Partnering for a New Level of Care Department of Defense Patient Safety Program

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Partnering for a New Level of
CareDepartment of Defense Patient Safety
Program

• Heidi King, MS, FACHE
• Deputy Director, DoD Patient Safety Program

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Partnering For a New Level of Care

• Overview of Patient Safety Program
• Mission and Goals
• Challenges
• Current and future focus, challenges
• How can we partner?
• Top Priorities
• Resources
• Collaborative Activities
• Leading the Military Health System to
• a culture of safety

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Patient Safety Program

• History
• Created in 2002 in response to the 2001 National
  Defense Authorization Act (NDAA), which
  established
• DoD Patient Safety Program within HA/TMA
• Patient Safety programs at every Military
  Treatment Facility
• Mission
• Provides products, services, and training to
  help ensure the safe delivery of healthcare to
  MHS beneficiaries
• Guiding Principles
• A systems approach across the Services
• Engage MHS leadership
• Fostering a culture of trust, transparency,
  communication, and teamwork
• Embracing of national initiatives deemed
  beneficial to the MHS

Partnering For A New Level Of Care
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Patient Safety Program Goals

• Promote safe care environments for a healthy
  military force structure.
• Support efforts to equip beneficiaries to partner
  with their healthcare providers to ensure safe
  care.
• Reduce overall DoD healthcare costs through the
  delivery of safe care.
• Develop processes and products to improve patient
  safety practices.
• Promote a culture that optimizes the use of
  resources to ensure delivery of safe care.
• Demonstrate patient safety impact.

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Patient Safety ProgramKey Objectives What do
we do?

• Objective 1 Implement a Centralized
  Error-tracking Process and Repository (Mandated
  by NDAA 2001, SEC 742 a SEC 754)
• Report, compile, and analyze errors
• Develop action plans for addressing patterns of
  errors
• Facilitate execution of action plans to mitigate
  and control errors
• Objective 2 Share Information (Mandated by NDAA
  2001, SEC 742 b SEC 754 c)
• Identify the systemic factors that are associated
  with errors
• Enable for action to be taken to correct the
  identified systemic factors
• Objective 3 Improve Communication,
  Collaboration, and Teamwork (Mandated by NDAA
  2001, SEC 754 d)
• Support and expand trained DoD facilities
• Study, plan, spread, and evaluate improvement
  efforts

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Patient Safety ProgramCurrent State and Future
Plans

• CURRENT STATE

• FUTURE PLANS

• Enable local patient safety champions (Patient
  Safety Managers) to identify, prevent, and
  address errors to enhance patient safety at the
  DoD facility level.
• Provide centralized resources, activities, and
  initiatives for local patient safety champions to
  promote patient safety

• Create more interactive forums where local
  champions can quickly learn from one another
• Establish relationships between errors and how
  patient safety initiatives address those
• Help local champions prioritize patient safety
  activities/initiatives

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Patient Safety Program Challenges

• Continued DoD Ops Tempo
• Local leadership engagement and support for
  initiatives
• High turnover
• Changing priorities
• Limited facility-level data/reporting sharing
  efforts
• Limited access to safety and quality improvement
  expertise
• Limited awareness of existing patient safety
  resources
• Restructuring/transition of training efforts

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Where Are We Going?

• Building a culture of quality and safety requires
  broad transformation-a tenacious commitment to
  achieving a sustainable effort that likely will
  change the way the we provide care and do
  business.

In the Military Health System (MHS), we have
extraordinary success stories and continued
opportunities for improvement.

• Spread, impact and sustainability
• take time and commitment.

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MHS Culture of Safety
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Top 3 Priorities - 2009

• Priority 1 Establish a Patient Safety Reporting
  System (Mandated by NDAA 2001, SEC 742 SEC 754)
• Collect, analyze and report errors within and
  across DoD Facilities
• Identify prevention techniques of systemic errors
• Facilitate assistance to implement systemic
  solutions to errors
• Priority 2 Launch a DoD Patient Safety Learning
  Center (Mandated by NDAA 2001, SEC 742 b SEC
  754 c)
• House patient safety information make
  accessible and understandable to all target users
• Educational courses, data reports, patient safety
  presentations, document sharing space
• Connect Patient Safety Managers and champions to
  communicate on preventing errors
• Leverage virtual collaborative activities
  discussion boards, webinars, and open forums
• Interact with local change champions to spread
  patient safety initiatives.
• Spread and translate learnings from studies and
  program activities for sustained implementation
• Priority 3 Spread and sustain TeamSTEPPSTM
  (Mandated by NDAA 2001, SEC 754 d)
• Create innovate methods to promote effective
  communication, collaboration, and team work.
• Target facilities where greatest impact and
  ability to implement successfully exists
• Share learnings from implementation efforts for
  other DoD facilities to use and adopt in their
  implementation and sustainment efforts.

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DoD Patient Safety Reporting System

• Description
• Patient Safety Reporting (PSR) will provide an
  electronic event reporting system
• Data required for analysis identifying trends
  and support development of corrective actions and
  policy
• Goal is to fully field to the brick mortar
  facilities (sustaining base)
• Mandate
• NDAA 2001 Congressional Directive
• Requirements driven by the Service Patient Safety
  Programs
• Current Status
• Plan to begin limited roll-out in 2010
• Facilities should submit events until PSR is
  available through Monthly Summary Reports/JAMRS.

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Patient Safety Communication Toolbox
http//dodpatientsafety.usuhs.mil
Login (via DKO account)
Patient Safety Centric Podcasts on MHS Dot Mil
Docs Shows 7, 35, 41, 49, 50 http//dodpatients
afety.usuhs.mil/dotmildocs
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DoD Patient Safety Website

• Resources include
• Patient Safety Alerts and Advisories
• In-dept analyses of sentinel/adverse event causes
  and corrective actions (Focused Reviews)
• Team Training resources (TeamSTEPPS)
• Learning Action Networks
• Patient Safety Quarterly Newsletters
• Toolkits for implementing patient safety
  initiatives
• Updates on DoD level activities
• Schedule of educational/training activities

http//dodpatientsafety.usuhs.mil
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2009 Patient Safety Awards

• Recognizes efforts designed to improve the care
  delivered within the Military Healthcare System.
• Categories
• Identification and Mitigation of Risks and
  Hazards (2 Awards 1 Hospital and 1 Ambulatory
  Center)
• Teamwork Training and Skill Building (2 Awards 1
  Hospital and 1 Ambulatory Center)
• Culture Measurement, Feedback, and Intervention
  (1 Award)
• Deadline Nov 6, 2009
• Website

• http//dodpatientsafety.usuhs.mil/patientsafetyawa
  rds

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TeamSTEPPS Spread At-A-Glance
2008
Within DoD
Beyond DoD
TRAINING (since 2005)
KEY PARTNERSHIPS

• 135 specialty units and clinics across 75
  facilities
• 1700 trainers/coaches in 26 disciplines
• 3000 trained by trainers in Iraq
• Over 25,000 CEU/CME granted
• Saved 1.4M in training/travel dollars (over 2
  years)

• Federal Partnerships AHRQ/DoD National
  Implementation. CMS, VA
• Held 3 Technical Expert Panel (with international
  patient safety leaders)
• South Australia Dept of Health sharing
  measurement and sustainment strategies
• Brigham Womens Hospital/DoD handoff study
• American Association for Family Physicians
  (AAFP)/ALSO collaboration
• National Patient Safety Foundation toolkit
• Extensive International Reach
• AoRN Handoff Toolkit
• Studies with various academic institutions

TEAM COMMUNICATIONS

• 34 academic journal publications
• Regular Learning Action Networks
• 1 visited page on the DoD Patient Safety website
  and highest stats
• Campaign underway to Improve Communication
  across the Military Health System leveraging
  multiple multi-media strategies

INTEGRATION

• 6 Team Resource Centers (CoE)
• Incorporated in simulation exercises
• Integrated into advanced nursing curriculum at
  USU
• TEAM UP designed for patient engagement
• Solid evaluation methodology for
  measurement-field kit in development
• Patient Safety Learning Center in development
• Pilot assessment and debriefing handheld
  technology

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Collaborating Private, Federal and DoD
Organizations
DOD PSP partners with many organizations to
promote patient safety
Federal and DoD Organizations
Private/Non-Federal
Selected Patient Safety Resources Department of
Veterans Affairs http//www.patientsafety.gov/ De
partment of Health and Human Services (Food and
Drug Administration, Agency for Research and
Quality, Centers for Disease Control)
www.hhs.gov Institute of Medicine
www.iom.edu Institute of Healthcare Improvement
www.ihi.org
The Joint Commission, www.jointcommission.org Nati
onal Quality Forum, www.qualityforum.org United
States Pharmacopeia, http//www.usp.org The ECRI
Institute, www.ecri.org National Patient Safety
Foundation, www.npsf.org
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Patient Safety Program Refocus
Do we manage a world class Patient Safety Program
in the MHS?

• CRITERIA
• Evidence-based
• Credible and consensus-based
• Specific and actionable
• Measurable
• Broadly applicable to many healthcare settings
  (e.g. inpatient, outpatient, operational)
• Aligned with practices, standards, guidance, and
  initiatives of other national bodies (Joint
  Commission, AHRQ, Institute for Healthcare
  Improvement)
• Ready existing technology, knowledge, skills
• Endurable (future relevance too)
• DoD participation/input (bonus)

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Aligning with National Quality Forum
Safe Practices, 2009 Update Creating
Sustaining a Culture of Safety

• Safe Practice 1 Leadership Structures and
  Systems
• Safe Practice 2 Culture Measurement, Feedback,
  and Intervention
• Safe Practice 3 Teamwork Training and Skill
  Building
• Safe Practice 4 Identification and Mitigation
  of Risks and Hazards

Are we leading the MHS to a culture of
safety? Focusing on 4 of 34 safe practices
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Madigan Army Medical Center

• 1st Regional Team Resource Center
• Andersen Simulation Center
• Mobile Obstetrics Emergencies Simulation
• Every military facility that deliveries babies
  will have equipment and training to run in situ
  drills (12/09).

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US Army Trauma Training Center

• Common language in teamwork
• Common language in trauma care

Army Trauma Training Center Operation Iraqi
Freedom
Training teams to be a team
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National Capital Area Medical Simulation Center

• Wide Area Virtual Environment

• Congressional support
• 4 million for WAVE
• Will incorporate patient safety RD and training
  component.
• MOA to develop, validate and share training
  curriculum with
• Air Force Medical Services
• AMEDD Center and School
• Development of virtual field hospital
• Reduce medical errors through pre-deployment
  practice.

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National Capital Area Medical Simulation Center

• WAVE Video

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David Grant Medical Center, Travis AFB

• FYO9 Update
• All new personnel trained in TeamSTEPPS during
  newcomers orientation.
• Mandatory, Multi-disciplinary team training
  integrated into weekly simulation training for 6
  units.
• TeamSTEPPS Train the Trainer course Sept 09
• Developed and implemented ISBAR form for patient
  information transfer during inter-unit transfers
  and shift change reports.
• Sponsored simulation conference

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Naval Medical Center Portsmouth

• Conducts training to sustain trainer capability
  in MTFs To date, 5 TeamSTEPPS Train the Trainer
  programs _at_130 trainees
• Initiated studies to assess team performance.
• Serves as a site for validating new measurement
  tools.
• Serves as a site for comprehensive TeamSTEPPS
  intervention and pilot evaluation processes.
• Test Site for the MTPAT.
• Goals for the TRC include the development and
  evaluation of TS curriculum adaptation and
  modifications based on the targeted use of
  modeling and simulation methodologies.

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The Patient Family Join the Team
TEAM-UP Patient Joins The Team
ENCOURAGE PATIENTS' ACTIVE INVOLVEMENT IN
THEIR OWN CARE AS A PATIENT SAFETY
STRATEGY GOALS Introduce TeamSTEPPS
Initiative to Patient and Family Encourage
involvement of Patient Family in their care and
decision making along with issues related to
patient safety METHOD Nurse, Physician, Patient
Family meet together on admission Teach
Patient Family how to be active team members
using common language within TeamSTEPPS Tools
Strategies Joint Commission 2007 National
Patient Safety Goal 13
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TeamUP The Patient Family Join the Team
At Admissions INTRO to the TEAM SHARE the
PLAN How the patient family can
participate ASK QUESTIONS, REPEAT if you dont
get it (Two-challenge rule) HUDDLE if you
still dont understand, call a huddle
(Huddles) NAME BIRTHDATE are your
identifiers MEDICATIONS patient reads labels on
all IV meds (Check backs) WASH YOUR HANDS when
returning to your room (Situation
awareness) POINT OUT CONCERNS encourage family
input (Situational monitoring) PATIENT
REPEAT THE PLAN (Shared mental model)
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Deployment in Operation Iraqi Freedom

TeamSTEPPS Goes to War
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TeamSTEPPS Deployment in Operation Iraqi Freedom
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TeamSTEPPS in Iraq

• 2008-2009
• First team training
• First time Team Training done in an active
  theater of war
• 1,730 medical personnel
• Establishment of Train the Trainer site in Iraq
• 8 separate Combat Support Hospitals and FSTs
• 10 different Task sites
• First time to train a units Cadre before
  deployment
• Preliminary Significant Results (Pre Post
  training Patient safety report)

• ? Patient Safety Incidents Reports
• ? Communications Errors
• ? Needle Sticks
• ? Medication Errors

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Partnering To A Level Of Care

• Keep the chargeyou each play an important role
  to transform healthcare in the Jacksonville
  community, across the Navy and beyond