Transcript No Slide Title

Quality & Safety at Hadassah:
A Progress Report
September 8, 2009
Mayer Brezis, MD MPH
Professor of Medicine
Center for Clinical Quality & Safety
Several Projects of Clinical Quality
 Family’s Involvement during Physician’s Rounds
Oded Lagstein, Liran Levy, Matan Cohen, Lois Gordon &
Mayer Brezis
 Ventilator-Associated Pneumonia
Ina Apelbaum, Nurit Katz, Philip Levine, Shmulick Benenson,
Carmela Shwartz, Colin Block, Lois Gordon & Mayer Brezis
 Disruptive Behavior
Orit Samuel Ben-Dov, Robert Cohen & Mayer Brezis
Perspective on recent years of activity by the Center of
Clinical Quality & Safety
National Priorities Partnership©
Setting a National Agenda for
Healthcare Quality and Safety
Patient and family engagement
Population health
Safety
Care coordination
Palliative care
Overuse
Involvement of family during
physician’s rounds in the
departments of Medicine
Oded Lagstein, BA, Liran Levy, MD,
Matan Cohen, MD MPH, Lois Gordon,
MPH & Mayer Brezis, MD MPH
Center for Clinical Quality & Safety
Patients (n=93)
To what extent would you like a family
member next to you during doctors' visit?
Very much 78%
Does presence of family member help
getting information on your condition? 92%
on your treatment 95%
making treatment decisions 84%
Does presence of a family member help
reducing your family's anxiety 85%
Family (n=105)
To what extent would you like to be
present during doctors' visit?
Very much 70%
Does presence of a family member help
getting information on pt’s condition? 96%
on the treatment 92%
making treatment decisions 82%
Does the presence of a family member
help reducing family's anxiety 88%
Nurses (n=55)
To what extent do you support presence
of family during doctors' visit?
Very much 56%
To what extent family involvement is
important for patient’s treatment?
Very much 71%
How does family presence affect
communication with the patient?
“Improves communication” 63%
Physicians (n=31)
To what extent do you support presence
of family during doctors' visit?
Very much 55%
To what extent family involvement is
important for patient’s treatment?
Very much 85%
How does family presence affect
communication with the patient?
“Improves communication” 55%
Duration of rounds was not affected
by presence of relatives
Observations on 129
rounds in 3 depts of
Medicine
Involvement of family during
physician’s rounds: conclusion
A majority of patients, relatives, nurses
and physicians:
• support the idea
• think it improves communication
• and relieves family’s anxiety
Observations show presence of relatives
during round does not affect its duration
Findings are consistent with literature
and suggest need for change in policy
Ventilator-Associated Pneumonia
Project aim: reduce VAP incidence at Hadassah
Ina Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson,
Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis
General Intensive Care, Unit for Infection Control and
the Center for Clinical Quality and Safety
VAP Prevention:
Recommendations Rated
With High Level of Evidence
ICHE 2008
Survey results
Period of observation:
February – March 2009
Department
Mean
ventilation
days/pt.
Ventilation days Total ventilated
during
patients during
observation
observation
period
period
ICU A
ICU B
12
11
449
175
32
19
Neurosurgical ICU
16
195
11
Medical ICU
10
220
17
Total
12
1039
79
Intern. Medicine A
Intern. Medicine B
11
10
212
139
17
13
Intern. Medicine C
Total
9
10
238
589
25
55
Diagnostic criteria for VAP
Rates of Ventilator-Associated
Pneumonia: Hadassah vs literature
Department
Patients observed
Ventilation days
Cases of VAP
Percent developing VAP
VAP cases/1000 ventilation days
ICUs
43
827
15
35%
18‰
Internal
Medicine
24
296
5
21%
17‰
Total
67
1123
20
30%
18‰
Mean cases/1000 ventilation days in literature* 11‰ (95%CI, 10-13)
* Chest 2008 (before interventions, down by 50% after interventions)
Process of Care Measures
Variable
Definition
Data Source
Elevation of
head of bed
Head of the bed elevated at
30o- 45o; measured daily with a
protractor but not during
treatment of patient
Daily observation
Hand hygiene
Washing hands with soap and
Patient record
water or an alcohol-based
solution before and after contact
with ventilator, patient or
patient’s belongings
Oral care
Documentation in patient record Patient record
regarding oral treatment with
chlorhexidine solution, once
every shift
Cleaning of
ventilator
tubing
No visible discharge or dirt in
ventilator tubing
Daily observation
All variables are dichotomous (yes/no)
Adherence to VAP Guidelines
Department
Total days
observed
Head of
bed up to
30o - 45o
Oral care
Ventilator
documented tubing
clean
%
%
%
ICU A
ICU B
Neurosurgical ICU
187
59
68
74
78
58
69
75
86
32
46
68
Medical ICU
Total
81
54
68
72
432
48%
61%
72%
79
36
34
71
Intern. Medicine A
Intern. Medicine B
Intern. Medicine C
55
37
35
68
106
37
37
69
Total
240
37%
35%
68%
Adherence to Hand Hygiene (nurses)
Department
Hands washed Hands washed
before contact after contact
Gloves put on
before
contact
%
%
%
ICU A
ICU B
Neurosurgical ICU
35
55
65
33
52
62
30
40
23
Medical ICU
Total
35
48
55
33%
47%
46%
29
40
22
27
37
25
27
38
24
27%
38%
23%
Intern. Medicine A
Intern. Medicine B
Intern. Medicine C
Total
Adherence to Hand Hygiene
(Respiratory Technicians)
Department
Hands washed Hands washed Gloves put on
before contact after contact before contact
%
%
%
ICU A
12
59
58
ICU B
Neurosurgical ICU
Medical ICU
Total
13
60
61
8
45
40
11
56
58
11%
54%
53%
Intern. Medicine A
11
49
44
Intern. Medicine B
Intern. Medicine C
Total
10
47
42
9
48
45
10%
47%
43%
Summary for the VAP project
1. The incidence of VAP in the ICUs of Hadassah
is higher than those reported in the literature.
2. The percent of adherence to guidelines
recommended for VAP prevention is lower than
desirable.
3. How can adherence to these guidelines be
improved? E.g.:
 Elevating the head of the bed between 30o- 45o
 Hand washing by staff before and after contact
with ventilator, patient and patient’s belongings
 Oral hygiene (including brushing and
documentation)
 Discontinuation of sedation once a day
Intervention
Findings discussed with senior staff
of surgical ICU’s
•
•
•
•
•
•
Review of guidelines at staff meetings
Email or newsletter
Sign at room entrance
Posters
Buttons or tags
Screensavers
Head of the bed elevated at 30o- 45o
Hand washing: soap & water or alcohol-based solution
before and after contact with
ventilator, patient or patient’s
belongings
No visible discharge or dirt in breathing tube
Oral hygiene (chlorhexidine solution), once per shift
Button on physician’s
Poster on door or bed
or nurse’s uniform
Don’t touch me until
you’ve washed your
hands!
“Ask Me if I’ve
Washed My Hands”
Intervention
Findings discussed with senior
staff of surgical ICU’s
•
•
•
•
•
•
Review of guidelines at staff meetings
Email or newsletter
Sign at room entrance
Posters
Buttons or tags
Screensavers
Re-evaluation scheduled for early 2010
Disruptive Behavior
“Do you have disruptive behavior at Hadassah?”
Mark Chassin, MD, MPP, MPH
Professor of Medicine & VP for Excellence
Mount Sinai School of Medicine
President of the Joint Commission
Joint Commission now requires hospitals to have a
written code of conduct and a process for enforcing it
Disruptive Behavior
“Conduct by individual
working in the organization
that intimidates others to
the extent that quality and
safety are compromised”
Joint Commission Definition
Disruptive behavior is a form of physician impairment and has become a
focus of public health attention due to its destructive impact on
hospital staff, institutions, and patient care (The Physician Executive 2008).
Disruptive Behavior at
Hadassah:
Survey of communication measures
critical to quality & safety
Orit Samuel Ben-Dov, MD, Robert Cohen PhD,
Mayer Brezis, MD MPH
Center for Clinical Quality & Safety, Hadassah
& Hebrew University
“Don’t be shamed of learning truth from any source, even from a lower person”
Rabbi Solomon Ibn Gabirol (ca. year 1030)
Methods
 Surveys tools validated in the literature (AHRQ)
 Departments of Medicine & Surgery, EK & MS
 Convenient sample during morning workdays
 Compliance: 96/108 (86%)
 37 physicians (29 residents, 8 seniors)
 59 nurses
 Average length of service 5 years (1 month – 39
years)
 Standard statistics
Last year exposure to intimidating behavior (%)
Frequently or
Very frequently
Sometimes
Rarely
or Never
Didn’t
answer
Refuses to answer
questions/calls
9
30
60
1
Arrogant tone
Impatience to answer
questions
Strong verbal insult
Threatening body
language
18
48
32
1
22
41
36
1
9
16
73
2
9
15
76
1
“Just do it”
8
16
75
1
Physical violence
0
3
97
0
Results (cont’d)
 29% report most of the time they don’t speak
freely when they perceive a risk to a patient
 23% report they pretended an order was correct, in
spite of their doubts, to avoid conflicts
 20% feel pressured to fulfill orders despite their
reservations about safety (3x during last year)
 5% report their were involved in an error during
last year, related to threatening behavior
 Perceived threat higher in surgery than medicine;
similar among nurses and physicians
 38% feel poor handover between shifts affects
quality
Perspective on recent years of activity by the
Center of Clinical Quality & Safety
Achievements
Dozens of projects in
important fields, e.g.:
Prevention of thrombo-embolism
Training patients for warfarin use
Safety in drug administration
Coronary care measures
Palliative care
ER (waiting, pain Rx, ankle Dx, UTI Rx)
Reliability of imaging readings
Specific surgeries (Hernias, Eye, ENT)
Hand hygiene
Impact of translators
Infections in central lines
hadassah.org.il/departments/quality
Correct identification of
improvement opportunities
Challenges
No translation of project
into routine work
No continous measure of
quality indices
No increase in error
reporting by physicians
No cultural change
Failure in a shift to
systematic improvement