trans-atlantic alliance to compare patient safety performance between the uk and us organizations...
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Trans-Atlantic alliance to compare patient safety performance between the UK and US organizations
The business case for preventing inpatient falls
Dr. Mahmood Adil – National Health Service, England
Diane Huntley - Kaiser Permanente, CAPascal Briot - Intermountain Healthcare, UT
Hospital Engagement NetworkFalls Affinity Group Call – March 7, 2013
Process and Methods
• Align on definition of fall severity between organizations*
• Develop methods to track incremental cost of harm that could be standardized and easily used by other global systems
• Generate effective partnerships between clinical, finance, and analytic experts in three organizations
• Demonstrate that international collaboration is an effective sharing and learning tool to make a difference in reducing patient harm around the globe
* See Appendix I
Journey of our collaboration
IdeaSept 2010
WillMay 2010
ExecutionNov-Dec 2010
OutcomesJan-May 2011
Cost of Falls Calculator 2012
IHI Forum 2011: Poster Presentation
International Forum & ISQua 2012: Oral Presentation
Sept. 2010: Initial Meeting with NHS, Kaiser Permanente, and Intermountain
Refining Falls project Starting ADE project 2013
Upcoming NPS Congress 2013: Oral Presentation
Challenges for All 1. How to identify rate and severity of falls
Impact of information measurement system and professional cultures
2. How to identify savings associated with reduction in rate of fallsMatched cohort comparison of length of stay, labs, imaging and Rx
utilization
3. How to track intervention “cost”Identification of intervention & accounting methodologies
4. How to “put it all together” Cost of falls calculator
B-C=DBenefits(costs of poor quality or service)
Costs (costs of improvement intervention)
Dividends (Case for Change)
1. Fall prevalence rate per 1000 patient days 2010 data
No Injury Minor Moderate Major0.0
0.5
1.0
1.5
2.0
2.5
1.95
0.72
0.140.03
1.74
0.63
0.03 0.02
2.09
1.37
0.64
0.07
NHS KP IH
Severity of Injury
Prev
alen
ce R
ate
per
1,00
0 Pa
tient
Day
s
N = 399 773 285 N = 873 1969 524
N = 83 40 29
N = 15 24 4 *
* IH sample size for major injury not statistically significant
2. Mean extended length of stay 2010 data
* IH sample size for major injury not statistically significant
No Injury Minor Moderate Major0
5
10
15
20
25
7.38.0
10.2
23.0
6.67.4
9.1
20.0
4.73.3
1.6
6.1
NHS KP IHSeverity of Injury
Day
s
N = 873 1,969 524 N = 399 773 285 N = 83 40 29 N = 15 24 4*
3. Tracking of interventionsIntermountain example
1998.1
1998.3
1999.1
1999.3
2000.1
2000.3
2001.1
2001.3
2002.1
2002.3
2003.1
2003.3
2004.1
2004.3
2005.1
2005.3
2006.1
2006.3
2007.1
2007.3
2008.1
2008.3
2009.1
2009.3
2010.1
2010.3
2011.1
2011.3
2012.10
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Rate of Falls with Injury per 1000 Patient Days
InjuryNo Injury
Year, Quarter
Falls
per
100
0 Pa
tient
Day
s
1998Creation of Patient Safety Team Meeting Prep and Follow-upNursing Falls EducationDevelop protocol
2005 - 2007Creation Safe Patient Handling team (earnedMagnet status, gait belts & lift system,awareness signs) Standardize Fall definitionAdded electronic risk scoring/protocolto event systemDeveloped web reports for front lineInclusion of falls on nurse manager dashboard
2010 - 2011Board Goal (2010)Designated Fall ChampionsPost Falls Assessment ImplementationMini-RCA for Falls (Falls Assessment Huddle)Patient Safety IndexSkill Pass Off for bed typesNew Bed (with integrated bed alarm)Nurse Call System Integration
3. Tracking of InterventionDimensions Intermountain
1998 - 2010Kaiser
2007-2010NHS
2009-2011
Leadership Teams and Champions•Creation of Patient Safety Team (1998) •Creation Safe Patient Handling Team (2005) •Board Goal & Designated Fall Champions (2010)
HEROES (Hospital & Emergency Dept Reliability & Operational Excellence for Safety) • Create reliable clinical practices in all 21
medical centers • Standards of practice & successful
practices shared on Monthly Collaborative Calls (2009)
The Strategic Team•Improvement Leader•Trust Chief Executive/Senior Sponsor•Medical Director •Finance Director•Dir of Nursing and Clinical Governance•Head of Health Informatics
Process improvement
Education & Assessment• Develop Protocol & Nursing Falls Education
(1998)• Standardize Fall Definition (2005) • Post Falls Assessment Implementation & Patient
Safety Index (2010)
Fall Prevention Bundle 2007•Start-of-shift huddle•Schmid assessment•Purposeful hourly rounding•Toileting assistance•Alignment with Pharmacy and PT•Staff, patient, and family education•Vital BehaviorsFalls Prevention Bundle May 2009• Schmid Plus ABCs Age, Bone, Coagulation,
Recent Surgery• Ongoing requirement for nurses to attend
yearly training
Multi-faceted Fall interventions Checklist(March 2010)•Toilet & Mobility• Environment• Assessment•Medication
•Raising Awareness•Education & Training
Infrastructure Patient Equipment & Staff Awareness• Magnet status, gait belts & lift system,
awareness signs (2005)• New Bed (with integrated bed alarm) • Nurse Call System Integration (2010)
Patient Equipment & Staff Awareness•Specialty low beds •Gait Belts•Chair alarms, bed alarm s•Door signs, yellow armbands•Care board
Patient Equipment & Staff Awareness•Low profile beds•New bed rails•Care board
Information system & reporting
Electronic Reporting• Added electronic risk scoring /protocol to event
system• Developed web reports for front line. Inclusion
of falls on nurse manager dashboard (2005)
Electronic Reporting•Electronic Responsible Reporting Form• KP Health Connect (Kaiser Permanente
electronic medical record)
Data Intelligence & Review System• Develop and integrate the safety fields in
clinical , administrative and financial patient level costing) data electronically
• Improve data availability and accessibility to frontline staff
• Regular audits to review performance and update protocols
4. Fall risk calculator
Pre-requisite to use the calculator1. Accurate identification of falls
Robust event system to identify falls and severity.
Culture of safety and no-blame
2. Calculating associated cost due to a fall Incremental length of stay by using cohort matching methodology
Convert incremental resource use into actual cost
3. Track & cost your intervention to reduce fall Identify intervention in terms of leadership, process improvement, infrastructure,
information system and reporting
Estimate the cost of intervention (allocated equipment cost over time)
4. Putting it all together using the calculator
Lessons learned due to our collaboration1. Accurate and consistent identification of falls
Agreed on use of standard definition of severity of falls and methodology to measure falls rate.
The WHO should include new codes for hospital associated falls in its next version of ICD classification system.
2. Track and cost your intervention to reduce fall Quality Improvement culture to track intervention: clinical and finance teams need to find ways to
share data and work together for creating the ‘business case for safety’ and achieving sustainable outcomes.
Need a good activity based cost accounting system. If it is not possible to separate out the effect of an intervention and the cost of it because interventions are cumulative, it may be best to look at impact over time.
3. Degree of similarity of interventions across institutions ‘Extended Length of Stay’ is a good indicator to quantify harm-related incremental cost and
resource utilization.
Multidisciplinary Team
California Analytics
Northern California Region Sponsors
Program Office Quality DeptProject Management
Northern California Risk and
SafetyHEROESInitiative
NCAL Quality
NCAL Finance
Institute for Health Care
Delivery Research
Patient Harm Reduction Program
Clinical ProgramLeadership
Patient SafetyClinical Quality
AnalyticsFinance
Wrightington, Wigan and LeighHospital
Finance
Analytic
Quality
ROI Tactical Team
Intermountain ROI tactical initiatives
• Led by our Asst. VP for quality and patient safety and reported to our CNO / VP for clinical operation
• Mission: – To build a partnership between clinical and financial experts to use the best
available data and expertise– To provide careful ROI analysis of quality and patient safety initiatives in order to
give leadership insight into strategic opportunities– To build a standardized approached to calculating ROI that can be “exported” to
other initiatives on a system, regional or facility level– To quantify existing quality improvement projects that may assist in meeting
Intermountain’s goal of maintaining a low rate of cost increases to CPI+1%
• Areas of concentrations:– Falls– Adverse Drug Events (ADE)– Central Line Associated Blood Stream Infection (CLABSI)
Intermountain fall with injury rate
2007 2008 2009 2010 2011 20120.0
0.5
1.0
1.5
2.0
2.5
Falls with InjuryIntermountain System
Average Falls with Injury LCL UCL
Falls
Rat
e pe
r 100
0 Pa
tient
Day
s
Falls Risk
TrainingSafe Patient
Handling
New beds with
alarmNurse call system
integrationFalls on nurse
manager dashboard
Methodology for ROI calculationSavings:
– Decrease payment on legal claims– Decrease variable cost due to
• reduction in complication associated with fall reduction• reduction in LOS
Potential impact on revenue stream?Expenses:
– Costs of implementation of falls prevention initiatives• Personnel (new staff, education, training, …)• IT / information / measurements (Risk event system, data tracking
and reporting, …)• Infrastructure (equipment, supply, …)
How to allocate capital expenditure?
Decreased Payment on Legal Claims
Reduced Patient Costs Savings
Approximation of Financial Outcome
Next Steps1. Refine Patient Cost Reduction Calculations
• Verify whether charges related to falls are billable• Determine appropriate comparison
I. No Falls : Falls II. No Falls : Falls with Injury
2. Investigate employee injury claims3. Refine allocation of capital costs
• Beds, remodeling• Across applicable risk events (pressure ulcer,…)
4. Create methodology for budgeting utilization changes at dept. level
5. Apply ROI methodology to other risk events
Lessons learned for a successful international collaboration
1. Clear and simple objective to be agreed from the outset2. Staged approach to build the momentum and measurable
goals for each stage3. An effective coordinator able to leverage the use of web
technology4. Establish common ground for data sharing and
incorporating each others standards in a practical manner5. Act like one team with commitment and flexibility to achieve
common results across the organizations
Questions
Thank you!
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Appendix I -Severity of Falls DefinitionsSeverity
Categorization National Health Service Intermountain Healthcare Kaiser Permanente Northern CaliforniaNo harm/injury Where no harm came to the
patient.Absence of harm or injury, with no requirement of care or treatment
An event not resulting in no harm or injury coupled with no explicit expression of dissatisfaction by affected member, visitor, or family; a reoccurrence of this event is not likely to result in a serious adverse outcome
Low/Minor harm/injury
Where the fall resulted in harm that required first aid, minor treatment, extra observation or medication.
Detectable harm or injury. Without treatment, the patient would have fully recovered
No Treatment An event resulting in an injury requiring no treatment, e.g. bruises, scrapes or bumpsWith Treatment An event that required minor intervention (e.g. application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, or x-ray), no loss of function;
Moderate harm/injury
Where the fall resulted in harm that was likely to require outpatient treatment, admission to hospital, surgery or a longer stay in hospital.
Detectable harm, injury, or functional impairment lasting for a limited time only. Injury or impairment would not restore itself if untreated
An event that resulted in an injury requiring physician treatment, such as sutures, splints, casts, minor surgical repair, closed reduction, or prescription for an antidote; An injury, which requires minor intervention to remain temporary;
Severe/Major harm/injury
Where permanent harm, such as brain damage or disability, was likely to result from the fall.
Temporary Non-treatment would result in the loss of life or permanent loss of function. Patient returns to baseline status without permanent injuryPermanentNon-treatment would result in the loss of life or permanent/long-term loss of function. Patient does not return to baseline
An event that resulted in a permanent injury or one that is life threatening, or requires close monitoring at an increased level of care, or intervention such as major surgery to keep injury from becoming permanent.
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Appendix II - Schmid Plus ABCS
Appendix III - Collaboration Team
KP Intermountain NHS
Leaders Mike RoweBarbara Crawford
Pascal BriotJefrey Huntington
Mahmood Adil Andrew Foster
Quality Improvement
Maureen HanlonDiane HuntleyJason Jones, PhD
Marlyn ContiEric CrawfordJan Orton
Christina Heaton Micky Milohtra Pat O’Brien
Finance/Analytics
Sabrina DahlgrenPatricia KipnisTom Winn Rebecca Gambetese
Andrew SorensonAndy Merrill
Keith Griffiths Claire Jacobson
Patient Care Services
Nancy CorbettCecelia CrawfordLorraine Woo
Marlyn ContiRobin Betts
Pauline JonesGill Harris