Indianapolis Coalition for Patient Safety, Inc.
(ICPS)
Michele Saysana, MD, FAAP
Board Chair, ICPS
Jim Fuller, PharmD
President, ICPS
Geertje “Trudy” Hill, RN, BSHA, CPPS, CPHQ
Director Patient Safety
Community Health Network
Working together to make
Indianapolis the safest place to
receive healthcare in the nation.
ICPS Members
Richard Roudebush
VA Medical Center
We will not compete on safety and will share openly best practice
Marion County
Public Health Dept
Indiana Hospital
Association
Indiana State
Dept. of Health
Eskenazi
St. Francis
Deans of Medical,
RN & Pharm Schools
Veterans
Admin
Indiana Blood Center
Indianapolis
Coalition
for Patient
Safety
St. Vincent
IHIE
QSource
(Local QIO)
(Local Health InfoExchange)
Community
I U Health
Regenstrief
Institutes
Eli Lilly
QIO = Quality Improvement Organization
IHIE = Indiana Health Information Exchange
Thought Leaders
Indianapolis Coalition for Patient
Safety, Inc.
Table of Organization
Project Selection
CURRENT WORK GROUPS:
COMMON CAUSE
HEART FAILURE READMISSION
MEDICATION SAFETY
FLU POLICY/GUIDELINES
THERAPEUTIC HYPOTHERMIA
BLOOD SAFETY
CONTRAST MEDIA USAGE and EXPOSURE
ALERT FATIGUE with Smart Pumps
MDRO’s (multi-drug resistant organisms)
MEDICATION LIST / MEDICATION ADHERENCE
WORKPLACE VIOLENCE
EMERGENCY DEPARTMENT PRESCRIBING
PEDIATRICS
ADDICTIONS
Blood Safety
• Goals
• Improve blood management safety
• Implement revised Red Blood Cell (RBC) guidelines
• Enhance the effectiveness of Transfusion Committees
• Process
• Finalized Guidelines: Adult Transfusion of Blood & Blood Products
• Finalized Template: Transfusion Consent/Refusal Form
• Developed list of tactics to improve blood management
• Action Plans for Implementation ongoing
• Implemented revised RBC guidelines
• Measurement
• Relative RBC utilization is decreased in all member organizations
• CHNw Representative (serves as workgroup chairperson)
Kimberly Waters, MSN, RN, CPHQ
Network Blood Management Officer
Quality Resources
Blood Safety
Flu Policy/Guidelines
•
Goals:
• Reduce Hospital Acquired Flu
• One standard of practice for healthcare workforce vaccination
•
Process:
• Developed comparative table of hospital policies and vaccination rates
• Finalized Coalition policy
• Coalition CEO/CMO Commitment Letter
• Developed Implementation Guide with resource materials
• Developed Implementation Plan for 2012-2013 Flu Season
•
Measurement:
• Flu vaccination rates
Flu Policy/Guidelines
• Key lessons learned
• Success due to unanimous support from
Senior Leaders
• Very low rate of adverse events reported
• Very low rate of employee terminations
reported (and primarily prn employees)
Flu Policy/Guidelines
•
FLU Vaccine mandatory compliance
•
•
•
•
CY11
CY12
CY13
CY14
59%
98.5%
100%
100%
Flu Policy/Guidelines
Reducing Heart Failure (HF)
Readmissions
• Coalition consensus on implementable tactics to improve
preventable heart failure patient readmissions
• Collaborating with Central Indiana Skilled Nursing
Facilities (SNFs) on minimum care for treatment of HF
patients
• Improving verbal handoff communication for patients
transferred from hospitals to skilled nursing facilities
• Collaborating with Central Indiana Home Health Care
agencies on minimum care standards for treatment of
heart failure patients in Home Health Care Agencies
Reducing Heart Failure Readmissions
*DATA FOR ICPS HOSPITALS FROM IHA
Pediatrics
• Bring together a group of content experts to create and promote new
safety strategies and assure that existing safety strategies are
reviewed and disseminated to ICPS Member health-systems that
treat pediatric patients.
• Assure pediatric patients are considered, identified and addressed
in existing ICPS workgroups as appropriate.
• Sharing and transparency around existing best practices and
standardization
• Perform gap analysis of current state compared to ideal
• Emergency Department (ED) Pediatric Readiness
• Weights in Kilogram (KG) only (including documentation)
• Choosing Wisely - continuous pulse oximetry use
Common Cause
• Identify and share lessons learned from root cause analysis, safety
newsletters, patient safety rounds findings
• Standardize high risk procedures and policies
• Promote use of just culture processes that result in just outcomes
for all
• Perform common cause analysis to better understand root cause
fixes to déjà vu recurring root causes
• Bring content experts together for specific projects: eliminating
EED’s and eliminating FALLS.
Education
Chief Nursing Officer (CNO) Leadership Forum
• Hosted by a different ICPS member organization annually
• CNO’s provide guidance for conference topic / agenda
• Each organization provides faculty for the event – subject matter
expert
• State or national speaker
• Nurse leaders (CNO’s, Directors, Managers, emerging nurse leaders)
attend
• Continuing Education Units provided
• Past Topics have included:
– Workplace Violence
– Institute of Medicine – Future of Nursing Report 2010
– Transforming the Workplace through Resilience and Self-Care
Recognition
• ICPS Annual Patient Safety Hero Awards
–
–
–
–
–
–
–
–
Started in 2005
Held at Eli Lilly Corporate Headquarters annually
Mayor or Governor, Indiana Health Commissioner attends
Each member organization selects their winner
Recognition of individual or team
Project related to patient safety (does not have to be an ICPS project)
Sharing
Recognition
2014 Winner
Community Health Network
Behavioral Health Inpatient Crisis Response Team
IHA Patient Safety Coalitions
2014 IHA Survey
Patient Safety Coalitions
There were 315 total respondents, and each coalition’s
respective participation is depicted in the graph below.
IHA = Indiana Hospital Association
Member Survey
Q32: What is your primary profession?
50%
40%
IPSC Response %
IN Response %
30%
20%
10%
0%
Response
Allied Health
Professional
Educator
Pharmacist
Physician
RN or Advanced
Practice RN
IPSC Response
Totals (n=119)
IPSC Response %
IN Response Totals
(n=277)
IN Response %
16
13.4%
50
18.1%
5
25
22
4.2%
21.0%
18.5%
12
38
29
4.3%
13.7%
10.5%
51
42.9%
148
53.4%
Member Survey
Q9: My organization publically endorses or
co-sponsors the Coalition's activities
60%
50%
IPSC Response %
IN Response %
40%
30%
20%
10%
0%
Don't Know
Not At All
Somewhat
Very Much
Response
IPSC Response
Totals (n=128)
IPSC Response %
IN Response Totals
(n=309)
IN Response %
Don't Know
Not At All
Somewhat
Very Much
21
5
20
82
16.4%
3.9%
15.6%
64.1%
42
23
84
160
13.6%
7.4%
27.2%
51.8%
Member Survey
Q27: How likely or unlikely do you think it is that the
Coalition will improve patient safety in your community?
60%
50%
IPSC Response %
40%
IN Response %
30%
20%
10%
0%
Don't Know
Strongly Unlikely
Somewhat Unlikely
Somewhat Likely
Strongly Likely
Response
IPSC Response
Totals (n=119)
IPSC Response %
IN Response Totals
(n=280)
IN Response %
Don't Know
Strongly Unlikely
Somewhat Unlikely
Somewhat Likely
Strongly Likely
3
0
1
43
72
2.5%
0.0%
0.8%
36.1%
60.5%
8
2
9
129
132
2.9%
0.7%
3.2%
46.1%
47.1%
96.6% think it likely or strongly
likely that ICPS will improve
patient safety in our community
Thank You
Questions?