS with Patient
Process Map - AFTER
LPN/MA Print out Snapshot of
Medications (if needed)
RN/LPN/MA Reviews Medication List with Patient in KPHC and
notates Snapshot Printout of Duplicates
NP/MD Reviews List in KPHC with Patient
MD/NP Reconciles List in KPHC and Cleans Up Duplicate Medications &
shreds snapshot if applicable
LPN/MA calls patient to bring in Medication Bottles to Office Visit
LPN/MA gives NP/MD List of Duplicate
Medications
Patient Registers/Checks In
RN/LPN/MA Updates List in KPHC via
marking ‘Taking’ or “Not Taking’
Exit WorkflowMD/NP Reviews AVS
with Patient
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
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
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
Our Key Learnings
• Increased and improved communication among staff led to more open communication with patients, families
• Challenging project strengthened our team
Our Rewards & Recognition
• Coverage on InsideKP Georgia intranet site• Coverage on LMP website: article, PowerPoint
slide, bulletin board poster
Questions
Questions for the Cumberland ID/oncology team
Please use the chat box
Send your question to everyone
Question #1
Would you like your team to work on a patient safety performance improvement project?
Type “yes” or “no” in the chat box
Rock Creek (Colorado) GI TeamMarch 5, 2013
Our Team
Name Title/Classification/Union
Angelina Dale, RN UBT Co-lead, UFCW L7
Jennifer Bias, Endoscopy Technician UBT Co-lead, SEIU L105
Kelly Schuster, RN UBT Co-lead, manager
Joseph Cassara, MD UBT Co-lead, physician
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.
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.
Background
Rock Creek GI performs nearly 200 colonoscopies and upper endoscopies a week
Equipment is re-used as many as three times per day
Tests of change
Test of Change Adopt Success
Adapt
Adjustment
Abandon
Did not work
Use tags to identify disinfected scopes
X
The nurse will remove the tag for the doctor X
Reminder cards on computers to look for blue tags on scopes
X
Sustaining success
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
Our Challenges
• Engagement
• Providing the right information
• Not having tags in inventory
Our Successes
Value Compass Award
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
Questions
Questions for Rock Creek GI team
Please use the chat box
Send your question to everyone
Question #2
What will your team’s next step be to improve patient safety?
Type your short answer in the chat box.
South San Francisco (NCAL) Radiology March 5, 2013
Our Team
Insert team picture hereFrom Bob photos
Name Title/Classification/Union
Tracey Fung 2011 UBT Co-lead, management
Derek Granzow 2012 UBT Co-lead, management
Donna Haynes UBT Co-lead, labor
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.
Our Timeline
Date Milestone
September 2011 Patient safety director approached us to start a Performance Improvement project
Invited Radiation Oncology to present their “Stop the Line” project to our UBT
October - December 2011
UBT did root-cause analysis for all significant events in 2011
Our Timeline
Date Milestone
Jan. 2012 Determined two key factors leading to significant events: staff feeling rushed and deviation from workflows
Feb. – March 2012
Adapted Stop the Line form from the radiation oncology team and created standardized workflow
April 2012 Launched Stop the Line at a department “town hall” meeting
Workflow Process Map
Stop the Line Form
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
Our Challenges
• Solving issues outside of radiology that impact our workflows and patient safety.
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
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
Questions
Questions for South San Francisco radiology team
Please use the chat box
Send your question to everyone
Closing Comments
Doug Bonacum
Vice President of Quality, Safety and Resource Management
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
