How to Use Data to Improve Patient Safety: Part 2
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Stan and Valere will discuss how using an automated trigger tool for all-cause harm reviews will provide timely, real-time patient safety data useful to drive down harm rates with earlier interventions. Additional benefits of this approach include having a more accurate and robust source of data for identifying harm trends to then be able to integrate the findings into existing quality improvement processes for further quality improvement efforts. Attendees will learn how to: Understand the importance of dedicating resources to impact downstream costs Identify their key sources of Patient Safety data Integrate Patient Safety data in to existing Quality Improvement Processes Learn and improve from real-time safety analytics combined with a Culture of Safety
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How to Use Data to Improve Patient Safety: Part 2
- 1. Stanley L Pestotnik, MS, RPh Valere Lemon, MBA, RN How to Use Data to Improve Patient Safety: A Two-Part Discussion
- 2. © 2016 Health Catalyst Proprietary and Confidential Agenda 2 The financial cost of patient harm. How real-time data and analytics can help. Developing a culture of safety and high reliability.
- 3. © 2016 Health Catalyst Proprietary and Confidential3 The prevention of harm caused by errors of commission and omission. Patient Safety Defined: Adverse event defined: An event that results in unintended harm (injury) to the patient by an act of commission or omission rather than the underlying disease or condition of the patient. Source: Institute of Medicine, Patient Safety: achieving a new standard for care, The National Academies Press, 2004
- 4. © 2016 Health Catalyst Proprietary and Confidential At what point do we care? 4
- 5. © 2016 Health Catalyst Proprietary and Confidential Primary Care Secondary Care Tertiary Care Care Paradigm TypeCare Setting Type GP/ Clinics Diagnostic/ Path Labs Ambulatory Centers Outpatient Clinics Hospitals/ ICUs Home/ Extended Care Alarm Fatigue Care Management and Transition Health IT Surgical/ Drug/ Device Safety Environmental/ Workforce Safety Patient Safety Issues Patient Falls HAP/ VAP Medication Errors Pressure Ulcers Patient Handoffs Diagnostics Errors Maternal Death Blood Administration EHR/ EMR Related Errors Evidence Based Diagnosis and Treatment Adherence PHI Compromise Patient Engagement Hospital Outcomes Data Transparency Medical Device/ Implants Cyber security Assessment Errors Leading to ED Admissions CAUTI Drug/ Device Contamination Off-label Drug Use Off-label Device Use Intravascular Air-Embolism Vascular Catheter Infection DVT/ PE Traced to Faulty Intervention Incisional/ Organ/ Space SSI Wrong Patient/ Site/ Indication Antibiotic Resistant Infections Foreign Object Post Surgery Sepsis Burns/ Thermal Injuries Hand Hygiene Compliance Personal Protective Equipment (PPE) Compliance Medication/ gas/ oxygen misuse Electrocution Occupational Physical Safety Hazards Incomplete/ ineffective immunization of health workers Psychological Health of Workers Resulting in Harm Patient Safety Issues across the Care Continuum The large number of safety issues are of significant epidemiological and economic impact
- 6. © 2016 Health Catalyst Proprietary and Confidential Please rate your organization’s effectiveness in measuring the cost of patient harm events. 73 respondents a) Not at all effective – 11% b) Somewhat effective – 27% c) Moderately effective – 24% d) Very effective – 12% e) Unsure or not applicable – 26% Poll Question #1 6
- 7. © 2016 Health Catalyst Proprietary and Confidential7 Organizational Costs of Patient Harm Accreditation Costs Human capital costs Staff redirected from patient care Decreased staff satisfaction Payment penalties Lower profit margins Marketing Costs Inability to generate new business Inability to generate new business Litigation costs Patient safety violation
- 8. © 2016 Health Catalyst Proprietary and Confidential Impact of Inpatient Harm on Hospital Finances 8 Never events Cost more than $50.0 billion annually, affecting an estimated 7.9 million people and average mortality of 9.5% in the United States. Other patient safety issues Antibiotic resistance is estimated to cost $55.5 billion annually in the US, affecting around 2 million people Health IT related patient safety issues Protected Health Information (PHI) compromises affect 16.6 million lives annually. Failure to use Evidence- Based Clinical Diagnosis and Treatment guidelines, costs an estimated $34.3 billion to healthcare systems annually.
- 9. © 2016 Health Catalyst Proprietary and Confidential Financial Challenges 9
- 10. © 2016 Health Catalyst Proprietary and Confidential Please rate your organization’s effectiveness in using data, analytics, and dedicated resources to impact downstream costs associated with patient harm: 75 respondents a) Not at all effective – 12% b) Somewhat effective – 35% c) Moderately effective – 20% d) Very effective – 4% e) Unsure or not applicable – 29% Poll Question #2 10
- 11. © 2016 Health Catalyst Proprietary and Confidential Creating a High Reliability Organization 11 Preoccupation with Failure Reluctance to Simplify Sensitivity to Operations Difference to Expertise Commitment to Resilience
- 12. © 2016 Health Catalyst Proprietary and Confidential12
- 13. © 2016 Health Catalyst Proprietary and Confidential13
- 14. © 2016 Health Catalyst Proprietary and Confidential Using Data and Analytics to Improve Patient Safety 14 Result: • 7% improvement in the percentage of patients therapeutic within 24 hours. • Zero incidence of major bleeds for more than six months.
- 15. © 2016 Health Catalyst Proprietary and Confidential Using Data and Analytics to Improve Patient Safety 15 Result: 980,527 fewer opioid pills prescribed in one year.
- 16. © 2016 Health Catalyst Proprietary and Confidential Using Data and Analytics to Improve Patient Safety 16 Results: • 79.7% relative reduction in OB ICU admission rate – avoidance of costly ICU transfers • 50.4% relative reduction in maternal readmission rate. • 33% relative improvement in maternal HTN rate, per 1,000 deliveries.
- 17. © 2016 Health Catalyst Proprietary and Confidential Using Data and Analytics to Improve Patient Safety 17 Results: • 35% relative reduction CAUTI rate. • 18 fewer patients with infections.
- 18. © 2016 Health Catalyst Proprietary and Confidential Using Data and Analytics to Improve Patient Safety 18 Results: • Two-day reduction in ICU LOS. • 5.9 percentage point reduction in ICU readmission rate. • $1.5 million savings. • 11.7 percentage point reduction in 30-day readmission rate.
- 19. © 2016 Health Catalyst Proprietary and Confidential Using Data and Analytics to Improve Patient Safety 19 Result: • $1.6 million savings - a result of a 30% relative reduction in the overall number of HACs. • Within 6 months, more accurate reporting, and a 90% reduction in resources required for surveillance.
- 20. © 2016 Health Catalyst Proprietary and Confidential20
- 21. © 2016 Health Catalyst Proprietary and Confidential21 The Future of Safety A Sociotechnical Solution Retrospective safety information • Detect fraction of all events. • Labor intensive and unwieldy. Frontline drenched with alerts • More burn-out. • More cynicism. • More risk. Poor clinical learning systems • Hard to use to change patterns. Other issues • Safety isolated from hospital business. • Safety data black-hole. Health Catalyst Approach Existing Systems Real-time safety analytics • Measure, trend, and learn from all defects. • Predict harm in specific patients and populations. Intelligent & clinically appropriate • Targeted intervention. • System of trust. • Controlled risk. Data-driven learning systems • Integration of culture and analytics. • Learning boards (organizational, unit and patient). • Focus on integrated value. • Transparency (sharing safety data with patients).
- 22. © 2016 Health Catalyst Proprietary and Confidential Healthcare Analytics Summit 17 ERIC J. TOPOL Author, The Patient Will See You Now and The Creative Destruction of Medicine. Director, Scripps Translational Science Institute DAVID B. NASH, MD. MBA Dean, Jefferson School of Population Health JOHN MOORE Founder and Managing Partner, Chilmark Research ROBERT A. DEMICHIEI Executive Vice President and Chief Financial Officer, University of Pittsburgh Medical Center THOMAS D. BURTON Co-Founder, Chief Improvement Officer, and Chief Fun Officer, Health Catalyst DALE SANDERS Executive Vice President, Product Development, Health Catalyst THOMAS DAVENPORT Author , Consultant Competing on Analytics*, , Analyitcs at Work, Big Data at Work, Only Humans Need Apply:Winners and Losers in the Age of Smart Machines. *Recognized by Harvard Business Review editors as one the most important management ideas of the past decade, one of HBR’s ten must-read articles in that magazine’s 90-year history. Summit highlights Industry Leading Keynote Speakers We’ll hear from well-known healthcare visionaries. We’ll also hear from two C-level executives leading large healthcare organizations. CME Accreditation For Clinicians HAS 17 will again qualify as a continuing medical education (CME) activity. 30 Educational, Case Study, and Technical Sessions We have the most comprehensive set of breakout sessions of any analytics summit. Our primary breakout session focus is giving you detailed, practical “how to” learning examples combined with question and opportunities. The Analytics Walkabout Back by popular demand, the Analytics Walkabout will feature 24 new projects highlighting a variety of additional clinical, financial, operational, and workflow analytics and outcomes improvement successes. Analytics-driven, Hands-on Engagement for Teams and Individuals Analytics will continue to flow through the three-day summit touching every aspect of the agenda. Networking and Fun We’ll provide some new innovative analytics-driven opportunities to network while keeping our popular fun run and walk opportunities and dinner on the down. Sept. 12-14, 2017 Grand America Hotel Salt Lake City, UT
- 23. © 2016 Health Catalyst Proprietary and Confidential Q&A 23