moving the needle: ihi and anticoagulation safety and
TRANSCRIPT
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Moving the Needle: IHI and Anticoagulation Safety and
StewardshipPresenter:
Frank Federico, RPhInstitute for Healthcare Improvement
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Institute for Healthcare Improvement (IHI)
Our vision: Everyone has the best care and health possible.
Our mission: Improve health and health care worldwide.
Our Values
• Courage
• Love
• Equity
• Trust
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
How IHI Works
• Teach our improvement methods- IA program, PSE, Open School
• Convene like minded organizations to share and learn – “All teach, all learn”- Leadership Alliance, European Health Alliance, expert panels, National Forum, Campaigns
• Organize and support collaboratives focusing on difficult problems in health and health care – medication safety, patient safety, flow
• Provide coaching and support to organizations – consults, contracts, grants
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Theory of Change
• Every system is perfectly designed to get the results that it getsBatalden/Berwick
• All improvement requires change, but not all change is an improvement
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
6
In order to achieve this…
We need to ensure that…
Which requires…
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Improve Medication Safety by Decreasing Harm and Errors
AddressMedication Reconciliation
Engage all layers of the organization
Patient/Family/CaregiverEngagement
Use Systems Approach
Primary Drivers
High Risk Areas identified
Reporting Culture Cultivated
Safety Lessons Learned & Shared
Build Will
Get Results
Effective Communication and Collaboration
within/ between organizations
Secondary DriversOutcomes
Segment the population
Collect Ideas
Standardized Protocols and Algorithms
Measurement /Assessment of Processes
Health Literacy
Mechanism to Listen and Learn from
Patients/Families
Patient and Family Engagement & Education
Reduce Polypharmacy
Use improvement science
Aim:
By When:
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021Langley, et al, The Improvement Guide, 2009
Our RoadmapA Model for Learning and Change
When you combine
the 3 questions with the…
…the Model for Improvement.
PDSA cycle, you get…
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Three Types of Measures
Outcome Measures: Voice of the customer or patient. What is the result of interest?
Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?
Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, factors influencing outcome)
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Clarify “Where” To Spread
What is your level of our ambition?
• Every unit or ward in a hospital?
• Every service line (clinical & operations)?
• Every hospital in a system or region?
• All primary care clinics?
• All inpatient and outpatient mental health?
• All levels of care across a population?
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Some Thoughts on Spread
• Adopters may need to “reinvent” the interventions
• Influencers or opinion leaders in the social system serve as the best messengers
• Identify key strategy to get early adopters from decision to action
• Identify issues that are barriers to adoption and remove
• The spread process needs to be managed
Langley J. Nolan K. et al. Improvement Guide. Jossey Bass, 2009.
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Vital Behaviors of Institutionalizing a Process
1. Develop the Infrastructure for sustainability
2. Make a prediction about whether the change will be sustained
3. Ensure you have capability & reliability of the change
4. Continuous ongoing control measurement both for the change and for the sustain process
5. Redesign sustainability support processes if something falls out of control
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16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
ReliabilityImprovement
&
Measurement
Continuous
Learning
Engagement of
Patients & Family
Engagement of Staff
What matters to you
Framework for Safe, Reliable and Effective Health Care
© 2017 Institute for Healthcare Improvement and Safe & Reliable Healthcare
Source: Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. (Available at ihi.org)
Learning System
Culture
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Six Interventions to Prevent Harm
• Prevent Pressure Ulcers
• Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection
• Prevent Harm from High-Alert Medications starting with a focus on anticoagulants, sedatives, narcotics, and insulin
• Reduce Surgical Complications
• Deliver Reliable, Evidence-Based Care for Congestive Heart Failure to reduce readmission
• Get Boards on Board
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
General Principles for Reducing Harm from High-Alert Medications
Hospitals and other care settings should adhere to the following principles of a safe system:
• Design processes to prevent errors and harm
• Design methods to identify errors and harm when they occur
• Design methods to mitigate the harm that may result from the error
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Suggested Changes Proposed During the Campaign
• Format anticoagulation flow sheet and orders to follow the patient through transitions from hospital to skilled care to home
• Use an anticoagulant dosing service or "clinic" in inpatient and outpatient settings
• To reduce compounding and labeling errors, ensure that the organization uses ONLY oral unit-dose products and pre-mixed infusions, when these products are available
• Ensure that staff undertaking anticoagulant duties are trained and competent
• Conduct an ISMP Antithrombotic Therapy Self-Assessment
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Spread of a Stewardship Program
• Explain WHY- who will benefit?
• Engage the willing
• Have a theory of change
• Use an improvement method to test your theory
• Track measures for process and outcomes
• Develop a spread plan
• Monitor process and outcome measures over time
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Transparency
Leadership
Psychological
Safety
Negotiation
Teamwork &
Communication
Accountability
ReliabilityImprovement
&
Measurement
Continuous
Learning
Engagement of
Patients & Family
Engagement of Staff
What matters to you
Framework for Safe, Reliable and Effective Health Care
© 2017 Institute for Healthcare Improvement and Safe & Reliable Healthcare
Source: Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. (Available at ihi.org)
Secure Administrative Leadership Commitment
Establish Professional Accountability and Expertise
Engage Multidisciplinary Support
Perform Data Collection, Tracking, and Analysis
Implement Systematic Care
Facilitate Transitions of Care
Advance Education, Comprehension, and Competency
16th National Conference on Anticoagulation TherapyOctober 28-30, 2021
Thank [email protected]