Transcript Slide 1
University Medical Center
Tucson, Arizona
Evidence Based Approach to Quality Improvement
Andreas A. Theodorou, MD Chief, Pediatric Critical Care Medicine Associate Head, Department of Pediatrics Professor, Clinical Pediatrics The University of Arizona Chief Medical Officer, UMC © 2010 College of Medicine
To Err Is Human: Building a Safer Health System (IOM, 2000)
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The first of 4 IOM reports “The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering.”
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44,000-98,000 people die each year from mistakes
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UMC Responded!
“Quality and Safety First”
© 2010 College of Medicine
Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001)
Second of 4 IOM reports Safety problems because: Inability to translate knowledge into practice, apply new technology safely and appropriately and to make the best use of resources (financial and human)
Blaming health providers is not the answer!
We must address the system flaws © 2010 College of Medicine
Health Professions Education: A Bridge to Quality (IOM, 2003)
• Third of 4 IOM reports • “All health professionals should be educated to deliver patient-centered care
as members of an interdisciplinary team
, emphasizing evidence-based practice, quality improvement approaches, and informatics.” © 2010 College of Medicine
J. Lyle Bootman (co-chair) Dean, U of A College of Pharmacy
© 2010 College of Medicine
Several Evidence Based Clinical Guidelines Including…
• Stroke • Traumatic Brain Injury • Sepsis • Core Measures • Central Line Bundle • • Ventilator Associated Pneumonia Bundle “Time-Out” check list © 2010 College of Medicine
National Patient Safety Goals
• • Established by The Joint Commission • • • Statistically found to be problem areas •
Improve the accuracy of patient identification.
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Improve the effectiveness of communication among caregivers.
Improve the safety of using medications.
Reduce the risk of health care-associated infections.
Accurately and completely reconcile medications across the continuum of care.
Reduce the risk of patient harm resulting from falls.
© 2010 College of Medicine
National Patient Safety Goals
• • • • • Continued…
Encourage Patients’ active involvement in their own care as a patient safety strategy Identify patients at risk for suicide.
Fulfill expectations set forth in the Universal Protocol (prevent wrong-site, wrong person, wrong procedure) Reduce the likelihood of patient harm with the use of anticoagulation therapy Recognize and Respond to Change in Patient’s Condition (RRT/EMT)
© 2010 College of Medicine
How Do We Measure Quality?
Who’s Doing the Measuring?
Internally
Incident reports Peer Reviews Physician Profiles Sentinel Events M & M’s Patient Satisfaction QI “projects” Root Cause Analysis FMEA
Externally
(some allow public access)
Gov’t Agencies CMS AHRQ Medical Boards Private Agencies The Joint Commission NQF UHC HealthGrades “Best Hospitals” “Best Docs” Health Care Plans © 2010 College of Medicine
Must have a reliable data source
University HealthSystem Consortium The University HealthSystem Consortium (UHC), Oak Brook, Illinois, formed in 1984, is an alliance of 103 academic medical centers and 219 of their affiliated hospitals representing approximately 90% of the nation's non-profit academic medical centers. UHC offers an array of performance improvement products and services. Powerful databases provide comparative data in clinical, operational, faculty practice management, financial, patient safety, and supply chain areas.
© 2010 College of Medicine
Core Measures
• Acute Myocardial Infarction • Heart failure • Pneumonia • • Surgical Care Improvement Project Children’s Asthma Care • http://www.hospitalcompare.hhs.gov/ © 2010 College of Medicine
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Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality Rates
• Rachel M. Werner, MD, PhD; Eric T. Bradlow, PhD
JAMA. 2006;296:2694-2702.
© 2010 College of Medicine
UMC MICU Quality Improvement Projects
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Multidisciplinary approach
• Nursing, physician, pharmacy, RT, quality improvement •
Data collection by staff/QI
• Success related to investment of individuals •
Introduce innovations
• Improvements in daily practice • Evidence based © 2010 College of Medicine
UMC MICU Quality Improvement Projects
• Monthly meetings- forum for discussion • Literature review of best practice • Discover problems and look for cause • Leaders in each project area • Discuss new ideas for change in practice © 2010 College of Medicine
CVL 1200 Packs 2Q04 1000
5 East Blood Stream Infections per 1000 CVL Days
IHI 2Q05 CVL Checklist 2Q06 Checklist Revised 3Q06 Full body Drape in Packs 3Q07 Clave 4Q07 PICC Team 1Q08 Infection Control Update 1Q08 14.00
Arrow kits w Anti microbial catheter 3Q08 12.00
10.00
800 8.00
600 400
Great Job, 5East! BSI's = 0!
6.00
4.00
200 2.00
0 BSI CVL Days Rate 2Q 04 3 624 3Q 04 7 966 4.81 7.25
4Q 04 4 801 1Q 05 3 971 4.99 3.09
2Q 05 6 745 3Q 05 5 752 4Q 05 3 502 8.05 6.65 5.98
1Q 06 4 566 2Q 06 6 499 3Q 06 3 889 4Q 06 3 778 1Q 07 3 893 7.06 12.02 3.37 3.86 3.36
2Q 07 4 811 3Q 07 5 765 4Q 07 3 887 4.93 6.54 3.38
1Q08 2Q08 1 853 1 889 1.17 1.12
3Q 08 0 825 0.00
Data Source: Infection Prevention Graph: G Priestley, RN 0.00
© 2010 College of Medicine
18 16 14
5East Ventilator-associated Pneumonia Rate Infection Prevention Update 1Q08
12 10 8 6
Prior Interventions: RASS, HOB, Oral Care, Daily Wake up,
4 2 0
5East VAP Rate 1Q 07 15.66
Data: Infection Prevention Graph: G Priestley, RN
2Q 07 15.6
3Q 07 9.33
4Q 07 4.33
1Q08 4.4
Focus on Oral Care 2Q08 2Q08 2.9
3Q08 7.33
Sedation Update: Intermittent Bolus Option 1Q09 4Q08 7.82
1Q09 4.4
2Q09 6.22
© 2010 College of Medicine
Medication Error Reduction Strategies
• What is the evidence of value of other technological innovations?
• What level of evidence is needed to justify expense of such innovations?
• Automated dispensing devices • Smart infusion pumps • Bar coding
Leape et al. JAMA 2002;288:501
© 2010 College of Medicine
Patient Safety Meets Evidence-Based Medicine
• Shonjania et al. Making health Care Safer: A Critical Analysis of Patient Safety Practices ;2001. AHRQ publication 01-E058 • UCSF-Stanford University Evidence-Based Practice Center • 40 investigators around the country • Over 80 “safety practices” reviewed © 2010 College of Medicine
Medication Error Reduction Strategies
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Medium strength of evidence 1
Computerized physician order entry (CPOE) fully implemented in few health systems On-site pharmacist with participation on ICU rounds- approximately 30% of health systems report having a pharmacist on attending rounds (survey not specific to ICU setting) 2
1. Shojania K et al. JAMA 2002;288:508-11 2. Pedersen et al. Am J Health-Syst Pharm 2001;58:2251
© 2010 College of Medicine
Medication Error Reduction Strategies
• Medication Reconciliation Pronovost et al. Journal of Critical Care, Vol 18, No 4 (December), 2003: pp 201-205 • 46% of medication errors occur on admission or discharge • Marked decrease in errors after initiation of discharge survey • The Joint Commission (Patient Safety Goal) © 2010 College of Medicine
The National Quality Forum/ Agency for Healthcare Research and Quality
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30 Safe Practices for Better Health Care
AHRQ March 2005, Pub No. 05-P007 • Pharmacists should actively participate in the medication-use process Implement CPOE system Standardize the methods for labeling, packaging, and storing medication Identify “high alert” drugs Dispense medications in unit-dose or unit-of-use form, whenever possible © 2010 College of Medicine
Organization-wide UMC QI Project
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Medication Delivery System
Implementations: • • • • • • • • Computerized Physician Order Entry (SCM) Electronic Medication Administration Record Established Medication Use Subcommittee Weekly audits of med bins and Pyxis Clinical pharmacists assigned to specific units Changed bin fill times Established 3rd Floor Pharmacy Satellite Clinic Separated look alike/sound alike drugs in pharmacy Evaluation showed Improvements: • Reported distribution errors decreased 16% • Rate of prescription errors reduced by 95% • Medications missing from patient bins decreased by 50% © 2010 College of Medicine
Medication Error Reduction Strategies Smart Infusion Pumps
• Rothschild et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 2005;33(3):533-540 • • • I.V. med errors and ADEs can be detected by smart pumps No measurable impact on serious error rate due to poor compliance “Smart pumps have great promise…” • Leape.
Crit Care Med 2005;33(3): 679-80 •
“Humans can always defeat technology if it is
perceived as a barrier.”
© 2010 College of Medicine
Five Years After To Err is Human What Have we Learned?
Leape and Berwick. JAMA 2005;293: 2384
Intervention CPOE Pharmacist rounding with team Reconciliation Medication Practices Reconciling and standardizing medication practices Standardizing insulin dosing Result 81% reduction in med errors 66 - 78% reduction of preventable ADEs 90% Reduction in medication errors 60-64% Reduction in ADEs Standardizing warfarin dosing Trigger tool and automation Hypoglycemic episodes decrease 63% Out-of-range INR decrease 60% ADEs decrease by 62% © 2010 College of Medicine
The New Yorker: The Checklist
December 10, 2007 Atul Gawande © 2010 College of Medicine
A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group. NEJM January 2009
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Results :The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
Conclusions: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
© 2010 College of Medicine
UHC Data with Benchmarks
UMC © 2010 College of Medicine
© 2010 College of Medicine