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Innovation, Advocacy, and Lessons Learned: How IHA Implemented a Patient Safety Learning Collaborative: 

Innovation, Advocacy, and Lessons Learned: How IHA Implemented a Patient Safety Learning Collaborative Cathy Grossi and Becky Steward Illinois Hospital Association The Quality Colloquium Harvard University August 21, 2006

About “Land of Lincoln”: 

Illinois Facts: 5th most populous state (12.5 M) 25th largest (57,918 sq. miles) Agriculture Springfield / Chicago 200+ Hospitals Academic Centers (19) S andamp; R (90) CAH (51) Top 3 employer in 48 / 102 counties 1.6 Million inpatients 4.9 Million ED Medicare (40%) / Med (13%) Uncomp care – $1.2 B About 'Land of Lincoln'

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Hx - Partners in Quality: Perinatal: 10 Networks / 148 Hospitals Newborn Hearing Screening: 144 report Metabolic Screening: Expanded testing (6-30) EMS / Trauma: 11 Regions / 67 Hospitals EMSC: 11 Regions / 206 Hospitals Organ / Tissue Donation andamp; Transplant Communicable Disease Cancer Registry Illinois Hospitals

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Hospitals Harm: Medical Error Inadequate Staffing Poor Infection Control Practices Patients at Risk

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2002 Springfield’s 'New World' Order: Democratic sweep of state government New Governor, Democrat Leadership of the General Assembly Largest turnover of state legislators in 25 yrs 46 new legislators (29 in the House, 17 in the Senate) Union-friendly environment Political Landscape

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Multiple Objectives: Internal improvement + Advocacy andamp; leadership IHA Collective Initiative

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Slam Dunk: 4 Billion prescriptions/yr 20% of medical errors 2 to 7 per 100 hospital admissions ADE – 1 to 5 day extended LOS Up to add’l $9000 cost Medication Safety

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Criteria: Addresses issue of public concern Contributes to real improvement Reasonable and fair to providers andamp; public Operationally feasible W/in provider control andamp; consistent w/accred Offers measurement activity Drive results bigger than one organization Proactive Focus

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Develop, adopt and/or support efforts for: Pt Safety Organizational Framework Hospital Compliance/Consumer Guide Medication Safety Initiative Simulation Training (Team Skills) Networking Roundtables Addressing the Issue

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From accreditation, gov’t, literature andamp; member sources Approved by IHA Board in May, 2003 IHA web site: Pledge Participants Member Pledge: 188/194 Hospitals (97%) Advocacy: On-going Leadership effort Organizational Framework * * Available at www.ihatoday.org

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Update–In-Progress: IHA Quality/Patient Safety Data Guide Federal/state/private activity Hard copy/PDF format Initial distribution: Mid-Quarter 2004 New section - Publicly available hospital info IHA Resource Guide * * Available at www.ihatoday.org

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From Medication Safety To Patient Safety Learning Collaborative IHA Medication Safety

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Med Safety = Do a Collaborative (2003-2004): Learning curve Business plan Internal marketing Job description Recruitment Marketing plan Project management tool Behind the Scenes

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Project Development : Phases (Pre-work, learning sessions, video-conferences, site visits, showcase conference): Marketing Budget andamp; Contracts Speakers Materials andamp; printing Registration Evaluations Meeting logistics Revision On-going Focus: Dedicated manager Faculty advisors Online Forum Measurement Strategy Participant Feedback andamp; Reports PSLC Visibility Just in Time

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Three Aims: Individual Hospital Improvement Aggregate Hospital Improvement IHA Process IHA Patient Safety Learning Collaborative

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Balance The Constant Challenge

Unique Illinois Patient Safety Nexus: 

PSLC Unique Illinois Patient Safety Nexus Quality Oversights Coalitions Safety Champions Patients andamp; Families Regulatory andamp; Legislative Other States Illinois Hospitals Media

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Becky Steward, BSN Manager, Patient Safety Learning Collaborative

Concept to Implementation: 

Concept to Implementation Framework Model for Improvement Learning from Leaders A tool and a philosophy

Establish Foundation: 

Advisors and Facilitators Role Involvement Speakers Criteria From external to internal Establish Foundation

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Develop Measures and tools * Processes Staff Labor intensive FTEs Build Infrastructure * Available upon request

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Preparation Content Materials and resources Evaluations Build Infrastructure

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Marketing Audience Message points Non-competitive Size Build Awareness

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Overview 2005 Participants Health System 1 Hospitals 25 Geographical cross-section Northern 10 Central 7 Southern 9 Staffed beds Less than 100 2 101 – 300 17 301 – 500 4 More than 500 2 Bring Program to Participants

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Pre-work Action Sharing Three Distinct Phases

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Engage Participants Letter Conference call * Baseline data collection * Phase One: Pre-work * Available upon request

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Build Relationships Access Follow-through Manage expectations Tracking tool * Critical Elements * Available upon request

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Information and Networking Learning Sessions Videoconferences Issues and adjustments On-line Forum Site visits Phase Two: Action

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Techniques Unlabeled profiles Of cameras and candy New ways to use data Unify Diverse Groups

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Each event involves one or more handoffs 2004 IHA Data, Participants 2006

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Imagine the number of handoffs Are we lucky? Or are we safe?

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Humor Imagery

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On-line Forum Limited to participants 'Voice from which I speak' Enable direct contact Facilitate Communication

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Monthly reports Succinct Inherent value Challenges Measuring progress Data 'Are you done yet?' Assess Progress

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Innovation in Measurement * Implementation across organization, monitoring data Expanding use beyond pilot units, collecting / reporting data Testing tool / process on pilot units, collecting preliminary data Developing initial tool / process Having preliminary discussions Level 1 Level 2 Level 3 Level 4 Level 5 Healthy Hospital in Jan-05 Healthy Hospital in Jun-05 Healthy Hospital in Sep-05 No Process Process Established Progress over time * Available upon request

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By facilitators Reports to participants Individual Aggregate Provide Feedback

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Excerpt – 2005 Final Report

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Excerpt – 2005 Final Report

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Excerpt – 2005 Final Report

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Excerpt – 2005 Final Report

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Outcomes Congress October 18, 2006 Bloomington, IL Phase Three : Sharing Highlights: Attendance Engagement Challenges Beyond Illinois

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Common Themes Commitment Expectations Resources Composition Effective meetings Small tests of change Elements for Success

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Building on 2005 17 of 26 return Experience Unique Challenges in 2006 Unique Challenges in 2006 Breaking new ground

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Participants Health Systems 4 Hospitals 21 Geographical cross-section Cook County 15 Northern 10 Central 6 Southern 10 Staffed beds Less than 100 4 101 – 300 26 301 – 500 9 More than 500 2 2006 - Handoff Communication

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Master calendar / timeline Role changes Changes to reporting Size Adjustments in 2006

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Save the Date! IHA Safety Connections: Relaying the Lessons Learned November 14, 2006 Hilton Hotel Lisle / Naperville Registration limited www.ihatoday.org

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'It's a job that's never started that takes the longest to finish.' J.R.R. Tolkien British scholar andamp; fantasy novelist (1892 - 1973)

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Questions?