New Year, Renewed Focus

The Indiana Patient Safety Center kicks off 2017 with new initiatives, new partnerships and new staff

Reducing all-cause harm. Reducing readmissions. Reducing infant mortality. These three goals remain at the heart of the work of the Indiana Patient Safety Center (IPSC), the quality and patient safety arm of the Indiana Hospital Association (IHA). They come together under IPSC’s bold aim: to make Indiana the safest place to receive health care in the U.S., if not the world.

They also are the focus of a number of initiatives IPSC will be leading in 2017. Through these initiatives and continued partnerships with the 11 regional patient safety coalitions and other stakeholders, IPSC strives to help hospitals improve quality, reduce harm, improve patient and family engagement and nurture leadership and culture.

“We couldn’t do what we do without strong partnerships,” said Karin Kennedy, IPSC’s administrative director. “It’s all about relationship-building and selling the value of working together to impact change.”

CONTINUING PAST SUCCESSES: THE HOSPITAL IMPROVEMENT INNOVATION NETWORK

A key focus of IPSC in 2017 will be continuing the past success of the work that began in 2012 under the Partnership for Patients campaign. IHA is partnering with the American Hospital Association’s Health Research and Educational Trust (AHA/HRET) on the Hospital Improvement Innovation Network (HIIN), which is expected to achieve hospital-level improvement by reducing all-cause harm by 20 percent and readmissions by 12 percent by 2019. IHA will lead AHA/HRET HIIN efforts in Indiana and provide education and assistance to hospitals statewide.

Hospitals participating in the AHA/HRET HIIN will receive access to technical assistance, educational opportunities, training, resources and learning collaboratives in the following target areas:

  • Adverse drug events (ADEs)
  • Airway safety
  • Catheter-associated urinary tract infections (CAUTIs)
  • Central line-associated bloodstream infections (CLABSIs)
  • Clostridium difficile infections
  • Culture of safety
  • Diagnostic errors
  • Health care disparities
  • Iatrogenic delirium
  • Injuries from falls and immobility
  • Malnutrition in the inpatient setting
  • Multidrug-resistant organisms
  • Patient and family engagement
  • Pressure ulcers
  • Radiation exposure
  • Readmissions
  • Sepsis
  • Surgical site infections (SSIs)
  • Venous thromboembolisms (VTEs)
  • Ventilator-associated events (VAEs)
  • Worker safety

From 2012 to 2014, more than 4,690 harms were prevented by Indiana hospitals participating in the Partnership for Patients Hospital Engagement Network, resulting in an estimated $22.3 million in health care cost savings. This included a total of 1,254 unnecessary readmissions with a cost savings of $11 million. This work continued under HEN 2.0, through which Indiana hospitals prevented 3,751 harms with associated cost savings of more than $32 million.

“Indiana hospitals have been true leaders in the work to improve quality and patient safety,” Kennedy said. “The team spirit in Indiana has been a huge part of our success. Indiana had the third-highest number of participating hospitals in the AHA/HRET HEN 2.0, and we’re seeing similar participation levels in the AHA/HRET HIIN. There is a sense of community and collaboration among Indiana hospitals and a real desire to improve outcomes for our patients.”

SIMPLIFYING SAFETY: THE UP CAMPAIGN

As improving quality and patient safety continues to remain a top priority for hospitals and health care systems, there are a growing number of resources and approaches to help guide them in their efforts. The sheer volume of these resources can be overwhelming, however, and clinicians and staff often find it difficult to prioritize and execute interventions. That’s why AHA/HRET developed the UP Campaign.

The UP Campaign aims to simplify safe care and streamline interventions, reduce multiple forms of harm with easy-to-accomplish activities and consolidate basic interventions that cut across several topics to decrease harm. It is made up of the following three components:

  • WAKE-UP: Reducing unnecessary sleepiness and sedation
  • GET-UP: Mobilizing patients to return to function more quickly
  • SOAP-UP: Implementing appropriate hand hygiene to reduce the spread of infection

“When we were working on HEN 2.0, we started to see that mobility was falling to the wayside,” said Jackie Conrad, RN, improvement advisor with Cynosure Health, who helped develop the UP Campaign. “In our efforts to reduce falls, we were keeping patients in their beds and actually creating an increased risk for falls due to the weakness and deconditioning that occurs with immobility. However, if we get patients up and moving, we can impact falls and so many other harms, including pressure ulcers, VTEs and CAUTIs. We realized we needed to create some alignment for our hospitals so they can move out of their silos and work together to reduce patient harm.”

The UP Campaign also aims to help hospitals reevaluate their quality improvement structure. Instead of having 10 different patient safety teams focused on 10 different patient harms, for example, a hospital could have three teams that focus on cross-cutting strategies.

“You could take your falls team and reinvent it as a mobility team,” Conrad said.

IHA is partnering with AHA/HRET on the UP Campaign. Each of the three components will be a key focus area during Patient Safety Awareness Week (see “Spreading the Word: Patient Safety Awareness Week” below).

“We understand that Indiana hospitals need simple, understandable guidance to improve patient safety in their facilities, and the UP Campaign can help provide that,” said Annette Handy, RN, IPSC clinical director. “For example, by emphasizing the need for appropriate hand hygiene through the UP Campaign and providing clear guidance through such resources as those available from the Association for Professionals in Infection Control and Epidemiology, we can prevent the spread of disease and keep patients safe from harm.”

SHARING EXPERIENCES: THE MHA KEYSTONE CENTER PSO

As of Jan. 1, hospitals with more than 50 beds must be enrolled in a patient safety organization or have a similar evidence-based health care improvement system in place in order to meet Centers for Medicare & Medicaid Services requirements. To help Indiana hospitals meet these new requirements, IHA is partnering with the Michigan Health & Hospital Association to encourage participation in the MHA Keystone Center PSO.

The MHA Keystone Center PSO was established in 2009. In the last eight years, it has successfully developed educational opportunities, initiated safety improvements and offered data collection and analysis tools to more than 100 hospitals and health care systems across Michigan. Indiana hospitals that wish to join the MHA Keystone Center PSO in 2017 will receive all the benefits and services that participating Michigan hospitals do, including access to data analytics services, protected collaboration and shared learning through local safe table meetings, a biennial integrated culture and employee engagement survey administration, root cause analysis review and feedback, and access to patient safety toolkits, education and training.

The MHA Keystone Center PSO uses a three-pronged approach to improving patient safety: education on legal protections, data analysis and learning opportunities. PSO members voluntarily report patient safety events for analysis, and trends from this data are used to develop future learning opportunities and guide improvement efforts.

“Participating in the MHA Keystone Center PSO offers a number of benefits to our hospitals, but the greatest might be the opportunity to share experiences and learn from one another in a protected environment,” Kennedy said. “The MHA Keystone Center PSO brings patient safety professionals together to speak candidly about adverse events that have occurred in their facilities. The insights gained from this experience can’t be overstated.”

FIGHTING INFANT MORTALITY: THE SAFETY PIN GRANT

Reducing infant mortality is a major priority for Indiana’s hospitals. Indiana ranks 43rd in the nation in infant mortality, and sudden unexplained infant deaths (SUIDs) accounted for 14.4 percent of these deaths in 2014. The majority of the SUID deaths were due to sudden infant death syndrome (SIDS) or accidental suffocation/strangulation in bed.

“Infant deaths due to unsafe sleep practices are 100 percent preventable,” Handy said. “We noticed there are many inconsistencies in how Indiana hospitals are approaching families and educating them on safe sleep practices. Hospitals are well-positioned to standardize their messaging and help reduce accidental suffocation deaths.”

In December, the Indiana State Department of Health awarded IHA a grant through the Safety PIN (Protecting Indiana’s Newborns) program. Through this opportunity, IHA will develop a statewide strategy to implement the hospital safe sleep practices approved last year by the Indiana Perinatal Quality Improvement Collaborative (IPQIC) Governing Council and the IHA Council on Quality and Patient Safety. These practices include safe sleep policy adoption, staff development to model safe sleep practices with consistent messaging, staff practice compliance audits, awareness of local safe sleep distribution sites and the Cribs for Kids® National Hospital Certification Program.

“Educating families on safe sleep practices is essential, but we also need to educate hospital staff,” Handy said. “Are we using the recommended safe sleep practices ourselves while patients are in our care?”

The Safety PIN project will be rolled out regionally, starting with the northwest Indiana region and a select cohort from one of central Indiana’s health care systems. It will then expand to the north central and northeast regions. Lessons learned from this initial phase will help as IHA expands the project across the rest of the state. Throughout the four years of the grant, IHA will continue to strengthen collective efforts and work with state and local partners to support all hospitals in the adoption of hospital safe sleep practices and work toward a state reduction in infant mortality.

“The northwest region already has an infant safety workgroup within its patient safety coalition, so we knew this would be a great area to start with,” Handy said. “We hope our efforts through the Safety PIN grant will complement the progress these hospitals already are making, so that together, we will influence a reduction in the statewide infant mortality rate.”

MOVING FORWARD: WHAT’S ON THE HORIZON

IPSC’s work will continue to evolve and expand in the coming years. Future plans include developing a mentoring program that makes connections and builds partnerships. IPSC also hopes to provide customized approaches to IHA members to help them achieve their patient safety goals.

“We want to be able to work with an individual hospital and ask, ‘What are your specific needs, and how can we help you meet them?’” Kennedy said.

Much of IPSC’s focus will remain on working with leadership to help hospitals develop a culture of safety. In the end, Handy notes, it all comes down to ensuring anyone seeking care in an Indiana hospital will get the best care possible.

“We’re going to continue to work at the local, regional and state level to bring together anyone who is working to influence and improve patient safety,” she said. “This will help us build better partnerships, provide better care and ultimately be a better state.”


SPREADING THE WORD: PATIENT SAFETY AWARENESS WEEK

Patient Safety Awareness Week is coming up March 12-18, and we need your assistance in spreading the word. Led by the National Patient Safety Foundation, Patient Safety Awareness Week promotes safe health care practices among health professionals and the public. IHA has created a toolkit to help hospitals promote Patient Safety Awareness Week through their social media channels, focusing on the following topics each day:

Sunday, March 12:
Opioid Awareness

Monday, March 13:
Wake Up: Know Your Meds

Tuesday, March 14:
Get Up: Falls Prevention

Wednesday, March 15:
Soap Up: Hand Hygiene

Thursday, March 16:
Safe Antibiotic Usage

Friday, March 17:
Could it be Sepsis?

Saturday, March 18:
Safe Infant Sleep Practices

Get creative! We encourage you to come up with your own messaging highlighting how your hospital is improving patient safety and protecting patients from harm.

For more information, contact Julie Brackemyre, IHA communications specialist, at jbrackemyre@IHAconnect.org.


MEET THE IPSC TEAM

The members of the IPSC team look forward to helping your hospital meet its patient safety goals. For more information on how your facility can get involved with IPSC’s current initiatives, please feel free to contact any team member listed.

Karin Kennedy
Administrative Director
317-423-7737 • kkennedy@IHAconnect.org
As administrative director, Karin oversees IPSC operations. She serves as the staff liaison for the IHA Council on Quality and Patient Safety with Annette Handy and works closely with a number of organizations outside of IHA, including the Indiana Association for Healthcare Quality and the Indiana Quality Improvement Network – Quality Improvement Organization.

Annette Handy, RN
Clinical Director
317-423-7795 • ahandy@IHAconnect.org
A registered nurse with more than 28 years of experience in acute care and community health settings, Annette leads IPSC’s clinical activities. She serves as the staff liaison for the IHA Council on Quality and Patient Safety with Karin Kennedy and is the co-chair of IPQIC’s Quality Improvement Committee.

Becky Hancock, RN
Patient Safety and Quality Advisor
317-423-7799 • rhancock@IHAconnect.org
From staff nurse to quality and performance improvement data analyst, Becky has served in a number of roles at Indiana hospitals and is one of the newest members of the IPSC team. She is a certified clinical research coordinator and is working toward her Ph.D. in nursing.

Madeline Wilson, RN
Patient Safety and Quality Advisor
317-974-1407 • mwilson@IHAconnect.org
One of the newest members of the IPSC team, Madeline is a registered nurse who has served Indiana hospitals for more than 30 years. As patient safety and quality advisor, she supports hospitals as they work to meet their quality and patient safety goals.

Cynthia Roush
Patient Safety Support Specialist
317-423-7798 • croush@IHAconnect.org
Cynthia joined the IPSC team in June 2016 and assists with the AHA/HRET Hospital Improvement Innovation Network efforts. She has extensive communications, marketing and legislative experience.