Webinar Recordings Available from Patient Safety Awareness Week

HQI and CHPSO kicked off Patient Safety Awareness Week with a presentation on the development of a Virtual Nursing (RN) program. This program, designed to support Kaiser Permanente patients in Northern California, began in 2014 with the implementation of eHospital, a virtual surveillance model, featuring real-time monitoring and identification of care delivery gaps.

The Virtual Quality Nursing Team has subsequently grown in support of other virtual programs aimed at improving safety. Examples include Advance Alert Monitor (AAM), implemented in 2016 in partnership with the Kaiser Permanente Northern California Division of Research. Utilizing a predictive analytic model, the program allows for surveillance of at-risk patients.

This predictive model proactively identifies adult ward and transitional care patients with considerable risk of mortality or up-transfer to the Intensive Care Unit (ICU), and it is used to coordinate early rescue. AAM uses multiple factors, including chemistry, hematologic, respiratory values and vital signs to predict early detection of impending deterioration for inpatient adults.

This tool gives clinicians a 12-hour lead time. Along with early rescue it enhances patient safety, quality, and experience outcomes with timely involvement of supportive care services, including social work and palliative care consults. Thoughtful conversations earlier in a patient’s disease trajectory and admission can promote understanding of one’s illness and clarify their care directive.

Each of the Virtual AAM RNs is responsible for five hospitals. These RNs all have a critical care background, an advanced degree, and must live within an hour of at least one of their assigned facilities. The program employs a standardized process and timeline for alert response. When an AAM Alert fires, the Virtual AAM RN has one hour to review the chart and call the local Rapid Response Team (RRT) nurse. Within three hours, the local RRT talks with the primary RN, re-evaluates the patient’s vital signs, and contacts the primary physician with a structured report (SBAR format). Within six hours, the physicianwill perform an evaluation, make diagnoses, and communicate with the care team regarding the plan.

The Virtual Quality Nursing Team program has been extremely successful in mitigating patient risk and preventing harm. The preliminary results (as of June 2018) showed that the program had saved 169 lives. The team shared with the audience during the webinar that the success has continued, and they look forward to sharing more current data soon. The next steps for this team are to build additional predictive models to expand the populations of patients served, make refinements to the dashboards, improve the integration into the medical record. The team is also working on expanding the program to their Southern California locations.

From 2006-2009, Enloe Medical Center was in crisis. With low physician engagement (44th percentile), poor patient experience (2nd percentile) and three immediate jeopardy incidents, Enloe needed to right itself. In 2009, the first Quality Summit was held. Designed to engage and empower, it established a culture of transparency and accountability. The results are shared online and in hospital corridors.

The Quality Summit was validated in a peer-reviewed journal and by leading organizations. From 10 Quality Summits have come 37 organizational quality initiatives, 504 staff-created quality improvement poster projects, sustainable quality improvements across multiple specialties, high physician engagement (85th percentile), external agency quality recognition and Planetree Gold Certification. The Quality Summit galvanized Enloe around quality and it can do the same for other organizations.

During the webinar, Dr. Marcia Nelson shared helpful insights into the development of the program and the elements that have helped sustain it over the years. The Summit is much more than one-day event, it is an ongoing, continuous process that makes quality improvement part of the daily focus. This is accomplished with three strategies:

Physician Culture of Leadership

• Ask physicians for leadership, don’t tell them what to do
• Create a unified quality committee

Everyone Owns Quality

• “Quality” isn’t just another department of the hospital
• Live stream IHI National Forum
• Posters created by units throughout the organization reinforce ownership and accountability
• Promote participation: MEC, medical director meetings, department leadership meetings and weekly senior leadership phone messages

Transparency Around Outcomes

• The path to improvement starts with something that needs to get better
• Report to Board of Trustees
• Publicly display posters
• Share Quality Summit Annual Report online, with community and new recruits

From their journey they learned seven key lessons:

• Trust each other
• Engage physicians
• Don’t over commit
• Stay on track
• Look ahead and back
• Make it easy
• Celebrate and share

For example, the team learned not to take on more than they could accomplish at one time. They also shared that, for a program such as this to be successful, they needed to make it easy for the physicians to engage. They made certain that the physicians understood that the commitment to the quality improvement program was not going to add a great deal to their weekly workload. They also made the development of the posters simple and streamlined with a template and print support available.

For the third webinar offering , the Sutter Health team shared its Enhanced Recovery after Surgery (ERAS) program. With the impressive outcome measures a very successful colorectal pilot was initiated in 2015, followed by similar success with their OB ERAS implementation in 2018. Sutter Health has now extended ERAS to general, gynecological, bariatric surgery and anesthesia and plans to extend ERAS to all applicable surgical specialties. During the webinar, the team shared its ERAS implementation journey and discussed how the program successfully impacted three key pillars of Sutter Health:  Patient safety, quality improvement and patient experience.

The primary goals of ERAS are to reduce complications, decrease length of hospital stay, promote an earlier return to daily activities, increase patient satisfaction, and decrease opioid use. Among other outcomes of the program, the team shared that more than 20% of the patients on this ERAS pathway do not received any opioids at all. The team also shared a story from a patient undergoing an elective, repeat cesarean birth. This new mom was thrilled with her experience and told the staff that she had significantly less pain, was up and moving much sooner, and that breastfeeding her newborn was much more successful that in her prior experiences.

The implementation of OB ERAS at Sutter Health required support from several stakeholder groups including OB physicians and electronic health record subject matter experts. Strong partnerships between Information Systems and Office of Patient Experience, OB/GYN Sutter Health Women’s Affiliated Group Clinical Improvement Community, and ERAS Champions at each affiliate were also critical to the success of the program.

The Sutter Health team also shared some of the barriers to success and lessons learned. The team relayed that earlier engagement with anesthesia departments would have been beneficial to the program. Some of the biggest clinical hurdles included NPO after midnight vs. just eight hours without food before surgery, the timing and administration of clear liquids, nurses getting used to the new medication orders, and communication between the surgeons and the anesthesiologists.

The vast majority of clinicians, health care workers, and organizations deeply and sincerely want to provide high quality and safe care to all their patients. Yet there has been little progress in the last two decades to address the pervasive racial and ethnic disparities that exist in health care quality and outcomes. This webinar focused on the often overlooked factors that may be at the root of our lack of progress – conscious and unconscious biases. Social biases are key to how we, as humans, think about and respond to each other and our world.  The webinar covered specific strategies for individuals that can help them mitigate the negative effects of unconscious biases, as well as steps leaders can take to create inclusive and equitable climate in organizations.

Your hospital’s infection/readmission/mortality rate is 50% above the comparison rate. How concerned should you be? It helps to understand the difference between relative and absolute effects before rushing to judgment, and worse, unnecessary action. Knowing when to respond can mean the difference between effective time management and data analysis or wasting time and valuable resources. This webinar will help you differentiate between large relative effects that may not be worthy of immediate action vs. smaller absolute effects that may require your immediate attention.