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Welcome to theNQF 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.orgOnline Access Password: Webinar1 (case-sensitive)
Welcome and Safe PracticesOverview
Toll-free Call-in number: 1-866-764-6260
Hayley Burgess, PharmDDirector, Performance Improvement Measures, Standards, and Practices
TMIT
Safe Practices WebinarNovember 19, 2009
2
5
Panelists
Peter Angood
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
Kimberly ViscontiDavid W. BatesHayley Burgess
Information Management and Continuity of Care
Medication Management
Healthcare-Associated Infections
Condition- and Site-Specific Practices
Consent & Disclosure
Culture
Workforce
Consent and Disclosure
Toll-free Call-in number: 1-866-764-6260
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
Information Management and Continuity of Care
Medication Management
Healthcare-Associated Infections
Condition-, Site-, and Risk-Specific Practices
Consent & Disclosure
Wrong-siteSx Prevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag. Therapy
VAP Prevention
Central V. Cath.BSI Prevention
Sx-Site Inf.Prevention
Contrast Media Use
Hand HygieneInfluenza
Prevention
Pharmacist Systems Leadership:High-Alert, Std. Labeling/Pkg., and Unit-Dose
Med. Recon.
Culture
CPOE
Read-Back & Abbrev.
Discharge System
PatientCare Info.
LabelingStudies
Culture Meas.,FB., and Interv.
Structuresand Systems
ID and Mitigation Risk and Hazards
Team Trainingand Team Interv.
Nursing Workforce
ICU CareDirect
Caregivers
Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care
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
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
CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Leadership Role Including: High-Alert
Med. and Unit-Dose Standardized Medication Labeling and Packaging
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
Informed Consent
Life-Sustaining Treatment
Disclosure
CHAPTER 3: Informed Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver
Consent and Disclosure
2009 NQF Report
Care of Caregiver
MDROPrevention
UTIPrevention
FallsPrevention
OrganDonation
GlycemicControl
New
MaterialChanges
No MaterialChanges
Legend:
PediatricImaging
7
Achieving Successwith Computerized
PhysicianOrder Entry (CPOE)
David W. Bates, MD, MScMedical Director of Clinical and Quality
Analysis, Partners HealthcareChief, Division of General Internal Medicine
Brigham and Women’s Hospital
Safe Practices WebinarNovember 19, 2009Toll-free Call-in number: 1-866-764-6260 8
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
9
10
Safe Practice 16: CPOE 2009
Toll-free Call-in number: 1-866-764-6260
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.
11
CPOE as part of the EHR
Toll-free Call-in number: 1-866-764-6260
• 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
12
Inpatient Prevention
Toll-free Call-in number: 1-866-764-6260
• 55% reduction in serious medication error rate with CPOE
Bates, JAMA, 1998• 83% reduction in overall medication
error rateBates, JAMIA, 2000
• Cost of each preventable ADE ~ $6,000
13
Systematic Review of Impact of CPOE on Medication Safety
Toll-free Call-in number: 1-866-764-6260
• 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 sinceKaushal, Shojania, Bates, Arch Int Med 2003
14
Other Recent Reviews of CPOE and Medication
Safety
Toll-free Call-in number: 1-866-764-6260
• 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
Wolfstadt et al., J Gen Intern Med 2008
Shamliyan et al., Health Services Res 2008
15
Selected Laboratory Interventions
Toll-free Call-in number: 1-866-764-6260
• 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”
16
Order Entry and Critical Paths
Toll-free Call-in number: 1-866-764-6260
• 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
17
Summary of Benefits
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• 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
18
How to Prioritize?
Toll-free Call-in number: 1-866-764-6260
• 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 preventionKaushal, JAMIA 2006
Meaningful Use is Being Defined and Will Follow an
“Ascension Path”2009
2011
2013
2015HIT-Enabled Health Reform
HITECH Policies 2011
Meaningful Use
Criteria (Capture/sh
are 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 19
20
Meaningful Use Matrix andDecision Support: Hospitals
2011
Toll-free Call-in number: 1-866-764-6260
• 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
21Toll-free Call-in number: 1-866-764-6260
• 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
Meaningful Use Matrix andDecision Support: Hospitals
2013
22
University of Pennsylvania: Unintended Consequences
Toll-free Call-in number: 1-866-764-6260
• 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
23
Issues with the Koppel Study
Toll-free Call-in number: 1-866-764-6260
• 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
24
University of Pittsburgh:Pediatrics Study
Toll-free Call-in number: 1-866-764-6260
• 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
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
Toll-free Call-in number: 1-866-764-6260
• 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
27
The Path To Success in Implementing CPOE
Toll-free Call-in number: 1-866-764-6260
• 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
28Toll-free Call-in number: 1-866-764-6260
• Strong leadership and long-term commitment
• Creating a culture of innovation• Excellent project management• Attention to clinical processes• A focus on quality
Critical Success Factors in Implementation
29
Getting Benefits—What Does It Take?
Toll-free Call-in number: 1-866-764-6260
• 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
30Toll-free Call-in number: 1-866-764-6260
• 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
How to Assess Where You Are Regarding Decision
Support
Simulations of EHR Use with CPOE
The Assessment Methodology
The assessment pairs medication orders that would cause a serious adverse drug event with a fictitious patient.
PatientAB
Female52 years oldWeighs 60 kgAllergy to morphineNormal creatinine
A physician enters the order…
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 31
Hospitallogs on
(Password access)
Complete sample
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
Aggregate score to Leapfrog
Order category scores viewed
by hospital
Review patient
descriptions
Review orders and categories
Review scoring
The Assessment Tool
AHRQ/NQF/Leapfrog Assessment Tool
32
33
Broader Context
Toll-free Call-in number: 1-866-764-6260
• Multiple technologies can improve medication safety
Address different stages of the process• Bar-coding• Smart pumps • Computerized monitoring for ADEs
34
Evidence Regarding Bar-coding
Toll-free Call-in number: 1-866-764-6260
• 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
0.19%
0.61%
0.88%
0.07%
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
Dispensing Error Rate Potential ADE Rate
Before Period (115164doses observed)After Period (253984doses observed)
31% reductio
n*
63% reductio
n*
* p<0.0001 (Chi-squared test) Poon et al., Annals Internal Medicine, 2006
Dispensing Errors and Potential ADEs: Before and After Bar-code
Technology Implementation
Projections for errors Projections for errors prevented per yearprevented per year at study hospitalat study hospital::
• >13,500 medication >13,500 medication dispensing errorsdispensing errors
• >6,000 potential >6,000 potential ADEsADEs
36
Conclusions
Toll-free Call-in number: 1-866-764-6260
• 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
37
Using the Re-Engineered Discharge (RED) to
Implement NQF Safe Practice 15:
Discharge SystemsKimberly Visconti, RN
Discharge Advocate, Project REDBoston Medical Center
Safe Practices WebinarNovember 19, 2009
Toll-free Call-in number: 1-866-764-6260
38
Background to Current Problem
Toll-free Call-in number: 1-866-764-6260
• 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
40
Communication Deficits at Hospital Discharge Are
Common
Toll-free Call-in number: 1-866-764-6260
• 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%)
41
Rehospitalizations and Medicare
Toll-free Call-in number: 1-866-764-6260
• 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
42
Major Changes in Hospital Payments
Toll-free Call-in number: 1-866-764-6260
• "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
MEDPAC Testimony before Congress March ‘09
Obama Administration Budget Document
43
NQF SP 15 Objective:
Toll-free Call-in number: 1-866-764-6260
“Ensure effective transfer of clinical information to the patient and ambulatory clinical providers at the time of discharge."
44
1. Patient education2. Follow-up appointments3. Outstanding tests 4. Post-discharge services5. Medication reconciliation 6. Reconcile DC plan with national guidelines 7. What to do if problem arises8. Assess patient understanding9. Written discharge plan for patient10. Timely transmission of DC summary to PCP11. Post-discharge telephone reinforcement
RED meets the NQF SP 15 objective using 11 mutually reinforcing
components:
45
• The RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until discharge
RED Component #1Educate patient about his/her
diagnosis throughout the hospital stay
SP 15: “preparation for discharge occurring with documentation, throughout the hospitalization”
46
• 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
RED Component #2Make appointments for clinician
follow-up and post-discharge testing
SP 15: “explicit delineation of roles and responsibilities in the discharge process”
47
• 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
RED Component #3Discuss tests/studies completed and who will follow up on results
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
• 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.)
RED Component #4Organize post-discharge services
Toll-free Call-in number: 1-866-764-6260
49
• 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
RED Component #5Confirm the Medication Plan
SP 15: “completion of discharge plan and discharge summaries before discharge”
50
• Communicate with medical team each day about the discharge plan
• Recommend actions that should be taken for each patient under a given diagnosis
RED Component #6Reconcile discharge plan with national guidelines and critical
pathways
Toll-free Call-in number: 1-866-764-6260
51
• What constitutes an emergency• What to do if a non-emergent problem arises• Where to find contact information for the
discharge advocate and PCP on the After Hospital Care Plan
RED Component #7Review appropriate steps for what
to doif a problem arises
SP 15: “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.”
52
• Fax the discharge summary and After Hospital Care Plan to PCP within 24 hours after discharge
RED Component #8Expedite transmission of the
discharge summary to the PCP
SP 15: “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”
“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”
53
• Deliver information to reach those with low health literacy level
• Include caregivers when appropriate• Utilize professional interpreters as needed
RED Component #9Assess degree of understanding by
asking patient to explain the details of the plan
SP 15: "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled. This information must also be communicated to the accepting physician.”
"Use the 'teach-back process' to ensure pt understands transition-of-care planning."
54
• After Hospital Care Plan includes:1) Principal discharge diagnosis2) Discharge medication instructions3) Follow-up appointments with contact
information4) Pending test results 5) Tests that require follow-up
RED Component #10Give the patient a written
discharge plan at time of discharge
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”
59
• Call patient within 72 hours after discharge• Assess patient status• Review medication plan• Review follow-up appointments• Take appropriate actions to resolve problems
RED Component #11Provide telephone reinforcement of the discharge plan after discharge
SP 15: “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post-discharge adverse events and unnecessary rehospitalizations"
Can Health IT assist with providing a comprehensive
discharge?
Toll-free Call-in number: 1-866-764-6260 60
Embodied Conversational Agents• Enhance patient education before discharge • Emulate face-to-face communication• Develop therapeutic alliance• Determines competency
• ECA is currently being tested at BUMC
New Horizons Using Health IT
Characters: Louise (L) and Elizabeth (R)Toll-free Call-in number: 1-866-764-6260
Automated Discharge WorkflowSP 15: “the development of IT systems to collect discharge information and create discharge plans from existing hospital databases could enable components of the plan to be easily collected”
62
Thank you!
• For general information about Project RED, please refer to our website:http://www.bu.edu/fammed/projectred/
• For information about implementing RED or obtaining RED software, please contact:[email protected]
64Toll-free Call-in number: 1-866-764-6260
65
Practical Implementation Approaches to Patient Care
Information, Order Read-Back and
Abbreviations, and Labeling of Diagnostic Studies
Peter B. Angood, MD, FRCS(C), FACS, FCCMSenior Advisor, Patient Safety,
National Quality Forum
Safe Practices WebinarNovember 19, 2009
Toll-free Call-in number: 1-866-764-6260
66
Safe Practice 12: Patient Care Information
Safe Practice 13: Order Read-Back and Abbreviations Safe Practice 14:Labeling of Diagnostic Studies
Toll-free Call-in number: 1-866-764-6260
67
Ensure that care information is transmitted and appropriately documented in a timely manner and in a clearly understandable form to patients and to all of the patient’s healthcare providers/professionals, within and between care settings, who need that information to provide continued care.
SP 12: Patient Care Information
Toll-free Call-in number: 1-866-764-6260
68
SP 12:•The fragmentation of care across many providers, and an inability to access key care information for patients, results in very dangerous, yet preventable, scenarios.
•One study reported that only 51% of potentially "life-threatening" critical test results received appropriate attention ... audit of patient charts revealed that 15% contained no documentation that clinicians were ever aware of the critical test result or that any corrective action was taken.
•Patient care information, for the purposes of 2009, is defined as “critical information regarding medical history, diagnostic test results, medications, treatment, and procedures.”
69
SP 12:•This practice instructs organizations how to ensure that care information is appropriately documented in a timely manner and clearly communicated to patients and all of the patient's health care professionals who need that information to provide continuity of care.
•This practice now includes establishing a process to communicate critical test results that are completed after the patient has been discharged from the organization.
Toll-free Call-in number: 1-866-764-6260
70
Incorporate within your organization a safe, effective communication strategy, structures, and systems to include the following:
•For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person who is receiving the information record and “read-back” the complete order or test result.
•Standardize a list of “Do Not Use” abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization.
SP 13: Order Read-Back and Abbreviations
71
SP 13: •Combined into one 2009 Safe Practice, the activities defined were merged from 2 separate 2006 Practices … combination addresses ineffective communication, which is most frequently cited category of root causes for sentinel events.•Implementing safeguards to relay accurate patient information, such as a verbal or telephone order, includes having the person receiving the information record and read back the complete order or test result.
Toll-free Call-in number: 1-866-764-6260
72
SP 13: •Organizations are instructed to standardize a list of "do not use" abbreviations and dose designations that should not be used.•Though now a combined practice, it does not have substantive changes to the 2006 practice elements.
Toll-free Call-in number: 1-866-764-6260
73
Implement standardized policies, processes, and systems to ensure accurate labeling of radiographs, laboratory specimens, or other diagnostic studies, so that the right study is labeled for the right patient at the right time.
SP 14: Labeling of Diagnostic Studies
Toll-free Call-in number: 1-866-764-6260
74
SP 14: • The potential exists for radiographs, laboratory
samples, and pathology specimens to be mislabeled, or incompletely labeled, and consequently misinterpreted across all care settings.
• This practice defines implementation of standardized processes to ensure accurate labeling of diagnostic studies.
• No substantive changes from 2006 practice.
Toll-free Call-in number: 1-866-764-6260
75
Roles for the Patient Advocate
(Are You Listening?)
Arlene Salamendra Patient Advocate Leader
Former Board Member and Staff Coordinator,Families Advocating Injury Reduction (FAIR)
Safe Practices WebinarNovember 19, 2009
Toll-free Call-in number: 1-866-764-6260