Next-Gen Patient Safety with Active Surveillance
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Eliminating avoidable harm is a problem that we can and should solve. The journey to become highly reliable at producing meaningful and sustainable outcomes improvements requires organizations to maximize their investments in safety. Safety improvements are the result of people, and process changes with data-driven insights as the underlying secret ingredient, but most PSOs are missing this tight integration between the three. Does your PSO? View this webinar announcing the next generation Health Catalyst Patient Safety Organization (HC PSO) and learn why coupling it with the Health Catalyst Patient Safety Monitor™ Suite—built by patient safety experts for patient safety experts—is such an important differentiator. Leading in this product announcement are two experts in patient safety, Michael Barton and Elaine St. James. In this webinar they share the following: - Importance of active safety surveillance and analysis to discover safety vulnerabilities that are often overlooked. - Operational efficiency and organizational risk avoidance available by hosting together the safety analytics and HC PSO. - Effective safety governance and application of safety best practices that will improve outcomes in a measurable, and sustainable way. - Integration of analytics, and benchmarking from a health care Data Operating System (DOS). Implementation of an active trigger surveillance tool into your existing system is just one step on your safety journey. Eliminating preventable harm requires commitment to change, organizational buy-in and a number of key components that will be discussed in this webinar. We hope that you will view the webinar.
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Next-Gen Patient Safety with Active Surveillance
- 1. Introducing the Next-Gen Patient Safety Organization Michael Barton, PharmD SVP, Patient Safety Operations, Health Catalyst Elaine St. James, RN VP, Patient Safety Services, Health Catalyst
- 2. • Understand common Patient Safety Organization (PSO) related terminology. • Learn why PSO participation matters. • Evaluate ongoing challenges that PSO participation may not solve unless you pick the right partner. • Gain an understanding of why active safety surveillance for all-cause harm is essential to a complete safety system. • Discover the advantages of housing your all- cause harm surveillance system and your PSO together. • Learn key criteria for selecting your PSO partner. Learning Objectives
- 3. © 2018 Health Catalyst Our Goal: Create a Data-Driven Culture of Safety To truly improve patient safety, healthcare systems must cultivate a culture of safety and become high reliability organizations. 3
- 4. © 2018 Health Catalyst 4 EDW Data 71 yr male 410 North 62 inches 51 kg Hospital day 2 ACS with r/o MI IDDM Glucose 38 mg/dL Hga1c 8.7% Scr 7.61 mg/dL Femoral hematoma Insulin Celecoxib Losartan Furosemide Iodixanol DOS™ Elderly male with diabetes and coronary artery disease who has developed a femoral hematoma post coronary angiography and has experienced hypoglycemia and decreased renal function since admission. Create information through advanced analytics 1. Glucose <=40 2. Hematoma following surgery or procedure 3. Creatinine >= 3*baseline 4. Nephrotoxic medication exposure Positive Triggers Actionable Knowledge 1. Medication-related hypoglycemia, Severity F 2. Procedure-related bleeding event, Severity F 3. Contrast-induced Acute Kidney Injury, Severity G 4. Medication-induced Acute Kidney Injury, Severity G Clinician Confirmed Events (RCA) 1. Medication Safety 2. Procedure Safety (PCI related AEs) 3. Use Patient Safety Monitor to track AE improvements Learning & Improvement Patient Safety Monitor™ Suite
- 5. © 2018 Health Catalyst Active Surveillance for All-cause Harm Patient Safety Monitor™- Literature-based trigger libraries 5 Patient Care e.g. Return to surgery, post- op MI Surgical e.g. Patient fall, intubation, ICU readmit e.g. Positive blood/urine culture, MRSA Hospital Acquired Infection e.g. Morphine milligram equivalents Pain Management e.g. Digoxin or Naloxone administration Medication Reversal e.g. Possible acute kidney injury Renal Injury e.g. Decrease in hemoglobin, PTT Coagulation e.g. Glucose levels, administration of glucagon Glycemic Management e.g. Total bilirubin, elevated drug levels, infiltrations Pediatric e.g. Pre-term birth, delivery method Perinatal e.g. Unplanned readmission, ER after hospital stay Readmission
- 6. © 2018 Health Catalyst Patient Safety Organization Terminology 6 • Patient Safety and Quality Improvement Act of 2005 (PSQIA) – Established a system of patient safety organizations and a national patient safety database. To encourage reporting and broad discussion of adverse events, near misses, and dangerous conditions, it also established privilege and confidentiality protections for Patient Safety Work Product (as defined in the act). • Patient Safety Organization (PSO) – An organization that is certified as a protected space for patient safety work and improvement. • Final Patient Safety Rule of 2008 – Defines the required framework for PSOs and their handling of PSWP. • Patient Safety Work Product (PSWP) – The information protected by the privilege and confidentiality protections of the PSQIA (2005) and the Final Safety Rule (2008). • Patient Safety Evaluation System (PSES) – The tools and processes used within a PSO to find and improve safety vulnerabilities. • Patient Safety Worker – One that has been specifically trained to work within a PSO.
- 7. © 2018 Health Catalyst • AHRQ-sanctioned, ‘legally protected’ space to conduct patient safety activities like: • Learn • Adopt best practices • Improve safety culture • Improve patient outcomes • ‘Legally protected’ means that the PSO patient safety data and deliberations may not be subpoenaed or used as evidence in a lawsuit*. • Health Catalyst PSO (HC PSO) provides protection to data within the Patient Safety Monitor™ Suite and any derivative patient safety work product. 7 Federally-Listed PSO Health Catalyst Patient Safety Organization HCPSO #P0201 https://www.pso.ahrq.gov/listed What is a Patient Safety Organization (PSO)? * Protection has been successfully challenged in FL. Check with your house counsel on protection of PSWP in your state(s).
- 8. © 2018 Health Catalyst AHRQ Listed PSOs 84 AHRQ De-listed PSOs 83 National PSOs 47 Regional/State 37 Umbrella PSOs 39* Specialty PSOs 41* Example Specialties: Anesthesia, Blood transfusion, Breast CA, Dental, Dialysis, Emergency, Geriatrics, Home Health, Medications, Pediatric, Radiology, Rehabilitation, Surgery, Surgical Specialties, etc. PSO Facts 8 Based on https://www.pso.ahrq.gov/listed * 4 PSOs – unknown
- 9. © 2018 Health Catalyst Tell us about your organizational approach to patient safety organization participation: 1. We partner with a single, umbrella PSO — 7% 2. We partner with multiple PSOs, both umbrella and specialty PSO — 7% 3. We have formed our own PSO within our healthcare system — 18% 4. We have elected to not participate in a PSO, but may participate in a PSO in the future — 45% 5. I have no idea – “What’s a PSO anyway?” — 22% Poll Question #1 9
- 10. © 2018 Health Catalyst CMS PSO Reporting Requirements for 2017 Options for CMS participation Requirement details per CMS Implications Option 1 (A) Utilizes a patient safety evaluation system [for reporting to a PSO] as defined in 42 CFR 3.20. Your PSO partner helps you comply with the reporting requirements and ensures that your patient safety work product (PSWP) is protected from subpoena or legal discoverability*. Option 2 Implement a system to accomplish the same thing as Option 1, sans PSO. No PSO relationship = No protection from subpoena or legal discoverability*. For hospitals >50 beds 10 * Protection has been successfully challenged in FL. Check with your house counsel on protection of PSWP in your state(s).
- 12. © 2018 Health Catalyst A PSO must provide the following six patient safety activities: What Does a PSO Do? 12 Collect and analyze patient safety work product (PSWP) 1 2 3 4 5 6 Develop and share best practices Encourage culture of safety and providing of feedback to minimize patient risk Preserve confidentiality and security of PSWP Utilize qualified staff Improve patient safety and the quality of health care delivery
- 13. © 2018 Health Catalyst PSO/Patient Safety Ongoing Challenges 13 1. Complicated/Manual – Align many manual processes and policy with PSO reporting. 2. Limited New Insights – Into all-cause harm; do we have better understanding of hidden safety vulnerabilities? 3. Struggle for Meaningful/Sustainable Improvement – Do we have a real, side by side partner for safety outcomes improvement? We improve, move to the next focus area, and prior improvement moves back to the mean. 4. Senior/Safety Leadership Connection to Front Line – We have a PSO relationship, but our internal patient safety governance is still a struggle. 5. The “Safety Glass Ceiling” – We know it’s working for other hospitals and health systems but how do we make it work here?
- 14. © 2018 Health Catalyst Which safety challenge do you wish your PSO would address? 1. Complicated/Manual – Align many manual processes, reporting. — 16% 2. Limited New Insights – Need better understanding of hidden safety vulnerabilities. — 17% 3. Struggle for Meaningful/Sustainable Improvement — 41% 4. Senior/Safety Leadership Connection to Front Line – Governance and/or culture challenges. — 16% 5. The “Safety Glass Ceiling” – …but how do we make it work here? — 10% Poll Question #2 14
- 15. © 2018 Health Catalyst Catalyze High Reliability • For those wanting to maximize the value of their investment in the Patient Safety Monitor™ Suite by accelerating tool adoption and patient safety outcomes improvement. • Offers services focusing on 4 action steps for reducing all-cause patient harm. 15 1 Detect 2 Intervene 3 Learn 4 Prevent
- 16. © 2018 Health Catalyst 16 Legal protection/security for derivative patient safety learning Participation in single patient safety collaborative (starting 2019) Patient Safety Monitor ™ Suite deployment, trigger selection, configuration, and training Quarterly learning/governance visits: • On-site 2x yearly • Remote 2x yearly Twice monthly patient safety event reviews: findings, trends, etc. Sharing of best practices for product Patient safety governance coaching – best practices for safety governance Patient safety improvement coaching – improved outcomes, sustained, best practices Participation in an additional patient safety collaborative (starting 2020) Detect Prevent Intervene Prevent Learn HC PSO Membership and Services LearnLearnIntervene Learn
- 17. © 2018 Health Catalyst We Are All Affected 17 What do all of these stories have in common? They are not just consequences of medical care. They are people with a face and name. They are someone’s child, wife, or loved one. Whether you are the provider, the patient, or the loved one, patient harm affects you. Source: HC Patient Safety Monitor webinar 20180718
- 18. © 2018 Health Catalyst 18 We believe to get upstream of patient harm requires integration of analytics, best practice and adoption … We believe the solution is the Patient Safety Monitor™ Suite and Health Catalyst Patient Safety Organization Services. Detect Intervene Learn Prevent A Data-Driven Culture of Safety
- 19. Data Operating System (DOS) Analytic & Clinical Workflow Applications Professional Services NLPMachine Learning Patient Safety TRIGGERS use ML and NLP capabilities Patient Safety Application Suite* Data Warehouse Cloud-basedSource Connectors Reusable Data Content Terminology Services The Patient Safety clinical workflow application is built on the DOS platform 3 2 1 Executive Dashboard & Reporting (Leading Wisely) Improvement initiatives can be tracked in Leading Wisely dashboards Benchmarks (Touchstone) Outcomes publicly reported show how improvement efforts are moving the needle CLABSI ANALYTIC ACCELERATOR Clinical analytic accelerators (e.g., CLABSI prevention) can be used for deep-dive analysis) – also PSO- protected Patient safety EVENTS are analyzed by client experts and sent to HC PSO for analysis and improvement work EVENTS PSO events and work product are PROTECTED FROM LEGAL DISCOVERY HC Patient Safety and Improvement experts work with client teams for FOCUSED IMPROVEMENT efforts using 7-guiding question methodology The Patient Safety Application Suite provides: • Digital surveillance •Clinician communication •Early detection, intervention, & prevention Patient Safety Story: Vision of how it all works together 19
- 20. © 2018 Health Catalyst 20 • Align patient safety goals and trigger selection • Deploy application • Trigger implementation, reviewer training and support • Integrate surveillance findings with outcomes improvement structure and teams Patient Safety Monitor™ Suite + HC PSO Services Seamless Workflow
- 21. © 2018 Health Catalyst 21 Twice monthly surveillance review • Interventions made to prevent or mitigate harm • Documentation and data analysis • Identify improvement opportunities and handoff to team Quarterly patient safety leadership meeting • Integrate governance for outcomes improvement • Enable organizational learning • Safety culture growth Patient Safety Monitor™ Suite + HC PSO Services + Outcomes Improvement
- 22. © 2018 Health Catalyst Patient Safety Technology and Clinical Services partner at each step Patient Safety Monitor™ Suite + HC PSO 22 Safety culture Patient Safety Governance Services Collaborative learning Quarterly reviews Post-production twice monthly reviews Installation & validation; Weekly reviews New opportunities identified New triggers Clinician confirm trigger (actual harm event?) Analyze and trend Care delivery system improvements Trigger (suspected harm event)
- 23. © 2018 Health Catalyst 2019 Patient Safety Vision 23 Clinician Burnout High Reliability
- 24. © 2018 Health Catalyst Which description best captures your organization’s patient safety vision for 2019? 1. High reliability organization; Quest for Zero Harm — 35% 2. Decrease or avoid penalties for defective care (HAC, VBC, readmission) — 5% 3. The Joint Commission 2019 National Patient Safety Goal compliance — 7% 4. Culture of safety — 44% 5. Not sure; Not a priority — 9% Poll Question #3 24
- 25. © 2018 Health Catalyst Provides domain oversight within patient safety and recommended priorities. PATIENT SAFETY DOMAIN GUIDANCE TEAM Leads specific patient safety improvement discovery intervention design and implementation. Lead unit based change. PATIENT SAFETY IMPROVEMENT TEAM(S) Assigned specific discovery and intervention design work by the improvement team e.g. order set, new workflow. PATIENT SAFETY WORK GROUP(S) Provides overall governance, prioritization, and cultural change leadership for all patient safety improvement. PATIENT SAFETY IMPROVEMENT LEADERSHIP TEAM ENSURE THAT… • Governance and Teams are appropriately empowered to make decisions. • Patient Safety Improvement Teams are created based on organizational safety priorities. • Teams are cross discipline, permanent and include the right stakeholders. DATA GOVERNANCE TEAM Governance to maximize the value of data by improving data quality, utilization, and literacy. 25 Patient Safety Improvement Organizational Structure
- 26. © 2018 Health Catalyst 26 Implementing Governance for Outcomes Improvement Principles and steps for implementing governance that helps your organization achieve and sustain meaningful improvement. 7 Guiding Questions: A Framework for Outcomes Improvement Flexible methodology and practical advice to help teams solve problems in clinical, financial, and operational work processes. Healthcare Data Governance: Improving decisions from the boardroom to the bedside Insight and advice for implementing data governance to maximize the strategic value of data in your organization. Our Client Handbooks Support outcomes improvement
- 27. Holly Rimmasch Chief Clinical Officer Michael Barton Patient Safety Services Operations SVP Elaine St James Patient Safety Services VP Stan Pestotnik Product Development SVP David Grauer Health System Leadership SVP, Former IMC CEO Clara Pugsley Assistant General Counsel, Chief Compliance Officer Stephen Grossbart Quality & Safety Leadership SVP Kathy Merkley Outcomes Improvement SVP Kevin Scharnhorst Chief Security Officer Patient Safety Service Leaders 27
- 28. Membership Health Catalyst Patient Safety Monitor™ clients with HC PSO agreements in place. Purpose • Promote rapid learning about the underlying causes of all-cause harm and risks in the delivery of health care • By sharing findings and best practices • To improve patient outcomes and increase efficiencies in healthcare delivery HC PSO Collaborative Membership and Purpose © 2018 Health Catalyst Proprietary and Confidential
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- 30. © 2018 Health Catalyst PSO/Patient Safety Solutions Pain points with most PSOs Health Catalyst PSO difference Complicated manual data processing. Extracting, scrubbing, and uploading data for reporting is time-consuming. The link to a tool. Data flows seamlessly to HC PSO from the Patient Safety Monitor tool. Limited insight. Reporting past events won’t necessarily help you understand why they occurred or your risk for repeat harm. The power of the technology. The surveillance module helps detect, monitor, and prevent patient safety events—delivering insight into all-cause harm and safety vulnerabilities. Struggle for meaningful, sustained improvement. Gains are hard-won, and all too often you return to the mean when the focus shifts to another area for improvement. Partnership with experts. The HC PSO provides a side-by-side partner for safety improvement work, a colleague with deep experience to help you meet goals and build a culture for continual improvement. Safety leadership disconnected from the front line. You have a PSO relationship, but your internal patient safety governance is still a struggle. A structure to drive change. Expertise in governance helps organizations balance centralized and frontline accountabilities, involve the right people, and maintain disciplined focus on your goals. “Safety Glass Ceiling. ” You know it is working for other hospitals and health systems, but how do you make it work at your own? Access to peers. The HC PSO houses our learning collaborative, a forum to explore, share, and learn with organizations facing similar challenges and deriving novel solutions. 30
- 31. © 2018 Health Catalyst • Give some thought to where your organization fits on the culture of maturity model. • Take some time to ask colleagues from different roles where they think the organization fits. • If your organization administers the SAQ/SOPS, ask what the results were and what actions plans/interventions are in progress and how are we tracking. • Ask front line colleagues to identify the organizational safety goals; what their unit is doing to accomplish them; and how connected their daily work is to the goals. Next Steps to Take Action 31
- 32. Q&A
- 33. © 2018 Health Catalyst Gathering insight from clinical notes remains one of the areas of untapped healthcare intelligence with tremendous potential. But extracting that value is difficult. Still, a few organizations across the country are demonstrating success using advanced technology tied to intuitive processes and procedures. Leading one such organizational effort is Wendy Chapman, PhD, chair of the Department of Biomedical Informatics at the University of Utah. Wednesday, December 5 1:00-2:00 PM EST Learning Objectives: • Understand NLP, both its challenges, and potential to drive clinical insight using social determinants of health • Gain insight into the technology that makes NLP possible • Consider the future potential of NLP Tapping Into the Potential of Natural Language Processing in Healthcare 33 WENDY CHAPMAN, PHD Chair, Department of Biomedical Informatics, University of Utah School of Medicine Wendy Chapman earned her bachelor’s degree in Linguistics and her PhD in Medical Informatics from the University of Utah in 2000. She joined the Division of Biomedical Informatics at the University of California, San Diego in 2010. In 2013, Dr. Chapman became the chair of the University of Utah, Department of Biomedical Informatics.
- 34. Thank You!