a Foundation for Change
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1 Continuous Quality Improvement ADEs: Steven Utilizing R. Abel, Measurement PharmD, FASHP as Nital Patel, PharmD. MBA a Foundation for Change Sheri Helms, PharmD Candidate Brian Heckman, PharmD Candidate John B. Hertig, PharmD, MS Justin Associate Bouw, Director PharmD Center for Medication Safety Advancement Purdue University College of Pharmacy Indianapolis, IN January 25, 2011
2 Learning Objectives Describe why continuous quality improvement (CQI) is essential for healthcare professionals Identify key components of the CQI process, focusing on the importance of measurement Apply CQI and measurement tools in improving processes related to adverse drug events
3 About Quality The Quality and Safety Conundrum What s the difference? How are they related? Quality is not an act, it is a habit -Aristotle
4 Continuous Quality Improvement Rooted in the idea that we can always do better Toolkit Flowchart Cause and Effect Diagram (Fishbone) Run Chart Control Chart Pareto Chart Root Cause Analysis Failure Modes and Effects Analysis *Scorecards and Dashboards
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6 Measuring: Why Metrics, Dashboards, and Scorecards?! Tools for measurement of our performance improvement activities How do we know if we are successful? Measure throughout process Baseline During After
7 Traditional Examples
8 What s the difference? Balanced Scorecard usually strategic; aligns organizational behavior with goals, objectives measures are defined, detailed Dashboard usually operational; monitors and measures processes measurement is visual; can lack details behind why something is important
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11 Developing and Implementing a Safety Dashboard
12 Approach to Developing and Implementing a Safety and Quality Dashboard Do Over Design Define Document Data Targets Courtesy of: M. Thoma
13 Get Ready! Assemble Dashboard Team Members Facilitator Managers Staff members Hospital or department quality representative Data analyst and/or informatics Clinical Engineering Other key stakeholders
14 Step 1: Define the Dashboard The most important (and time consuming!) step for successful development and implementation of a safety dashboard Establish the dashboard name Establish dashboard categories Establish measures/indicators Establish targets/goals
15 Step 2: Establish Measures/Indicators May be pre-defined Partnership for Patients (encyclopedia of measures) Center for Medicare and Medicaid Services National Patient Safety Goals Etc Could be generally accepted as safe Smart pump usage BCMA Engage staff in defining measures Better to use rates and percentages; not numbers; define measure so numerator and denominator are both obtainable and quantifiable Be SMART
16 Medication-Related Quality Measures Antibiotic selection (ICU/Non-ICU) Pneumococcal vaccination Influenza vaccination Blood cultures prior to antibiotic Pre-op antibiotic selection Antibiotic discontinued within 24 hours Thrombolytic administration Peri-operative beta-blocker administration VTE prophylaxis ordered VTE prophylaxis administered ACE/ARB for LVSD Discharge Medication Instructions Aspirin on arrival Aspirin on discharge
17 Step 3: Establish Targets and Goals Consider your ability to meet and/or exceed Start with measures with well defined targets based on best practice, industry standards, literature review, quality measures Internal and external benchmarking Alignment is important Peer institutions National initiatives Use retrospective data, strive for 10% improvement over last year average
18 Benchmarking Where are we now? Where do we want to be? How do we get there? How do we know when we have arrived? Types Internal: measuring performance against ourselves External: measuring performance against others
19 External Benchmarking
20 Guidelines for External Benchmarking Compares internal data against data of other institutions Helps assess how one organization is doing compared to external peer groups Can be utilized to help drive improvement projects and development of internal benchmarks
21 Guidelines for External Benchmarking May not be as completely accurate External reporting is sometimes filtered or reported inconsistently Very important to pick an appropriate comparison group Bed size Location Affiliation Specialty Care mix Inappropriate peer group comparison can lead to incorrect strategic planning and frustration!
22 Guidelines for External Benchmarking Develop a specific peer group May change depending on what is being measured i.e., heart failure rates vs. local Heart Hospital i.e., orthopedic infection rates vs. local Trauma Center Use national resources to gather data American Hospital Association University Health-System Consortium
23 Internal Benchmarking
24 Guidelines for Internal Benchmarking Compares timely (e.g., monthly, quarterly) data elements against themselves Measures can be defined so they meet the needs of the organization; more controlled Can be utilized to support or dispute external benchmarking data More reflective of true clinical workload
25 Guidelines for Internal Benchmarking Measures should be validated, accurate and applied consistently over time Consider both volume and time Consider separating functional areas or patient care units Design with the end in mind!
26 Guidelines for Internal Benchmarking Clinical Workload Examples the % of patients where medication reconciliation is documented as completed within 24 hours of admission % of interventions/recommendations accepted (route interchange, renal dosing, therapeutic and formulary interchange, pharmacokinetic consults, TPN adjustments) % patients receiving heart failure discharge instructions % patients returning for subsequent ambulatory visits
27 Step 4: Document For each measure, document: Category in which it resides Definition (numerator and denominator) and targets Purpose Owner and/or accountable party Data Collection method Reporting frequency and due date Weekly, monthly, quarterly, biannually Data submission method
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29 Steps 5: Design the Dashboard Purpose To communicate to end users Consider sharing with non-end users, survey for potential conflicting messages (pharmacy, nursing, quality/risk, physicians, c-suite, etc.) Use simple visual cues Include at a minimum Dashboard name Dashboard categories Dashboard measures Dashboard display tool
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31 Step 6: Do Over
32 Learn and Improve A P S D Changes That Result in Improvement A P S D Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change P: Plan D: Do S: Study A: Act Courtesy: Kim Voss, MD
33 Remember to Make it Visible! Make the measures everyone s responsibility Encourage accountability Post publicly reported data Reward and share successes Communicate feedback often Present at regularly scheduled intervals Work together to overcome challenges Review dashboards and scorecards at least annually
34 Summary Apply a team-based, plan, do, study, act approach to designing and implementing a safety and quality dashboard Focus on developing and benchmarking measures to evaluate and communicate the positive outcomes of safety work Share with others Align with national standards and initiatives (i.e., PfP)
35 The Indiana Experience: Indiana Hospital Association and CMSA Collaboration
36 Medication Safety Alliance Educating Medication Safety Sharing Supporting
37 Eleven regional safety coalitions Members agree not to compete on patient safety Layered model of regional coalitions and affinity groups supports transformation, learning and spread Benefits: Innovate at the front lines Align with state and national efforts, and standardize when beneficial Builds local and hospital-specific capacity for improvement and innovation Encourages safety leadership at all levels across multiple professions
38 Medication Safety Alliance Overview Purpose Framework Partnerships Over 30 hospitals More than 45 healthprofessionals Path for involvement
39 Indiana Medication Safety Alliance Conference on Readmissions and ADEs Held November 8 th 2012, and sponsored by Indiana Hospital Association Readmissions and ADEs: Causal Links and Strategies for Action Engaged hospitals and state organizations Medication Safety Continuing Education Program Launched on September 17 th 2012 On-line, on-demand course 7 CE hours for physicians, nurses and pharmacists 10 spots per hospital for inter-professional medication safety education 645 modules completed
40 Indiana Medication Safety Alliance Self-assessment tool Focused on high-risk medications leading to readmissions Help identify areas for additional research and root-cause analysis Coaching webinars and strategies Online web portal for members only Statewide ADE measures initiative
41 State Measures Initiative Nationally, ADE measure reporting is lowest of all harm categories Measures have been adopted as the statewide areas of emphasis for reporting adverse drug events for 2013 as part of the MSA Purpose is to identify best practices and share improvement strategies throughout the State Develop our statewide ADE safety dashboard
42 State Measures - Outcome Highest priority correlate directly to harm Select at least one to report 1) Manifestations of Poor Glycemic Control Definition: Inpatients who experienced manifestations of poor glycemic control during hospitalization 2) Excessive Anticoagulation with Warfarin Inpatients Definition: All inpatients who had excessive anticoagulation with warfarin
43 State Measures - Process Important for performance improvement efforts! 1) Maintenance of Active Medication Allergy List 2) Heart Failure Discharge Instruction (HF-1) 3) Automated Dispensing Cabinets Override Rates Others?
44 Measuring for Success Measures used to identify and statewide ADE trends Help drive statewide continuous quality improvement efforts Feedback and data provided via web portal Share successes and challenges, resulting in sustainable, ongoing, improvement P D S A
45 Conclusion Keys to Success Partnerships Multidisciplinary collaboration Strategic Measurement Specific strategies and events Focus on delivery with purpose: VALUE! Keeping the Momentum! Make it meaningful and visible
46 Continuous Quality Improvement ADEs: Steven Utilizing R. Abel, Measurement PharmD, FASHP as Nital Patel, PharmD. MBA a Foundation for Change Sheri Helms, PharmD Candidate Brian Heckman, PharmD Candidate John B. Hertig, PharmD, MS Justin Associate Bouw, Director PharmD Center for Medication Safety Advancement Purdue University College of Pharmacy Indianapolis, IN January 25, 2011
Conflict of Interest Disclosure
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