Download Document

Patient Safety
March 5, 2013
Cumberland (GA) ID/Oncology
March 5, 2013
Our Team
Name
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
MDs
Lingam, Harvey Hamrick
Linda Turner, Gwendolyn
Brown, Janine Feliciano
RNs
Darlene Cokley, Julia Siler
MAs
Bianca Cooper
PA
Cumberland ID/Oncology
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
Start
Patient Registers/
Checks In
RN/LPN/MA Reviews
Medication List with
Patient
RN/LPN/MA Updates
List in KPHC via
marking ‘Taking’ or
“Not Taking’
MD Reviews List in
KPHC with Patient
MD Reconciles List in
KPHC
MD/RN/MA Reviews
AVS with Patient
Exit Workflow
Process Map - AFTER
LPN/MA calls patient
to bring in Medication
Bottles to Office Visit
Patient Registers/
Checks In
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
RN/LPN/MA Updates
List in KPHC via
marking ‘Taking’ or
“Not Taking’
LPN/MA gives NP/MD
List of Duplicate
Medications
MD/NP Reviews AVS
with Patient
Exit Workflow
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 Team
March 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
Use tags to identify disinfected
scopes
X
The nurse will remove the tag for
the doctor
Reminder cards on computers to
look for blue tags on scopes
Adapt
Abandon
Adjustment Did not work
X
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 here
From 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
[email protected]
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-savingteams
• 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