Transcript Slide 1
Welcome to the
NQF Safe Practices for Better Healthcare 2009 Update Webinar: Creating Transparency, Openness, and Improved Safety (Safe Practices 5-8)
Hosted by NQF and TMIT Attendee dial-in instructions: Toll-free Call-in number (US/Canada): 1-866-764-6260 (direct number, no code needed) To join the online webinar, go to:
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Online Access Password: Webinar1 (case-sensitive) 1
Welcome and Safe Practice Overview
Charles Denham, MD Chairman, TMIT; Co-chairman, NQF Safe Practices Consensus Committee; Chairman, Leapfrog Safe Practices Program
Safe Practices Webinar October 22, 2009 Toll-free Call-in number: 1-866-764-6260 2
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Panelists
Charles Denham Timothy McDonald Lucian Leape Charles Denham: Welcome and Safe Practice Overview Timothy McDonald: Looking Forward: Principles Applied Lucian Leape: Looking Back: Lessons Learned Peter Angood: Rebecca Martins: The National Quality Forum Perspective Opportunities for Patient and Family Involvement
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Peter Angood Rebecca Martins
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Changes of 2006 Version to 2009 Update Practice Line-Up Changes:
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From 30 to 34 Practices Culture Practice Elements Broken Up into 4 Practices 2 Practices Discontinued 4 Medication Management
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Practices Combined into 1 2 Communication Practices Combined into 1 8 New Practices Added CMS Care Settings Defined Patient and Family Involvement Section Added Final Report:
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Format Structure Preserved Lightly Edited Text of Most Practices New Practices Updated References Corrections and Clarification Care Setting Clarification Using
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CMS Classification Measures To Be Considered (in formulation)
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Soft Copy Document Hyperlinks Crosswalk Tables Glossary
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Harmonization – The Quality Choir
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Culture Consent & Disclosure Consent and Disclosure Workforce Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices
2009 NQF Report Legend: No Material Changes Material Changes New Structures and Systems Culture Culture Meas., FB., and Interv.
Team Training and Team Interv.
ID and Mitigation Risk and Hazards Informed Consent Life-Sustaining Treatment Disclosure Care of Caregiver Nursing Workforce Workforce Direct Caregivers ICU Care Information Management and Continuity of Care Patient Care Info.
Read-Back & Abbrev.
Labeling Studies Discharge System CPOE Medication Management Med. Recon .
Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central V. Cath.
BSI Prevention Sx-Site Inf.
Prevention VAP Prevention MDRO Prevention UTI Prevention Condition-, Site-, and Risk-Specific Practices Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy Contrast Media Use Organ Donation Glycemic Control Falls Prevention Pediatric Imaging
CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices]
Leadership Structures and Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions
Identification and Mitigation of Risks and Hazards
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CHAPTER 3: Informed Consent and Disclosure
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Informed Consent
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Life-Sustaining Treatment Disclosure Care of the Caregiver CHAPTER 4: Workforce
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Nursing Workforce
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Direct Caregivers
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ICU Care CHAPTER 5: Information Management and Continuity of Care
Patient Care Information
Order Read-Back and Abbreviations Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE CHAPTER 6: Medication Management
Medication Reconciliation Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging
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CHAPTER 7: Hospital-Associated Infections
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Hand Hygiene
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Influenza Prevention
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Central Venous Catheter-Related Blood Stream Infection Prevention Surgical-Site Infection Prevention Care of the Ventilated Patient and VAP MDRO Prevention UTI Prevention
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CHAPTER 8:
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Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention
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Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging
Values Systems Structures Behaviors Outcomes LEADERSHIP STRUCTURES and SYSTEMS Patients and Community Leadership Structures and Systems Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Identification and Mitigation of Risks and Hazards NQF 34 Safe Practices
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Looking Forward: Principles Applied
Timothy McDonald, MD, JD Chief Safety and Risk Officer for Health Affairs; Professor, Anesthesiology and Pediatrics, University of Illinois
Safe Practices Webinar October 22, 2009 Toll-free Call-in number: 1-866-764-6260
National Quality Forum Safe Practices
#5 Informed Consent #6 Life-Sustaining Treatment #7 Disclosure #8 Care of the Caregiver Toll-free Call-in number: 1-866-764-6260 16
NQF SP #5
#5 Informed Consent Toll-free Call-in number: 1-866-764-6260 17
Background to Current Problem
Arch Surg 2000; 135:26-33 Only 24% of consent forms contained the four elements considered essential for informed consent. Designed more to protect institution than inform patient.
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Background to Current Problem
The gap between patient reading comprehension and the readability of patient education materials. Davis, Crouch et al.
J Fam Pract 1990; 31(5):533-8 Average reading comprehension was 6 th grade; Educational materials – 11
at college-level
th to 14 th grade;
Informed consent written materials – written
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NQF SP #5
• Informed Consent: Safe Practice Statement • Ask each patient or legal surrogate to “teach back,” in his or her own words, key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent.
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NQF SP #5
• Informed Consent: Additional Specifications - Informed consent documents for use with the patient should be written at or below the 5 scope of the procedure. impairments. th -grade level. - Shared decision-making: the patient and the family should be engaged in a dialogue about the nature and - A qualified medical interpreter or reader should be provided to assist patients with limited English proficiency, limited health literacy, and visual or hearing - The risk that is associated with high-risk elective cardiac procedures and high-risk procedures with the strongest volume-outcomes relationship should be conveyed.
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Informed Consent: Looking Forward
• Full disclosure begins with the first visit to the caregiver’s office or with obtaining an informed consent • Consider a random selection of patients for follow-up and assess degree of “recall” related to the informed consent process and “teach back” • Future with computerized, internet-linked adult learning methodologies to engage patients and their families Toll-free Call-in number: 1-866-764-6260 22
NQF SP #6
#6 Life-Sustaining Treatment Toll-free Call-in number: 1-866-764-6260 23
NQF SP #6
• Life-Sustaining Treatment: The Problem • The provision of unwanted end-of-life care is an adverse event that can be avoided by effective patient/provider collaboration • In one study, 48% of patients with advance directives received mechanical ventilation against their wishes Fins JJ, Miller FG, Acres CA, et al. End-of-life decision-making in the hospital: current practice and future prospects.
J Pain Symptom Manage
1999 Jan;17(1):6-15.
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NQF SP #6
• Life-Sustaining Treatment: Safe Practice Statement • Ensure that written documentation of the patient’s preferences for life-sustaining treatments is prominently displayed in his or her chart.
• Additional specification: Organization policies, consistent with applicable law and regulation, should be in place that address patient preferences.
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A Not-Uncommon Ethical Dilemma
• Elderly patient, with DNR order - GI suite for peg • Peg for nutrition and pain management • Is alert and conversant • In error, patient over-sedated • Patient becomes apneic • Code called • DNR form recognized • Caregivers panic Toll-free Call-in number: 1-866-764-6260 26
Ethical Principles
• Beneficence • Non-maleficence • Patient autonomy • Truth telling • Ethical dilemmas – when principles conflict Toll-free Call-in number: 1-866-764-6260 27
The Dilemma
• Beneficence – put the tube in/give reversal • Non-maleficence – put the tube in/give reversal • Patient autonomy – do not resuscitate!
• Truth telling - ?
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Life-Sustaining Treatment: Looking Forward
• Should advance in parallel with informed consent • Involves shared decision-making • Can “force function” with documentation requirements • Electronic medical record solutions Toll-free Call-in number: 1-866-764-6260 30
#7 Disclosure
NQF SP #7
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NQF SP #7
• Disclosure: The Problem • We “deny and defend” • We “shame and blame” • We hide behind a “wall of silence” • We fail to learn from our mistakes • Patients and their insurers pay for our mistakes Toll-free Call-in number: 1-866-764-6260 32
NQF SP #7
• Disclosure: Safe Practice Statement • Following serious unanticipated outcomes, including those that are clearly caused by systems failures, the patient and, as appropriate, the family should receive timely, transparent, and clear communication concerning what is known about the event • Disclosure: Additional Specifications - Support system, reporting, communication, apology, performance improvement, remedy Toll-free Call-in number: 1-866-764-6260 33
Hard-wiring NQF SP #7 A Comprehensive Approach to Adverse Patient Events
Data Base Patient Communication Consult Service No Patient Harm?
Yes Consider “Care for Caregiver” Error Investigation hold bills?
Unexpected Event reported to Safety/Risk Management “Near misses” Process Improvement No Inappropriate care?
Yes
Full Disclosure with Rapid Apology and Remedy Activation of Crisis Management Team
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Disclosure: Looking Forward
• Full engagement of stakeholders - Patients and families - Caregivers - Administrators - Malpractice insurers - Health insurers - Legal community - A cultural transformation – the “Trojan horse” Toll-free Call-in number: 1-866-764-6260 35
NQF SP #8
#8 Care of the Caregiver Toll-free Call-in number: 1-866-764-6260 36
NQF SP #8
• Care of Caregiver: The Problem • Caregivers are also hurt by medical error • Can develop psychological impairment • Impairment can lead to future errors • Vicious cycle West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.
JAMA
Sep 6;296(9):1071-8. 2006 Toll-free Call-in number: 1-866-764-6260 37
NQF SP #8
• Care of the Caregiver: Safe Practice Statement • Following serious unintentional harm due to systems failures and/or errors that resulted from human performance failures - the involved caregivers should receive timely and systematic care: treatment that is just , respect , compassion events.
, investigation supportive medical care , and the opportunity to fully participate in event and risk identification and mitigation activities that will prevent future Toll-free Call-in number: 1-866-764-6260 38
Hard-wiring NQF SP #8 A Comprehensive Approach to Adverse Patient Events
Data Base Patient Communication Consult Service No Patient Harm?
Yes Consider “Care for Caregiver” Error Investigation hold bills?
Unexpected Event reported to Safety/Risk Management “Near misses” Process Improvement No Inappropriate care?
Yes
Full Disclosure with Rapid Apology and Remedy Activation of Crisis Management Team
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Care of Caregiver: Looking Forward
• Rapid response teams for patients, caregivers • Psychological support for all • Ongoing support and assessment • Implementation of “just culture” concepts Toll-free Call-in number: 1-866-764-6260 40
Looking Back: Lessons Learned
Lucian Leape, MD Chair, Lucian Leape Institute; Adjunct Professor of Health Policy, Harvard School of Public Health
Safe Practices Webinar October 22, 2009 Toll-free Call-in number: 1-866-764-6260
Making Disclosure Happen: What Do Patients Want?
1. Know what happened 2. Receive an apology 3. Be assured the hospital is doing all it can to prevent a recurrence Toll-free Call-in number: 1-866-764-6260 42
Why Are Disclosure and Apology So Difficult?
1. It is very difficult for anyone to apologize - No one likes to admit guilt and apologize - It’s even harder in the medical encounter 2. Medical injury is very different from the other reasons people apologize 3. Many of us lack the skills for delivering bad news Toll-free Call-in number: 1-866-764-6260 43
Why Are Disclosure and Apology So Difficult?
4. It is very difficult for doctors to accept failure 5. The sense of shame and guilt can be overpowering 6. Fear of consequences: - Loss of patient’s trust, respect - Loss of colleagues’ respect - Risk of being sued Toll-free Call-in number: 1-866-764-6260 44
We Have Serious Hang-ups About Being Open and Apologizing
Our fear of being sued overpowers our sense of responsibility to the patient and our recognition of the patient’s need for full, open, honest disclosure.
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Bad Advice from Lawyers
• Framing apology as a liability issue sabotages the needs of both the patient and the doctor for healing • Withholding information and not apologizing for our mistakes makes a difficult situation infinitely worse Toll-free Call-in number: 1-866-764-6260 46
The Malpractice Myth
Myth: If you tell the patient what happened or apologize, he is more likely to sue, and it will be used against you in court Reality: Patients are much less likely to sue if you level with them - Plaintiff lawyer experience - Evidence: VA, U. Mich, COPIC Toll-free Call-in number: 1-866-764-6260 47
The Malpractice Myth
1999: 136 2000: 122 2001: 121 2002: 88 2003: 81 2004: 91 2005: 85 2006: 61 2008: 14 Toll-free Call-in number: 1-866-764-6260 48
University of Michigan
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The Experience with Transparency
• University of Michigan Hospitals • University of Illinois Medical Center at Chicago • Kaiser Permanente (CA) • Children’s Hospital & Clinics of Minnesota • Johns Hopkins Hospital • Catholic Healthcare West • Physicians Reimbursement Fund (CA) • COPIC (CO) Toll-free Call-in number: 1-866-764-6260 50
The Doctor is the Second Victim
• He/She also has an emotional wound - Shame, guilt, and fear can be profound • We ignore it, give no support • We ask him/her to lie Toll-free Call-in number: 1-866-764-6260 51
An Effective Disclosure Program
• Board and leadership establish a clear policy • Training and support • Hospital shares responsibility with doctor • Prospective compensation for patient’s expenses • Patient support – continuing after discharge Toll-free Call-in number: 1-866-764-6260 52
The Power of Apology
For the patient: • It begins the healing process • Helps to restore the patient’s dignity and self-respect • Begins to restore trust • Provides assurance that patient is not at fault • Shows that you also suffer Toll-free Call-in number: 1-866-764-6260 53
The Power of Apology
For the doctor: • Gives expression to the normal empathic concern we have for the harmed patient • Begins to relieve guilt and shame • Begins to restore the emotional balance • Makes forgiveness possible (but not inevitable) Toll-free Call-in number: 1-866-764-6260 54
www.macoalition.org
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The National Quality Forum Perspective
Peter B. Angood, MD, FRCS(C), FACS, FCCM Senior Advisor, Patient Safety, National Quality Forum
Safe Practices Webinar October 22, 2009 Toll-free Call-in number: 1-866-764-6260
Top 5 Issues for CEOs
1. Safety and Quality 2. Revenue Enhancement 3. Capital Enhancement 4. Technology Investment 5. Medical Staff Development
Cejka & Solucient
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Barriers to Patient Safety
• 29 Overall; Top 7 are: - Competing priorities for scarce resources - Lack of resources - Availability & cost of PS technology - Resistance to change - Culture of blame - Lack of senior leadership understanding and involvement with PS - Negative culture that permits cover-ups
Atkins & Cole 2005 (Delphi - Texas A&M)
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Changing USA Demographics
• Today, one in four Americans is a member of a racial or ethnic minority group; by 2070, it will be one in two.
• A much higher percentage of Americans under the age of 50 are members of minority groups than those over 50 there may be important cultural differences between older patients and the people who provide services to them.
• In the future, the population over 65—the heaviest users of healthcare—will be far more diverse, and the majority of them will be women. Of the “oldest old” (those over 85) — 70%will be women.
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Changing USA Demographics
• More than one in ten Americans were born in another country and are more likely to come from non-English speaking cultures.
• Literacy is not a given; 10 million Americans cannot read in any language, and 40 million cannot read English at a 5th-grade level. • AMA estimates that 90 million Americans do not understand what they are told by their providers.
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Communication is the Cornerstone of Patient Safety
“The communications gap between the abilities of ordinary citizens, and especially those with low health literacy or low English proficiency, and the skills required to comprehend everyday healthcare information must be narrowed.” Toll-free Call-in number: 1-866-764-6260 61
To That End:
• Make effective communications an organizational priority to protect the safety of patients • Address patients’ communication needs across the continuum of care • Pursue policy changes that promote improved practitioner-patient communications Toll-free Call-in number: 1-866-764-6260 62
The Four Levels of Every Organization
Easiest
Physical
(processes, tools, and structures)
Infrastructure
(management systems, measurements, and rewards)
Behavioral
(what groups and individuals do) Most difficult
Cultural
(values, beliefs, and norms)
© 1997, Russell Consulting, Inc. Used with permission.
Long term Short term
The Nature of Change*
Change is the disruption of the status quo • A break in the continuities that represent the steady stream of our lives.
Change and the forces of change introduce disruptions • Diminishes one’s personal and organizational capacities to envision himself beyond today and into the future.
The path of change is unpredictable… • Where’s this coming from?
• How will it affect me?
• What’s going to happen?
• When will this end?
* Leading Change Training, Jeff and Linda Russell, 2003
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What are Your Tasks… as a Change Leader?
Stability Looking Back
Comfort and Control Learning, Acceptance, and Commitment 4 1 Create a Felt Need for Change Stabilize and Sustain the Change Leader Actions Fear, Anger, Introduce the Change and Resistance 2
Looking Forward
Revise and Finalize the Change Plan 3 Inquiry, Experimentation, and Discovery
Chaos * Leading Change Training, Jeff and Linda Russell, 2003
Diffusion of Innovations
Definition: • The process by which an innovation is communicated through certain channels over time among members of a social system.
• It is a special type of communication concerned with the spread of messages that are perceived as new ideas. • Five attributes: - Relative advantage - Compatibility - Complexity - Trialability - Observability
E. Rogers
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Opportunities for Patient and Family Involvement
Rebecca Martins Founder, www.voice4patients.com
Safe Practices Webinar October 22, 2009 67
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Upcoming Safe Practices Webinars
November 19 – Healthier Communication and Safe Information Management (Safe Practices 12-16) December 17 – Optimizing a Workforce for Optimal Safe Care (Safe Practices 9-11) 70