Transcript Safety Across the World October 12, 2011

Safety Across the World
International Patient Safety Symposium
November 10, 2011
Maureen Bisognano
President and CEO
IHI
At 2pm yesterday, the urologist's office called to say that Bob was scheduled for 8am surgery
today and to make sure he was drinking only liquids. Everything was OK at their end.
At 4pm yesterday, Bob's cardiologist's office called to say that they just got a call from the
anesthesiologist - the one who would be working w/the urologist - to say that the surgery cannot
be performed since Bob's cardiologist did not fill out the 'approval for surgery letter' with the
right terminology, and that the cardiologist is on vacation this week and cannot be contacted at
all. Sonsabitches!! Bob's blood pressure shot up so high I thought he was gonna have a stroke!
Bob then proceeded to leave voice mail messages for 3 people in the urologist's office, finally
getting a human being to ask that the surgeon give him a call asap.
At 6:30pm, the surgeon called to say that he had just spoken to the anesthesiologist and he
concurs that the surgery cannot be performed until said cardiologist returns to the office to fill
out the proper paperwork and for Bob to possibly have more invasive testing before surgery, even
though he's had every battery of pre-surgery tests known to man.
It seems that the person in the pre-surgery office OR the assistant to the anesthesiologist did
not take the time to make sure ALL of Bob's paperwork was in order for the surgery before the
11th hour!
Bob already filled out office paperwork to take a leave of absence from work, along with a halfpay medical leave, so he's pretty mad about this last minute cancellation and so am I.
Today 11am - the very busy urologist called back to give a tentative surgery date of Tuesday,
11/08 (another 2 wks. from now)
The waiting continues, along with the emotional drain and frustration for Bob and our family.
Thanks for caring.
Hi Sophie,
Of course you can tell our ongoing saga about Uncle Bob’s eventual
surgery. Even though the surgeon is not in any hurry, this surgery is
important to us since Bob has a large cancerous tumor growing outside his
bladder PLUS a non-functioning left kidney that must be removed before it
becomes dangerous in any way. And adding to these problems, Bob has high
blood pressure and diabetes, along with other medical issues! I guess I
definitely need to stay strong and healthy to keep this family going.
Hang in there toots.
Hugs, Aunt Rhonda
Safety in Aviation
•
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•
•
Sully Sullenberger
Design
Reliability
Checklists
Human Factors
Sullenberger’s Priorities
• Fly the plane
• Deal with the situation
• Communicate
208 seconds
Sullenberger’s Decision
“My aircraft” … “your aircraft”
• All options for landing on
left side
• More hours in that plane
• 11 months since simulation
training…co-pilot: 1 week
• Co-pilot’s first time in Airbus
Sully on Sully
• Physical stress causes
increased blood pressure,
increased heart rate, and
narrowed vision
• Forced calm on himself
• “Be the swan”
• Imposed order on chaos
• Chose to do only critical
things
Safety in Healthcare
•
•
•
•
Design
Reliability
Checklists
Human Factors
• Systems
knowledge
“To Err is Human”
(1999)
How can we learn about our
system performance?
Diagnostic Journey
• Do people die unnecessarily every day in our
hospitals?
• In order for us to understand this, we need a
diagnostic journey that moves out of a model for
judgment and into a model for learning.
The Mortality Diagnostic – 2x2 Matrix
• Review most recent 50 consecutive
deaths
• Place them into a two by two matrix
based on:
- Was the patient admitted for palliative care?
- Was the patient admitted to the ICU?
• Focus your work initially on boxes that
have at least 20% of your mortality
Diagnostic – The 2 x 2 Matrix
Admitted to the ICU?
Yes
Admitted
for
Palliative
Care
Only?
No
Yes
Box #1
Box #2
No
Box #3
Box #4
The Mortality Diagnostic:
Failure to Recognize, Plan, Communicate
• Analyze deaths in box 3 and 4 for
evidence of failure to: recognize,
communicate, plan
• This will help you understand the local
environment
Recognize, Communicate, Plan
Failure to Recognize: Any situation in which a patient has
died and there was evidence that an intervention could have
been made anytime prior to the patient’s death Example:
the staff was worried, change in heart rate, change in
respiratory rate, change in blood pressure, change in O2
saturation or change in consciousness or neurological status
that was not responded to.
Failure to Plan, such as: diagnosis, treatment, or calling a
rescue team.
Failure to Communicate: Patient to staff, clinician to
clinician, inadequate documentation, inadequate supervisor,
leadership (no quarterback for the team), etc.
The Mortality Diagnostic:
The Impact of Care
Evaluate ALL deaths in box 3 and box 4 to assess
the estimated impact of our care on mortality:
*As you review the deaths in box 3 & 4, ask
yourself the questions honestly (focusing on
learning, not judgment):
─
─
Was perfect care rendered?
If perfect care wasn’t rendered, could the outcome
of death have been prevented if the care had been
better?
 What number of deaths could have been
prevented?
The Mortality Diagnostic:
Evidence of Adverse Events
• Analyze deaths in box 3 and 4 for
evidence of adverse events using the
Global Trigger Tool
• This will give some further direction to
local problems
Global Trigger Tool
• Review chart for triggers that are sensitive
and specific for harm
• Find a trigger – Was there harm?
• Not all triggers mean there was harm!
Global Trigger Tool Modules
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•
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•
•
Cares (General)
Critical Care
Medication
Surgery
L&D
ED
Example of a trigger:
Transfer to higher level of care
• Endoscopy
• Post procedure somnolent and
hypotensive (BP 80) transferred to ICU
• Placed on Bi-Pap
• Received standard Demerol and Versed
for procedure
• Given Romazicon; stayed in unit 12 hours
Global Trigger Tool Examples
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•
Readmit within 30 days with recurrence of abscess right hip
Readmit next day w/ileus s/p exp lap for tumor
Stopped lasix-acute renal failure
Readmitted in 30 days for wound revision due to incisional
seroma
Readmit related with wound infection
Volume Depletion with altered mental status caused by Lasix
-resulted in hospital admission
ARF due to nephrotoxicity due to combination of ACE and
NSAIDS taken at home
Ischemic colitis had rt hemicolectomy. New onset CP=MI
Unresponsive, coded. Decreased loc & sats on
Morphine PCA. Rec'd Narcan
Safety Initiatives
Studying Mortality
Kaiser Permanente:
“Saving Lives by Studying Deaths”
• To address substantial variation across their
hospitals, KP quality leaders led an efficient
and effective method of investigating mortality
to find patterns of harm
• Used IHI’s Global Trigger Tool and 2x2 mortality
matrix, as well as other tools
• Multidisciplinary teams studied the 50 most
recent inpatient deaths at 11 KP hospitals
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality
Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality
Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality
Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality
Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Storytelling
• Project leaders incorporated the use of deidentified patient narratives to get at the
circumstances behind the data.
• Stories were selected to share with
hospital leaders to identify common issues
that would help drive improvement.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality
Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Results
• 10 categories of harm were identified (listed below in
order of decreasing frequency):
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Harm occurring before hospitalization
Hospital-acquired infection
Failure to plan
Failure to communicate
Other harm
Hospital-acquired pressure ulcer
Surgical/procedural complication
Failure to rescue
Medication event
Fall
• In response, hospital leaders identified 36 quality
improvement goals to pursue.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality
Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Scottish Patient Safety Program
Specific Outcome Aims for
Academic and District General Hospitals
By January 2011
• Mortality: 15% reduction
• Adverse events: 30% reduction
• Ventilator associated pneumonia: 0 or 300 days between
• CL CR-BSI: 0 or 300 days between
• Blood sugars w/in range (ITU/HDU): 80% or > w/in range
• Staph aureus bacteraemias: 30% reduction
• Crash Calls: 30% reduction
• Harm from anti-coagulation: 50% reduction in ADEs
• Surgical site infections: 50% reduction (clean)
The Scottish Patient Safety
Program
• NHS Quality Improvement Scotland
• The Scottish Government Health
Directorate
• The Institute for Healthcare Improvement
Patient Safety Alliance
Programme
Driver Diagram
Improve Safety of
Hospital Healthcare
Services in Scotland
Primary Drivers
Boards Accept
Safety as Key
Strategic Priority for
Effective
Governance
Scottish Executive
Sets PSA as
Strategic Priority
Robust, evidence
based proven
clinical changes
Secondary Drivers
Ownership of agreed upon set of outcomes
Review of outcomes at each meeting
Quality and safety comprises 25% of agenda
Recovery plans for unmet outcomes
Infrastructure supports improvement and
measurement
Involve patients in safety
Demonstrable results to community
Clear, shared measurement set
Visible on all senior leader agenda
PSA represents & demonstrates
cohesive, united programme
Acceptance of pragmatic science Royal College
Supports PSA Programme
IHI/QIS Team Expert
at Content, Coaching
and Programme
Management
International expert clinical faculty
Faculty expert at improvement methods and
coaching
Programme design and structure
Align national SPSP
with national
improvement
programmes and
measures
Inventory national programmes and
measurements
Meet with programme leader to understand
programme intent, audience, history
Harmonize our metrics
Technical
Driver Diagram
Primary Drivers
Leadership
System for Safety
Secondary Drivers
Safety as a Strategic Priority
Sustainable Infrastructure
Engaged and Committed Leadership
.******
Improve healthcare
safety by
reducing:
1. Mortality by 15%
2. Adverse events
by 30%
Care of General
Ward Patients
Perioperative
Care Management
Medicines
Management
** Infection
Prevention
**National Priorities,
Programs,
Strategies
Care for Acute MI
Patents
Pressure Ulcers
CHF key processes
Handoffs **Hospital at Night
Communication
Failure to Rescue *SEWS
Clean Surgical Site Infection**
Medicines Reconciliation**
High Alert Medicines (**antioagulation,
narcotics, insulin)
Handoffs and Transitions
MRSA + MSSA infections
C-difficile infections
Hand hygiene and general infection
prevention
AMI mortality
Seven key AMI processes
Scottish Patient Safety Program (SPSP)
Critical Care Central Line BSI Rate
November 2007 through December 2010
Central Line BSI rate (BSIs per 1000 central line days)
(Goal: 0 CL BSIs)
12
10
8
6
T1 Median = 2.7
4
T2 Median = .71 (74% decrease)
2
0
Scottish Patient Safety Program (SPSP)
VAP Rate
March 2008 through December 2010
(Goal: 0 VAPs)
VAP Rate (VAPs per 1000 ventilator days)
20
18
16
14
12
T1 Median = 8.4
10
8
6
4
2
0
T2 Median = 4.6 (45% decrease)
Scottish Patient Safety Program (SPSP)
Critical Care C. Diff Rate
January 2008 through December 2010
(Goal: 50% reduction)
5
C. Diff Rate per 1000 patient days
4.5
T1 Median = 1.6
4
3.5
3
2.5
2
1.5
1
0.5
0
T2 Median = .44 (73% decrease)
Financial Impact of Safety Initiatives
Serious Safety Event Prevention
Hospital Wide Effort - #1 Priority
Serious Safety Events per 10,000 Adj. Patient Days
Rolling 12-Month Average
1.8
Desired Direction
of Change
36 SSE’s Prevented
1.4
1.2
1.0
0.8
0.6
2010 Goal
0.4
aSSERT Began
July 2006
0.2
0.0
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Events per 10,000 Adj. Patient Days
1.6
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010
** Each point reflects the previous 12 months. Threshold line denotes significant difference from baseline for those 12 months (p=0.05).
** The narrowing thresholds in FY2005-FY2007 reflect increasing census. Adjusted patient days for FY07 were 27% higher than for FY05.
SSEs per 10,000 Adj. Patient Days
Baseline [ 1.0 (FY05-06) ]
Fiscal Year Goals (FY07=0.75 / FY08=0.50 / FY09=0.20)
Threshold for Significant Change
Case Study - HAI
• Reducing hospital
acquired infections
– Our “breakthrough” effort
Reducing Hospital Acquired Infections
Improved Medical Outcomes & Error Elimination
• Clinical initiatives to reduce Catheter Associated
Bloodstream Infections (BSI), Surgical Site Infections
(SSI) & Ventilator Associated Pneumonia (VAP) were
initiated
• At time, our rates were close to the national averages:
– BSI rate = About 2 out of every 100 children with a catheter
– SSI rate = About 1.5 out of every 100 children receiving
surgery
– VAP rate = About 4 out of every 100 children placed on a vent
• Our own data suggested that maybe 15-20% of kids in
the ICU who acquired a BSI, VAP or other serious
infection might be expected to die
Reducing Hospital Acquired Infections
Improved Medical Outcomes & Error Elimination
• Interventions aimed at reducing infection rates
were developed from published best practices &
our own observations & thoughts
• Development of Pediatric Specific Bundles for
Care Delivery
• Intense focus on Execution
• Transparency of Results
– Outcomes drive Culture Change
Reducing Hospital Acquired Infections
Improved Medical Outcomes & Error Elimination
• What was achieved in first 2 years:
– BSI rate reduced by 60%; meaning 29 fewer kids
suffered a preventable infection
– SSI rate reduced by 60%; meaning 50 fewer kids
suffered a preventable infection
– VAP rate reduced 90%; meaning 70 fewer kids
suffered pneumonia in our ICU
• MOST IMPORTANTLY potentially 20 children went
home from our hospital that statistically may not have
been expected to be do so!
4.0
0.8
Quantifying the Financial Impact of An
Enormous QI Success
• Brilliant Hypothesis: A HAI is “Bad Business”
– Clinical Outcome not as good – inability to differentiate
our product
– Poor customer Value - dollars spent in treating
infection = waste
– Potential high opportunity cost – bed occupied by HAI
could effect flow and ability to meet access needs of
out-of-area admission
– Poor Patient Experience
• We needed a proven methodology to test and
conclusively measure our hypothesis
Comparative Matched-Case
Study Design
• Chart reviews to define candidates and assess
whether SSI was potentially preventable
• Matched Case-Control Design
– Initial OR Cost of SSI case = Control (No SSI) OR Case
– Cumulative Cost at time of discharge of Control case =
SSI Case
– Match criteria: same or equivalent surgical procedure,
age, procedure date, co-morbidities
– Excluded patients with cancer, immune deficiency,
neonates or over 19 yrs old
• 16 Patients in final statistical analysis
Sparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health
Care 2007;16:219-225.
SSI Results
Aggregate Cumulative Charges
$2,000,000
SSI
Match
$1,500,000
$1,740,000
Ave LOS = 16.0 days
$1,000,000
$793,000
$500,000
Ave LOS = 4.6 days
$0
0
5 10
15 20 25 30 35
40 45 50 54 60 65
Days after surgical procedure
Sparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health
Care 2007;16:219-225.
8
70 75 15
80
Reducing Hospital Acquired Infections
Improved Medical Outcomes & Error Elimination
Nothing compares to the human impact of this effort &
nothing is even remotely as important; but there is more:
– We reduced the costs to the health care system by
$11.2 million annually
– And we reclaimed 5 beds per year previously dedicated
to infections that could now be dedicated our core
strategy of unique program development
Maximizing Asset Production –
Revenue Production Associated with SSI
90 Day Revenue Production Cycle
When 6 Patients Develop an SSI
Bed Cycle For SSI Patients
Average LOS for Surgery Patients With Infection = 15 Days
Total Revenue Produced in 90 Day Cycle = $622,000
$40,000
$20,000
$10,000
Day
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
$0
0
Daily Charges
$30,000
Same 90 Day Cycle of Revenue Production
If No Patients Acquire SSI (18 patient potential)
$40,000
Bed Cycle For Non-SSI Patients
Average LOS for Surgery Patients Without Infection = 4.4 Days
Total Revenue Produced in 90 Day Cycle = $892,000
Annualized Incremental Revenue = $1,080,000
$20,000
$10,000
Day
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
$0
0
Daily Charges
$30,000
J-09
F-09
M-09
A-09
M-09
J-09
J-09
A-09
S-09
O-09
N-09
D-09
J-10
F-10
M-10
A-10
M-10
J-10
J-10
A-10
S-10
6
Diuretic Related Harm per 100 Patients on Loop
Diuretics
5
4
3
2
1
0
HFH
Henry Ford Health System
Total Harm-Associated Costs 2009*
Harm Issue
Pressure Ulcer stage 2 or higher
Total Associated Costs
$10,624,410
Coded Procedural Complication ICD9 (998-999.99)
UTI using coded data and AHRQ definition.
Glucose below 40
Coded Acute Renal failure
$7,670,520
$5,662,895
$3,846,375
$2,665,680
Coded DVT/PE in both medical and surgical patients
No Pulse Blue Alert
Coded Medication issue
Clostridium difficile infection
Reported Fall with injury
Bloodstream Infections using NHSN criteria
Coded Pneumothorax using AHRQ definition
SSI using NHSN criteria
VAP using NHSN criteria
$2,365,470
$1,535,808
$1,216,078
$824,544
$696,527
$640,000
$340,260
$280,000
$190,352
*Henry Ford Hospital Only
The Leader’s Role
•
•
•
•
Executive WalkRounds
Deep dives in safety data and stories
Signs and symbols of a just culture
Move from past tense to future tense
─Huddles
─Inquiries
• Aims, prototype sites, spread plan and
tempo
Thank You!
• Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
20 University Road, 7th Floor
Cambridge, MA
[email protected]