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June 2017 Archive for High Reliability Healthcare

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Systemic solutions to analyze underlying causes of specific care breakdowns and improve overall quality.

Beyond the Study: A Q&A with Eisenberg Patient Safety and Quality Award Recipients: Part 2


Jun 29, 2017 | Comments (0) | 1409 Views

Baker_DavidBy David W. Baker, MD, MPH, FACP
Executive Vice President, Division of Health Care Quality Evaluation
Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety
The Joint Commission

 

 

ClancyCarolyn M. Clancy, MD
Deputy Under Secretary for Health for Organizational Excellence
Veterans Health Administration, U.S. Department of Veterans Affairs (VA)

 

 

This is the second post in a three-part series highlighting the quality improvement and patient safety achievements of this year’s John M. Eisenberg Patient Safety and Quality Award recipients, showcased in the July 2017 issue of The Joint Commission Journal on Quality and Patient Safety. This post examines the quality and patient safety efforts of Dr. Clancy, recognized in the award’s individual achievement category. 

Here are the highlights of a conversation between the Journal’s Editor-in-Chief Dr. David Baker and Dr. Carolyn Clancy.

Dr. Baker: The VA has enormous riches in its electronic health record (EHR) database. What plans do you have for developing its big-data role in evidence-based clinical decision making? 

Dr. Clancy: For nearly three decades, the VA has led the way with foundational contributions to the delivery of clinical care, including advanced EHR and performance measurement systems that have been integrated into alerts and clinical reminders. Without question, these advances have improved quality. In recent years, however, the limitations of these approaches, in terms of information overload and inefficiency, have become apparent.

The VA clearly recognizes that future improvements hinge upon advanced analytics to capitalize on the full value of our vast data systems in a manner that is seamlessly integrated into defined clinical workflows. To this end, we are working with partners such as Oakridge National Laboratory, Google and IBM Watson to construct analytic environments. These environments are capable of delivering critical information, including predictive analytics, to the point of clinical decision-making in a manner that is viewed by providers as both constructive and as “making it easy to make the right choice”. Although ambitious and challenging, we view these efforts as essential to the next quantum improvements in providing optimal care to both individual veterans and larger populations. 

Dr. Baker: In your interview in the Journal, you state “Patient empowerment is critical to quality”. The latest talk in this area concerns co-production, an approach that emphasizes the collaboration between care providers and patients, such as in the redesign of care. Is this an area of interest for the VA? 

Dr. Clancy: We are truly privileged at the VA to say that for decades we have been collaborating with veterans in the design of their care—from our 90-year-old research program where veteran volunteers participate in studies such as the Million Veteran Program, a voluntary research study on how genetics effect health—to our joint Department of Defense effort on clinical practice guidelines (CPGs) where veteran focus groups discuss topics such as the management of opioid therapy for chronic pain. More recently, we have been working with veterans regarding our new Access to Care website. 

Dr. Baker: What are your exact quality and safety priorities, as evaluated in terms of specific measures, for the next year or so?

Dr. Clancy: As noted by our new Access to Care website, we have already embarked upon a path toward greater transparency and accessibility by addressing: 

  • Access. We report on wait times by facility, patient-reported experiences regarding routine care and how often veterans received needed care right away. 
  • Quality. Our new website shows how each VA medical center performs compared with private sector counterparts in their market area. 
  • Patient safety. We continue to build upon a solid foundation that includes reporting (e.g. patient harms and near misses) and routine disclosure to veterans and their families when patients are harmed by care. 

In addition, we sponsor several extensive educational training programs which remain a key quality and safety focus for the VA, including:

  • The VA Chief Residents in Quality and Safety program, which trains approximately 60 chief residents yearly
  • A Quality Scholars program for physicians and nurse leaders
  • Clinical team training for groups of clinicians and allied health professionals

We take an enterprise approach to assessing risks at all stages of care so that we may detect potential vulnerabilities at the earliest stages. This approach takes into account:

  • Enterprise risk management 
  • Expressed concerns of leaders and frontline clinicians and staff
  • Regular review of findings from external entities such as The Joint Commission and other accreditors, the U.S. Government Accountability Office (GAO) and the U.S. Inspector General  

The Joint Commission Journal on Quality and Patient Safety provides open access to articles about the Eisenberg Award recipients in its July 2017 issue. 

Our next post in the series will publish next week, featuring more from the interview with Christiana Care Health System’s Carelink CareNow and its quality and patient safety priorities. 

Reporting Adverse Events: An Important Step Toward Establishing Learning Culture


Jun 26, 2017 | Comments (0) | 3282 Views

Nether_3-11By Klaus Nether,  D.H.Sc., MT (ASCP) SV, MMI, CSSMBB
Director, Solutions Development
Joint Commission Center for Transforming Healthcare

This is the fourth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic on safety culture.

For a culture to be truly safe, organizational leadership must establish, enforce and communicate policies for reporting adverse events, close calls and unsafe conditions.

Implementing these policies – from the board level to front-line staff – is an important step toward developing a “learning culture, and ultimately becoming a culture of safety. “When an adverse event is reported, a learning culture’s immediate response is not to assign blame, but to take the necessary steps to learn how the error happened and to prevent it from happening again.

Effective leaders see safety issues as problems with organizational systems, not their employees, and see adverse events as providing data for learning and systems improvement.

Tracking System for Reported Incidents
Citrus Valley Health Partners (CVHP) President/CEO Rob Curry offers his organization’s work as an example, CVHP, a family of four hospitals and a hospice in East San Gabriel Valley, CA, has a sophisticated tracking system for all reported incidents of actual and potential harm, as well as for concerns and general observations related to safety, Curry said. The incidents and concerns are shared throughout the organization, all the way up to CVHP board-level quality improvement committee.

The tracking system is reviewed daily for safety-related findings and situations that may need intervention. Solutions are discussed within departments and shared both verbally and in writing. “Our eyes are wide open, and there’s more willingness to stop the line as well as more adherence to safety protocols that are part of our policies,” Curry explained. “We’re focused on both the practice of the safety initiative and on our response in the reporting of anything that could be adverse, otherwise known as near-misses.”

Multi-Level Reporting
While nurses make up about half of CVHP’s workforce and thus make the predominant number of reports, Curry said physicians and other team members also have filed reports. “We have had environmental services employees report that a ‘wet floor’ sign was not put up,” he recalled.

The reports are discussed each month at CVHP’s leadership meeting, and each team leader takes them back to their respective departments so that “every worker gets that learning,” Curry explained. “I publish a weekly newsletter where the learning is also included, or a request to be more compliant about a problem is addressed. We believe that communication and openness is key, and use multiple platforms to ensure that message gets out.”

Constant Safety Culture Communication
“Our culture of being harm free is well understood and expected. Zero harm is our mantra,” Curry said.

CVHP’s risk management, compliance, performance excellence and performance improvement departments identify major opportunities for improvement that are distributed throughout the organization. “The day typically begins with a daily huddle, and safety issues are always addressed. We’re constantly reminding people to think about how we can stop harm from occurring and how we need to continue to report if harm occurs or if there are near misses. Everything is talked about in the huddle – it’s just another affirmation of the zero-harm culture we’re seeking.”

Stopping that harm is what we do every day at The Joint Commission’s Center for Transforming Healthcare. Learn more about our mission.

Beyond the Study: A Q&A with Eisenberg Patient Safety and Quality Award Recipients: Part 1


Jun 22, 2017 | Comments (0) | 1123 Views

Baker_DavidBy David W. Baker, MD, MPH, FACP
Executive Vice President, Division of Health Care Quality Evaluation
Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety
The Joint Commission 
 

 

ClancyCarolyn M. Clancy, MD
Deputy Under Secretary for Health for Organization Excellence
Veterans Health Administration, U.S. Department of Veterans Affairs (VA)
 

 

 

3136_022_CR2_detail_AndersonSharon Anderson, RN, BSN, MS, FACHE
Senior Vice President of Quality and Patient Safety
Chief Population Health Officer
Christiana Care Health System   

 


 
This is the first post in a three-part series highlighting the quality improvement and patient safety achievements of this year’s John M. Eisenberg Patient Safety and Quality Award recipients, showcased in the July 2017 issue of The Joint Commission Journal on Quality and Patient Safety. This post examines the efforts of two of the recipients to address quality and patient safety issues to advance on their journey to high reliability. 

Here are the highlights of a conversation between the Journal’s Editor-in-Chief Dr. David Baker and Eisenberg Award recipients: Dr. Carolyn Clancy of the U.S. Department of Veterans Affairs and Sharon Anderson, who represents Carelink CareNow, a technology-driven, care coordination program based in Wilmington, Delaware.

Dr. Baker: Quality and patient safety represent overlapping domains. How is this reflected in the way you organize and operationalize for quality and patient safety?

Dr. Clancy: We are building a standard structure for quality and safety governance in the Veterans Health Administration (VHA) with boards and committees at every level of the organization. This structure supports front-line improvement teams focusing on the quality of care in particular clinical service lines, facilitating the rapid sharing of best practices across the entire enterprise. 

Anderson: We have embedded quality and patient safety into Carelink CareNow’s operational foundation. An interdisciplinary team of quality- and patient safety-trained professionals support the constant measurement of clinical patient safety and quality measures that are specific to the population we serve. 

Based on the outcomes, identified opportunities are pursued using a rapid cycle, Plan-Do-Check-Act methodology. Of critical importance in this work is Carelink CareNow’s integration with providers. To support improvement in clinical outcomes and the patient experience, we recognize that the redesign of care delivery may be necessary. 

Dr. Baker: Incident reporting systems are known to be problematic. How do they fit into your own overall surveillance for possible patient safety issues?

Dr. Clancy: We use a standard patient safety incident reporting system, which captures both near-misses and adverse events across all of our hospitals. This same system is used by patient safety managers to conduct root-cause analyses for incidents of a certain severity level or higher. This is a useful tool to learn about trends and patterns in safety risks and vulnerabilities for patient harm. When connected to quality improvement efforts, outcomes for veterans can change for the better. 

Anderson: Through its IT integration and real-time feeds that work concurrently to mitigate possible patient harm, Carelink CareNow has a unique ability to recognize possible patient safety issues. When there is an identified issue, we work directly with health systems, providers and payers to investigate the issue, participate in root cause analyses, as necessary, and identify global patterns and trends that may place patients at risk across the continuum of care.

Dr. Baker: What is your strategy for providing high-value care—that is, reducing cost/utilization while maintaining or improving quality?

Dr. Clancy: Providing value-driven care for veterans is an organization-wide journey. VHA strives to integrate values-based decision making into daily activities, from decisions about the quality of clinical care delivery to veterans’ experience of care to resource allocation. Leading edge value-based metrics are used to help identify opportunities for ongoing improvement and consistent approaches are adopted for systems redesign and performance improvement. 

We also leverage other core dimensions of value through:

  • strengthening veterans’ experience of care
  • enhancing transparency and public reporting
  • rigorous internal research on comparative effectiveness and low-value processes
  • focusing on continuous learning
     

As with all health care organizations, the VA recognizes that high-value care is an evolving and ongoing commitment to the veterans we serve. At the end of the day, the most important dimension of value derives from veterans’ reported experiences, concerns and preferences. 

Anderson: Carelink CareNow focuses on improving clinical outcomes and patient experience while reducing cost and eliminating unnecessary utilization. Specifically, the program helps enable its populations to adhere to preventive screenings and to better mitigate risk factors that lead to chronic conditions, as well as the self-management of chronic diseases. We transition our patient populations to an overall more healthy state, which subsequently improves quality of care and helps patients achieve a better quality of life. 

Dr. Baker: What is the level of your organization’s interest or progress in aspiring to become a high reliability organization?

Dr. Clancy: The VA is highly interested in the topic of high reliability. The roots of high reliability in health care began with our National Center for Patient Safety (NCPS) and Dr. Jim Bagian, who lived the tenets of high reliability as an astronaut in NASA. To this day, the VA is a leader in high reliability efforts, advancing the fields and study of “just culture,” patient safety culture and crew resource management. We also are piloting a new quality governance framework in high reliability in two of our large service networks. 

Anderson: Christiana Care is on a journey to high reliability. Our organization is committed to achieving zero harm and embedding a strong safety culture throughout the entire health care system. We also aspire to use more Robust Process Improvement® (RPI®) processes to achieve better patient outcomes and decrease variations in care. 

The Joint Commission Journal on Quality and Patient Safety provides open access to articles about the Eisenberg Award recipients in its July 2017 issue. 

Our next post in the series will publish next week, featuring more from the interview with Dr. Clancy and her quality and patient safety priorities. 

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