Past Projects

Improving Safety of Computerized Prescriber Order Entry through Event-based Testing (CPOE)

 

The CPOE collaborative, funded by the Cardinal Health Foundation and the Partnership for Patient Care, was a one-year collaborative ending in November 2016 that aimed to improve the utilization of hospital CPOE systems so that they provide the maximum safety benefit for patients.  Over the course of the collaborative, the Institute for Safe Medication Practices (ISMP) evaluated the CPOE systems of six participating hospitals for their adequacy in detecting and preventing serious prescribing orders.  Using test scripts developed by ISMP, hospital CPOE systems were challenged with orders known to have caused harm or fatalities.  In doing so, hospital teams learned about their system limitations and vulnerabilities, such as inactivated maximum dose warnings, missing duplicate therapy alerts, the need for decision support for specific populations (such as pregnancy/lactation) and high risk drugs.  ISMP experts provided participating hospitals with specific recommendations for ways to optimize their medication systems and prevent future harm.

Goals:

1. To evaluate the level of medication safety afforded by clinical decision support (CDS) of CPOE systems in regional hospitals

2. To identify opportunities to improve medication safety through modifications to CDS and current practices around the use of the organization’s CPOE system

Contact:

Pam Braun, Senior Director of Patient Safety Partnerships and Initiatives

pbraun@hcifonline.org

OB Adverse Events Collaborative

Through Partnership for Patients, the Centers for Medicare and Medicaid Services (CMS) contracted with 26 state and national organizations to create hospital engagement networks (HENs).  These networks promote the use of strategies that foster a culture of safety and offer opportunities for hospitals to participate in projects to reduce adverse events, as well as prevent complications and readmissions. Through Partnership for Patients HEN funding from 2012 – 2016, hospitals across Pennsylvania worked together to establish Pennsylvania’s first obstetric improvement collaborative aimed at reducing maternal adverse events.  HCIF was a subcontractor to the Hospital & Healthsystem Association of Pennsylvania, a HEN.

The program curriculum reflected national quality and safety priorities which have been shown to contribute to maternal and neonatal morbidity and mortality.  Programming consisted of in-person meetings, webinars, networking calls and individualized coaching with project teams.  Activities were designed to yield organizational improvement, sustain results, build physician engagement and accountability, provide intensive support to lower performers, leverage results to drive improvement, foster transparency and trust among hospital providers, establish formal channels for dissemination of best practices, integrate safety culture tools and approaches, engage senior leaders, engage patients and families as partners in their care, and address disparities.

Key Successes and Outcomes:

1. 64% reduction in non-medically indicated early elective deliveries

2. A drop from 13.1% to 1.7% in the rate of severe morbidity in women with pre-eclampsia, eclampsia or pre-eclampsia superimposed on pre-existing hypertension

3. A drop from 16.4% to 4.1% in the rate of severe morbidity in women with maternal hemorrhage

4. 31% reduction in the rate of OB trauma related to vaginal deliveries with an instrument – achieving the lowest rate over a 6-year period during the final reporting month

5. 26% reduction in the rate of OB trauma related to vaginal deliveries without an instrument – achieving the lowest rate over a 6-year period during the final reporting month

Although the collaborative concluded in September 2016, Pennsylvania hospitals are well positioned to continue this important work though the relationships they developed, the strategies they implemented, and the resources and tools they shared with one another.

Contact:

Pam Braun, Senior Director of Patient Safety Partnerships and Initiatives

pbraun@hcifonline.org

The PAVE Project: Reducing Readmissions

 

In order to assist hospitals to improve care transitions and reduce readmissions, HCIF launched in May 2010 the PAVE Project (Preventing Avoidable Episodes: Smoothing the Way for Better Transitions), an 18-month regional collaborative to engage health care providers and community-based service organizations across the continuum of care.  Fifty-three organizations, including hospitals and health systems, non-acute providers, and community organizations, collaborated on the PAVE Project.  In order to accelerate the adoption of evidence-based strategies, encourage multi-organizational innovations and experimentation, and develop at least one strategy or achievement with significant regional impact, three workgroups were created:  Medication Management, Personal Health Record, and Care Transitions.

Goals:

1. Reduce readmission rates by 10% over the course of the 18-month project

2. Improve transitions of care from one provider to the next for patients being discharged

3. Increase patient and family engagement in the management of the patient’s health care plan

4. Engage providers and health care professionals within the entire continuum of care

Key Successes and Outcomes:

1. After two years, readmission rates improved from 12.2% to 10.7%.

2. Workgroup members developed various passports to set standards, enable communication, and improve transitions of care among providers.

a. Hospital Care Transitions Passport– A document with contact information for key departments involved in care transitions at the hospitals, as well as a description of the hospital’s care transitions process, in order to improve communication between hospitals and other providers across the continuum of care.

b. Hospital Discharge Passport – A set of standards that incorporates all of the critical components of an effective care transition at the time of hospital discharge.

c. Medication Passport – A set of standards that incorporates all of the critical components of an effective, clear, and concise medication reconciliation and transfer form.

d. Payor Passport – A document with payor contact information to be used by hospital utilization management, emergency department and discharge planning staff as a way to improve communication between hospitals and insurers.

3. Facilities implemented numerous interventions and strategies, including but not limited to:

a. Implementing screening tools to identify inpatients at high-risk for readmission

b. Improving processes to educate patients about their condition

c. Utilizing transition coaches or nurses that follow up with patients after discharge to address issues, answer questions, etc.

d. Providing patients with checklists and reminders

e. Sending discharge summaries to a patient’s primary care physician

Contact:

Pam Braun, Senior Director of Patient Safety Partnerships and Initiatives

pbraun@hcifonline.org