Uncategorized | Washington Patient Safety Coalition

UNTANGLING VARIATION IN EHRs & HIE: A COMPLEX PATIENT SAFETY ISSUE

by Gwen O’Keefe, MD, FACP | Principal, GO Healthcare Strategy Imagine you’ve just spent a harrowing 4 days in the hospital with sudden onset of heart problems, had many tests, and are sent home with multiple appointments and new medications. The conversations with hospital staff passed in a blur. You don’t understand what the results of some of the tests showed, but you are confident that at your appointment with your primary care doctor, Dr. Sue Caring, all will be explained. Now, imagine you are Dr. Caring, about to see one of your favorite patients. You are dismayed that he has developed a severe cardiac condition and know he will have many questions. You prepare for the visit by reviewing the discharge summary from the hospital but are frustrated with the amount of data presented in the 15 screens of that particular hospital’s discharge summary. It looks very different than the one from a different hospital you read earlier in the day. It’s nearly impossible to quickly comb through the overwhelming amount of data to find the key 5 pieces of information you need to really make sense of what happened. You have a nagging sense of unease that you may be missing a key follow-up item and could end up dropping the ball and harming your patient. THE PROBLEM: HOW DID IT GET THIS WAY? Nationally, most hospitals and physician practices have adopted Electronic Health Records (EHR). At the same time, national health information standards continue to mature and a variety of options exist to facilitate electronic health information exchange (HIE). This ready access to standardized electronic clinical information offers great promise to enhance care coordination, improve patient safety, and simplify both administrative and clinical workflows. However, to date, this promise has not been realized to the degree it should. While there are a variety of factors responsible for this diminished return on investment, one key issue relates to variability across EHR vendors and clinical organizations in how clinical information standards are being implemented. Of particular concern are the diverse approaches taken to implement the national standard for clinical information exchange, the Consolidated Clinical Document Architecture (C-CDA). The C-CDA was designed as the vehicle to extract, summarize, and transmit clinical information from a certified EHR. Regional clinical and informatics leaders have recognized that the wealth of variations in C-CDA exchange across EHR vendors and clinical organizations makes...

Northwest CRP Leader Retreat: Achieving Benefits, Avoiding Pitfalls

When: September 27-28, 2017 Where: Marriott, SeaTac International Airport | 3201 176th Street | SeaTac, WA 98188 Learn how your organization can implement an effective communication and resolution program (CRP) at this retreat for healthcare leaders. Despite our best efforts as care providers, adverse events happen far too often. Most efforts to respond to them don’t actively improve patient safety or meet the needs of patients and providers. CRPs turn adverse events into opportunities for improvement. They ensure open communication after an adverse event is discovered, a comprehensive analysis of what happened with subsequent safety improvements, emotional support for patients and providers, and an appropriate resolution. At this retreat, healthcare leaders will learn how to implement CRPs effectively in their organizations. At the conclusion of this two-day program, participants will be able to: Define the core components of a CRP and why each component is critical to a CRP’s effectiveness Describe the common barriers healthcare organizations experience when implementing a CRP and the strategies for overcoming them Conduct a CRP gap analysis at their institution and interpret the results Develop a plan for their organization to effectively implement a CRP This two day event will feature: Thomas H. Gallagher, MD, University of Washington Timothy McDonald, MD, JD, MedStar Institute for Quality and Safety Local CRP Leaders including: Paula Bradlee (Overlake), Claire Hagan (Providence), Dana Kahn (Virginia Mason), Marcia Rhodes (University of Washington) Plus, a panel of Board/C-suite members from local hospitals discussing CRP challenges and opportunities The SeaTac Marriott hotel is offering a discounted rate for conference attendees. Click here to make online reservations with the discount (or call 206.241.2000 and mention “UW Medicine”). You must book by September 6 to receive the discounted rate of $179 per night. The agenda and prospectus are available here: NW CRP Leader Retreat Prospectus Interested in sponsoring this event? Download our sponsorship package to learn more about the benefits: NW CRP Leader Retreat Sponsorship Package ...

TAILORING A COMMUNICATION AND RESOLUTION PROGRAM TO YOUR MEDICAL SYSTEM

Organization: Confluence Health Project Name/ Title: CRP Point of Contact: Randal Moseley, MD, FACP, FHM, Medical Director of Quality | randal.moseley@confluencehealth.org About Confluence Health Confluence Health is an integrated healthcare delivery system located in North Central Washington. We serve a population of about 250,000 dispersed over 12,000 square miles. Our resources include two hospitals, 13 clinic locations, over 270 physicians covering more than 40 medical specialties and primary care, and 150 advanced practice clinicians. Starting the Journey: CRP Foundations Communication and Resolution Programs (CRPs) consist of a bundle of strategies to improve response to patient harm events, learn from them, and execute needed changes to prevent similar events in the future. In our quest for a best practice way to handle patient harm events in our system, we found CRP strategies to be culturally very compatible with Confluence Health quality philosophy. To implement CRP strategies into our system, we began by educating leadership and key operational personnel in CRP principles and methods, and now have top executive support to adopt CRP as the foundation for the majority of our incident response and quality improvement activity within our facilities. From what we’ve learned, the CRP journey requires: Making a commitment to transparency with patients Employing rigorous event analysis using just culture and human factors principles Supporting the emotional needs of the patient and care team affected by the event Proactively seeking appropriate financial and non-financial resolution for patients Continuously assessing the impact of the program From Vision to Action: Essential Building Blocks Our core action team leading this work is called the Culture of Safety Committee, with representation from incident management, quality improvement, and members of the senior leadership team. We have used the “key steps” list from the Collaborative for Accountability and Improvement for our roadmap, and these are the lessons and tools we’ve employed: 1. Facilitating the Initial Response: It is important to have an engaged workforce that is not hesitant to report patient harm events quickly. To gain the confidence of employees, it is critical to operate with just culture principles and a human factors perspective when approaching error events. While this foundation is critical to the success of CRP implementation, this cultural environment is impossible to create quickly. At Confluence, we had a fortunate accidental segue into CRP needs – we had been working on a “speak up” program from the beginning of our organization in 2013....

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