Muskie School of Public Service Tennessee Rural Hospital Patient - - PowerPoint PPT Presentation

Muskie School of Public Service Tennessee Rural Hospital Patient Safety Demonstration

Presented at the Tennessee Hospital Association’s 14th Annual Small or Rural Hospital Conference Nashville, TN April 6, 2007

Judy Tupper, MS, CHES Research Associate

Muskie School of Public Service Institute for Health Policy

GOAL To test the feasibility, cost, and impact

• f implementing a set of patient safety

interventions with a sample of small rural hospitals.

Muskie School of Public Service Institute for Health Policy

Demonstration Participants

• Tennessee Hospital Association
• Universities of Southern Maine (Lead), Minnesota, and

North Dakota

– Andy Coburn (PI) and Judy Tupper (Project Director), Maine Rural Health Research Center, University of Southern Maine – Ira Moscovice, Upper Midwest Rural Health Research Center, University of Minnesota – Jill Klingner, University of Minnesota – Mary Wakefield, Center for Rural Health, University of North Dakota

• QSource (Tennessee QIO)
• Eight Small Rural Tennessee Hospitals
• Funder: BlueCross/BlueShield of Tennessee

Muskie School of Public Service Institute for Health Policy

Activities of Project

• Patient Safety Culture Survey
• Record of survey process
• Record of feedback to hospitals
• Intervention prioritization process

– Safety culture, ER protocols, PDA utilization

• Intervention planning
• Intervention collaborative with QIO

– Monthly conference calls, quarterly gatherings – Structure, technical assistance, best practices

• Repeat Safety Culture Assessment 3/06, and 12/06
• Evaluation of implementation process and initial results
• f interventions – (site visits, phone surveys)
• Provide lessons learned for spread to other rural

hospitals

Muskie School of Public Service Institute for Health Policy

The Hospital Survey on Patient Safety Culture was distributed in 3/2005, 3/2006, and 12/2006, to staff at 8 participating hospitals in the Tennessee Rural Hospital Patient Safety Project.

~ 3 rounds of surveys averaged 74% response rate (AHRQ pilot 29%)* ~ 3 rounds of surveys averaged direct patient contact 76% (AHRQ pilot 84%)*

* Benchmark data from AHRQ survey pilot of 1400 staff from 20 hospitals.

Muskie School of Public Service Institute for Health Policy

Strengths

• Supervisor/manager expectations

and actions promoting safety

• Organizational learning
• Teamwork within hospital areas
• Hospital management support

Weaknesses

• Non-punitive response to errors
• Hospital handoffs and transitions

Muskie School of Public Service Institute for Health Policy

Overall Perceptions of Safety

69%a 67%a 56% 56% 56% 56% 0% 20% 40% 60% 80% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96- 0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

AHRQ Culture Survey: Tennessee Hospitals

Muskie School of Public Service Institute for Health Policy

Frequency of Events Reported

51% 63%a 69%a,b 52% 52% 52% 0% 20% 40% 60% 80% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey b Significantly different from April 2006 survey Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96- 0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

AHRQ Culture Survey: Tennessee Hospitals

Muskie School of Public Service Institute for Health Policy

Supervisor/Manager Expectations & Actions Promoting Patient Safety

80%a,b 76% 72% 71% 71% 71% 0% 20% 40% 60% 80% 100% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey b Significantly different from April 2006 survey Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

AHRQ Culture Survey: Tennessee Hospitals

Muskie School of Public Service Institute for Health Policy

Organizational Learning/Continuous Improvement

76% 74% 77% 71% 71% 71% 0% 20% 40% 60% 80% 100% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

AHRQ Culture Survey: Tennessee Hospitals

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals

Teamwork Within Areas

83%a,b 79%a 68% 74% 74% 74% 0% 20% 40% 60% 80% 100% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey b Significantly different from April 2006 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals

Communication Openness

50% 60%a 67%a,b 61% 61% 61% 0% 20% 40% 60% 80% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey b Significantly different from April 2006 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals

Feedback & Communication about Error

53% 63%a 68%a,b 52% 52% 52% 0% 20% 40% 60% 80% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey b Significantly different from April 2006 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96- 0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals

Non-Punitive Response to Error

50%a,b 44%a 35% 43% 43% 43% 0% 20% 40% 60% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey b Significantly different from April 2006 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals

Staffing

52%a 54%a 46% 50% 50% 50% 0% 20% 40% 60% 80% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals Hospital Management Support for Patient Safety

78%a 78%a 72% 60% 60% 60% 0% 20% 40% 60% 80% 100% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 2

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals Teamwork Across Hospital Areas

64% 67%a 60% 53% 53% 53% 0% 20% 40% 60% 80% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

a Significantly different from March 2005 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96- 0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey: Tennessee Hospitals Hospital Handoffs & Transitions

49% 52% 48% 48% 48% 48% 0% 20% 40% 60% March 2005 April 2006 December 2006

Survey Date

TN Hospitals AHRQ Benchmark

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96- 0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

AHRQ Culture Survey Tennessee Hospitals Comparison of Composite Scores for 12 AHRQ Dimensions DIMENSION March 2005 Dec 2006 AHRQ Benchmark Overall Perceptions of Safety 56% 69% * 56% Frequency of Events Reported 51% 69% * 52% Supervisor/Manager Expectations & Actions Promoting Patient Safety 72% 80% * 71% Organizational Learning, Continuous Improvement 76% 77% 71% Teamwork Within Areas 68% 83% * 74% Communication Openness 50% 67% * 61% Feedback & Communication about Error 53% 68%* 52% Non-punitive Response to Error 35% 50%* 43% Staffing 46% 52% * 50% Hospital Management Support for Patient Safety 72% 78% * 60% Teamwork Across Hospital Areas 60% 64% 53% Hospital Handoffs & Transitions 48% 49% 48%

* Significantly different from March 2005 survey

Source: AHRQ Benchmark, Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westa under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Resea and Quality. September 2004.

Muskie School of Public Service Institute for Health Policy

• Rewards and Recognition Program
• Administrative Rounds
• Leadership Walk-arounds
• Employee Forums
• Staff Education
• Customer Service – combining departments to work together
• Reporting System Taskforce
• Patient Safety standing agenda item on administrative meetings
• New Event Reporting Form and database
• Online reporting system
• Regular data and feedback to staff and administrators about progress
• Established Medical Safety Committee
• Policy reviews – review of patient safety plan & risk management plan
• Changed staff orientation

Actions taken to address culture

Muskie School of Public Service Institute for Health Policy

• Eventline – 311
• Thank you notes to those who report
• New Medication Management forms
• “Hand-off” review – communication during shift

changes, transfers – institute a SBAR process (shared mental model for information transfer – situation, background, assessment, recommendation)

• Suggestion boxes
• Patient Safety video shown to staff, discussion
• f incident reporting

Muskie School of Public Service Institute for Health Policy

The PDA Intervention Goal: Implement 100% use of PDA (personal digital assistant) devices by prescribers. Rationale: Essential drug information should be readily available in useful form and considered when ordering, dispensing, and administering medications. Access to computerized drug information systems should include current protocols, guidelines, dosing scales and checklists for high-alert drugs, and information about herbal and alternative medicines.

“Inadequate drug information, such as outdated or limited references, is one of the most common causes of medication errors, with 35% of preventable adverse drug events caused by lack of drug information, according to one study. More than half of these events occurred because of a lack of drug information at the time of prescribing.”

Jenkins RH, Vaida, AJ. Simple Strategies to Avoid Medication Errors. Family Practice Management. Feb 2007; 41-47.

Muskie School of Public Service Institute for Health Policy

Intervention Process

• Selection of PDA device (Palm) & software vendor (Epocrates)

(2005)

• “Talking Points” flyer distribution (Late 2005)
• Train-the-trainer session (University of New England) (Feb 2006)
• Site trainings, contracts (ETSU, THA, Hospital reps) (Mar-Apr 2006)
• On-site follow-up (ETSU, Hospital reps) (Apr – May 2006)
• Technical Assistance (THA, ETSU) (ongoing)
• PDA Users Survey (July-Aug 2006)
• Survey analysis and report (Sept 2006)
• Lessons learned

Muskie School of Public Service Institute for Health Policy

PDA Users Survey – Summer 2006

• Post-training 5 to 6 months
• 122 surveys distributed – 117 returned – 96% return rate!
• Survey process tightly controlled, individual tracking, expectation

set through initial contract with recipients.

• Survey very slightly adapted from Rothschild online survey of 3000

Epocrates users in the year 2000 (paper published in 2002)*

*Rothschild, J.M., Lee, T.H., Bae, T., & Bates, D.W. (2002). Clinician Use of a Palmtop Drug Reference Guide. Journal

• f American Medical Informatics Association, 9 (3): 223-229.

Muskie School of Public Service Institute for Health Policy

The survey addressed four major areas: 1) Providers’ experience with and use of Epocrates Rx

• and the impact of Epocrates Rx on

2) Provider behavior 3) Practice efficiency 4) Patient care

Muskie School of Public Service Institute for Health Policy

Experience and Use of Epocrates

• Majority (71%) reported NOT using PDA prior to

project period.

• Half now report using Epocrates at least twice a

day.

• Significant behavior change in clinical

information seeking

Muskie School of Public Service Institute for Health Policy

• 95% reported reduced use of prior sources of information
• Information found more quickly – over 80% said that it took

them a minute or less to find what they are looking for with Epocrates.

25 17 4 1 2 56 6 1 12 25 28 34 25 50 75 <5 sec 5-10 sec 10-20 sec 20-60 sec 1-5 min >5 min Time Taken to Look Up Number of Survey Respondents Traditional ePocrates

Muskie School of Public Service Institute for Health Policy

Impact on knowledge and clinical behavior

• 90% felt that Epocrates answered all their

questions at least ¾ of the time

• Increased drug knowledge base (83%)
• Contributed to improved drug-related

decisions (89%)

• Affected clinical decisions at least
• nce per week (75%)

Muskie School of Public Service Institute for Health Policy

Impact on Practice Efficiency

• Improved outpatient (87%) and inpatient (81%)

efficiency

• 44% reported saving at least one minute per

patient encounter

Muskie School of Public Service Institute for Health Policy

Impact on Patient Care

• Better able to inform patients (93%)
• Patients more satisfied with care (66%)
• 65% providers stated that Epocrates prevented

at least on Adverse Drug Event per week.

• 9 out of 10 providers expected to increasingly

incorporate Epocrates into their practice workflow.

Muskie School of Public Service Institute for Health Policy

ER Protocol Intervention

• Hospitals shared current protocols with QIO who produced a CD compilation
• Each hospital worked with their own teams to decide which protocols to adopt,

adapt, approve, implement.

• Some physician resistance to protocols still exists at some locations.
• Coordination with hospital system protocols, transfer hospitals takes significant

energy and “buy-in”

• Once protocols are approved, an on-going update process should be established.
• Substantial benefit in standardizing treatment regardless of shift and reducing staff

variances, patient flow, hand-offs and transfers.

• Issues/barriers
• Resistance to change
• Infrequency of clinical event → forgotten protocol
• Nurses varied in acceptance – particularly with nurse initiated protocols
• ER staff “champion” helps with process and implementation

Muskie School of Public Service Institute for Health Policy

Three pronged approach

Looking Back at the Three Interventions

• Culture survey stimulated environment for patient safety
• PDA led to observable tangible benefits
• ER protocols are a long-term investment in patient safety and quality

improvement and collaborative process (at site, project hospitals and partners, hospital systems, and transfer hospitals.

Muskie School of Public Service Institute for Health Policy

Final Lessons Learned

• Financial support of BCBS/THA enabled collaborative activities

and technical assistance

• Process structure, transparent action steps, and attention to timeline key to success
• Working group large enough to gain economy of scale, yet small enough

to work productively together

• Small rural hospitals can produce change in short periods of time.

Muskie School of Public Service Institute for Health Policy

Contact Information (Research Team)

Judy Tupper, Project Director Muskie School of Public Service University of Southern Maine jtupper@usm.maine.edu (207) 228-8407 Andy Coburn, PhD Muskie School of Public Service University of Southern Maine andyc@usm.maine.edu (207) 780-4435 Ira Moscovice, PhD University of Minnesota mosco001@maroon.tc.umn.edu (612) 624-8618 Jill Klingner, PhD University of Minnesota klin0089@d.umn.edu Mary Wakefield, RN, PhD University of North Dakota mwake@medicine.nodak.edu (701) 777-3848