The following are some of the 2014 Quality Improvement Initiatives implemented at CVMC.
PROMOTING A CULTURE OF SAFETY THROUGH IMPLEMENTATION OF SAFETY INTELLIGENCE SYSTEM
Central Vermont Medical Center
Performance Improvement Goal: One of the most important steps towards establishing and sustaining a culture of safety in healthcare is a commitment to assuring every voice is heard at every level of an organization and effective responsiveness to adverse events occurs in a timely manner. Implementation of the Safety Intelligence System will promote a culture of safety at Central Vermont Medical Center.
Background: Reporting is fundamental to detecting patient safety problems, learning from failures in the health care system, improving processes and disseminating strategies to prevent harm. As part of a performance improvement initiative to reengineer the existing safety program, Central Vermont Medical Center partnered with Fletcher Allen Health Care to implement the Safety Intelligence System in January 2014.
Action: As with any new electronic system, a period of “just in time” training was necessary to supplement the pre-implementation instruction and orient managers to a multidisciplinary approach for follow up action plans. This system allows for notifications of multiple department leaders who require awareness of an event and a communication forum to address each event. This feature has proven to be a powerful tool for improvement in action plans. Through peer communication, directors and managers are more knowledgeable about organizational system vulnerabilities and better understand how interdisciplinary knowledge, skills and attitudes promote utilization of safety science leading to safer care for patients, families and staff. The messages between departments demonstrate accountability, excellence, honesty, integrity and mutual respect.
The system also includes a Quality Management review which has served as a vehicle for clarification and analysis of each reported event. Although each event is unique, similarities and patterns in sources of risk have been uncovered which may otherwise have gone unnoticed. The ability to trend safety issues, keep better track of follow up actions and develop meaningful reports for senior leadership has proven to be very valuable and well received.
Evaluation: A strong response from front line staff over the last six months in reporting adverse events and near misses is a testament to Central Vermont Medical Center’s organizational engagement in patient/ workforce safety and the system’s ease of use. Most all reporters have been able to enter an event accurately without assistance or adjustment. Recent ongoing education through National Patient Safety Awareness Week activities resulted in a 95% pass rate on daily quiz results. An average of 85 staff members per day, representing the majority of departments, participated in this activity. This was considered a significant response given the daily staffing in a small community hospital. Staff feeling valued is absolutely vital to the effective delivery of patient care. It is very encouraging that CVMC staff has confidence in reporting their concerns and know how to do so through the Safety Intelligence system.
ACTION PLANNING WITH PATIENTS: PATIENT CHOICE
Medical Group Practices
Performance Improvement Goal: The goal of the project was to help patients self-determine and focus education and support needed for management of a chronic disease such as diabetes.
Background: This quality improvement project originated from a checklist that Dr. Jeremiah Eckhaus had created for his Diabetic patients to educate them on their status with regards to several diabetic care measures. Knowing that we needed to integrate more formal patient self-management into outpatient chronic care visits, we decided to expand the function of this form to incorporate patient self-management.
Actions: We modified the checklist form to guide patients toward setting a SMART goal (specific, measurable, achievable, relevant, and time sensitive). The form has since undergone several revisions to include additional relevant diabetic care markers, a patient tracking tool, educational resources, and an opt-in phone call for additional support in achieving their goal.
Use of the tool required changes to staff work and clinic visit flow. Each member of the care team assumed a specific role with regards to the action plan form, review of diabetic care measures, goal setting with patients, scanning the document into the record, and closing the loop with the Community Health Team. A panel coordinator was added to the practice, who performs research regarding the patients individual care measures, and identifies when patients plans are to be reviewed and updated.
Training for staff included topics such as action planning, motivational interviewing and techniques to enable staff to enhance goal setting with patients. A survey was conducted pre-and post-training which showed an increase in perceived value of action planning with patients among practice staff.
Evaluation: Patient response to the action plan has been overall positive. We found that more patients completed action plans and set goals following staff training, which reviewed the concepts of motivational interviewing and patient engagement.
Though the form itself could not be integrated into CVMC’s computer system, we designed a template which incorporates many aspects of the form into structured data so we can begin to understand the impact that self-management action planning has on our patients. We have begun collecting structured data to hopefully correlate a positive effect on health outcomes when patients set and achieve goals. The responses to date were inadequate to draw any statistically significant conclusions.
We began this process with one clinician at Montpelier Integrative Family Health refining the process before bringing all of the clinicians on board. We have since expanded the form and process to eight of the primary care practices, with hopes of expanding to pediatrics this year.
OPIOID PRESCRIPTION MANAGEMENT
Waterbury Medical Associates
Performance Improvement Goal: The goal of this project was to create a process for the management of patients prescribed opioids. This involved facilitating consensus among providers in developing a practice wide plan for prescribing. This plan reduced the burden on practice staff handling challenging situations with patients and provided clear, safe, and effective expectations for patient opioid prescription management.
Background: Waterbury Medical Associates sought to have clear and well-organized policies in place for managing opioid prescriptions (i.e. Narcotic Agreement Contracts, use of the Vermont Prescription Monitoring System, etc.). The practice sought process improvements to handle early refill requests of opioid prescriptions and offer additional non-pharmacological alternatives to treatment.
Action: A core group met once a month for nine months and included representation from all disciplines of the practice. Staff began by collaborating on a defined process to identify chronic pain management patients. Chronic pain management patients were defined as those patients who receive opioid treatment extending four weeks or more, a stable dose and fixed interval visits not more than 84 days apart. The practice was able to track the chronic pain management patients via the electronic health record and implement a series of process improvements which included:
- Prior to the visit, the nurses utilized the Vermont Prescription Monitoring System to verify the patient’s prescriptions.
- During the visit, patients were asked to sign an updated Controlled Substance Agreement.
Providers also ordered urine drug screen testing, thoroughly discussed the expectations of the Controlled Substance Agreement, scheduled the next follow up visit, and provided three prescriptions to reduce refill and call volumes as well as early refill requests.
Evaluation: Staff satisfaction and call volume for early prescription refills was measured before and after the improvement initiative. Provider satisfaction increased as well as confidence in the Vermont Prescription Monitoring System by 40%, urine screen testing increased by 60% and confidence in prescribing increased by 25%. Nursing and administrative staff were satisfied overall with the process changes and felt more effective delivering care. The early prescription refill request call volume also declined significantly. In February 2013, the average request for early prescription refills was 15 per day. Current average daily requests for early refills are zero.