Patient Safety and Quality Improvement

What, Why and How Can We Teach It?

ACGME Requirements…

  Practice-based Learning and Improvement: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.  identify strengths, deficiencies, and limits in one’s knowledge and expertise;       set learning and

improvement goals

; identify and perform appropriate learning activities;

systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement ;

incorporate formative evaluation feedback into daily practice; locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems; use information technology to optimize learning; participate in the education of patients, families, students, residents and other health professionals.

Systems-based Practice: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.       work effectively in various health care delivery settings and systems relevant to their clinical specialty; coordinate patient care within the health care system relevant to their clinical specialty; incorporate

considerations of cost awareness and risk-benefit analysis

based care as appropriate; in patient and/or population advocate for

quality patient care

and optimal patient care systems;

work in interprofessional teams to enhance patient safety and improve patient care quality

; ‘

participate in identifying system errors and implementing potential systems solutions

.

So far, what do we have?

  Teachers      VA Chief Resident(s) for Patient Safety and Quality Improvement Hospitalists (VA) including Assistant Chief for Patient Safety and QI Primary Care (VA, USF and 30 th St) Simulation Center Dr Fabri Learners     Internal Medicine Residents- elective and ward months, outpatient block Medical Students- 3 elective, AI rd year internal medicine rotation, 4 th year Occupational Medicine Residents VA Nursing Staff

Outline

    Patient Safety Principles/Activities  Swiss Cheese Model   Root Cause Analyses Human Factors Engineering Quality Improvement Tools  Flow Chart   Fishbone Plan-Do-Study-Act Quality Improvement Initiatives  Examples of Plan-Do-Study-Act Cycles Conclusion   Logistics Goals for the Future  Resources

Error

Highly publicized Errors in Medicine Normal Accidents?

Libby Zion 18 yo woman dies of a medical mistake, partly due to lax resident supervision Institution Cornell’s NY Hospital Year 1984 Impact Public discussion regarding resident training-> work hour regulations

Betsy Lehman, a Boston Globe healthcare reporter, dies of a chemotherapy overdose Harvard’s Dana Farber Cancer Institute 1994 New focus on med errors, computerized prescribing Willie King, a 51 yo diabetic, has the wrong leg amputated 18 month old Josie King dies of dehydration Jessica Santillan, a 17 yo from Mexico, dies after receiving a heart lung transplant of the wrong blood type University Community Hospital, Tampa Johns Hopkins Duke 1995 2001 New focus on wrong-site surgery, Joint commissions’s universal protocol Josie’s parents form an alliance with Hopkin’s leadership 2003 New focus on errors in transplantation and on enforcing strick high reliability protocols for communication of crucial data

Wachter, R. M. (2008). Understanding patient safety. New York, McGraw-Hill Medical.

Patient Safety

  1991- Harvard Medical Practice Study, NEJM   Reviewed >30,000 medical charts Adverse event was defined as: “injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge or both.”   

>50% were preventable (although lots of disagreement on this) Brennan, T. A., L. L. Leape, et al. (1991). "Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I." N Engl J Med 324(6): 370-376.

1999/2000 Institute of Medicine report: “To Err is Human: Building a Safer Health System”   Estimated 44,000-98,000 Americans die each year from medical mistakes 50% of these deaths were counted as “not preventable”   4% of admissions were injured 13.6% of these adverse events led to death Deaths due to preventable adverse events were greater than MVA, breast cancer or AIDS

Equal to a jumbo jet crashing every day Kohn, L. T., J. Corrigan, et al. (2000). To err is human : building a safer health system. Washington, D.C., National Academy Press.

Patient Safety Principles and Activities



Swiss Cheese Model



Tracers



Root Cause Analyses



Mock- RCA



Human Factors Engineering



HFE workshops

Swiss Cheese Model

• Need to focus on the “root causes” not just the sharp end of the error Culture of Low Expectations No procedural ID protocol Steep Authority Gradients Production Pressures

Reason, J. T. (1990). Human error. Cambridge England ; New York, Cambridge University Press.

Activity: Tracers

     Examine common hospital processes with high impact on patient safety and quality of care, identify vulnerabilities and safeguards MRI Tracer Pharmacy Tracer Thoracentesis Tracer GI consult Tracer 1.

2.

Identify “layers of cheese” Identify “holes in the cheese”

How do we analyze these adverse events?



Root Cause Analyses



What happened, why did it happen, what can be done?



Triggered from actual events and close calls with “severe” potential

Activity: Mock RCA

4 Basic Steps in an RCA

    1) Identify the Problem 2) Event Flow Chart 3) Cause and Effect Diagram 4) Develop Solutions or “Actions”  Strong- architectural/physical plant changes, new devise, engineering control or interlock, remove unnecessary steps  Intermediate- increase staffing/decrease in workload, software enhancement modifications, checklists  Weak- double checks, warning and labels, new procedure memorandum, training

What is Human Factors Engineering?

   Designing systems devices, software and tools to fit human capabilities and limitations  Minimize error and optimize safety Using established methods to gather unique information about   Hidden needs of the end-user Unexpected interactions between the system and the user Taking advantage of knowledge bases about human system interaction

Human Factors Engineering

VS .

“ At one point, the pulmonologist tried to put a mask over [Steve Jobs] face when he was deeply sedated. Jobs ripped it off and mumbled that he hated the design and refused to wear it. Though barely able to speak, he ordered them to bring five different options for the mask and he would pick a design he liked…He also hated the oxygen monitor they put on his fingers. He told them it was ugly and too complex.”

- New Yorker, Nov 14th

Activity: HFE Workshop

  Identify and understand how human strengths and weaknesses affect system design, interact with the environment and contribute to errors - Glucometer - Insulin Pen - Spiriva - Thoracentesis Kit - Venti-masks - Suction on code cart - Ideas?

Identify weak/intermediate/strong actions Make

sure

to use the correct color Adaptor!?

Better

Epidemiology of Quality Problems

   1987: Wennberg et al compared New Haven and Boston university hospitals  In 1982 expenditures per head for inpatient care were $451 in New haven and $889 in Boston  Found widespread deviations from best practices Wennberg, J. E., J. L. Freeman, et al. (1987). "Are hospital services rationed in New Haven or over-utilised in Boston?" Lancet

1

(8543): 1185-1189.

Many studies since have demonstrated large variations in quality of care based on race, income and gender (“ healthcare disparities”) 2003: McGlynn et al evaluated 12 metropolitan areas in the US, looked at performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventative care  54.9% of patients received recommended care McGlynn et al. “The Quality of Health Care Delivered to Adults in the United States.” NEJM 2003; 348: 2635-45 Question: “how can doctors and hospitals be practicing high quality, evidence-based medicine yet have such stunningly different approaches to the same problem?”

What is Quality?

  

In 2001, IOM report: Crossing the Quality Chasm defined 6 aims for a quality healthcare system

    Patient safety Patient-centeredness Effectiveness Efficiency  Timeliness  Equity • Quality is not just delivery of EBM, its much broader Lean: Maximizing value-added processes, eliminating waste, from the perspective of the end user (the PATIENT) Six Sigma: Remove defects, reduce variability

QI Tools: Process Flow Diagrams



Graphic representation of the sequence of steps in a process



Often, one member of the process is not aware of what the other members are doing



Stay as high as possible, for as long as possible (the Woodstock rule)

Sample Flow Chart

Scheduling Patient makes appointment Prearrival Sign instructs patient to stop at prearrival desk Appt. at least X days in advance?

Yes Scheduling mails New Patient Questionnaire (NPQ) to patient No Scheduling instructs patient to arrive 30 minutes in advance of appointment for completing paperwork Established patient?

Yes Print out patient medication list No Ask whether patient received and completed NPQ Front desk NPQ completed?

Yes Obtain insurance information No Instruct patient to return to prearrival desk NPQ complete Yes No Give NPQ to patient and instruct to complete form in waiting room No Call patient from waiting room Weigh, bring into exam room, vitals Established patient?

Nurse or MA Yes Print and review patient medication list Physician Look at changes entered by nurse in AllScripts Read annotations and questions on paper medication list Adjust as appropriate Review medication list from NPQ 1) enter definite changes into computer using record function 2) enter over-the-counter medications using record function 3) enter allergies 4) enter pharmacy 5) ask about refills; write “R” in the left margin beside medications that need refills 6) write issues/questions on paper list Print updated medication list and give to patient at end of visit

What is an Ishikawa Diagram

      Developed by Ishikawa in Kawasaki Shipyards Made famous when used in the development of the Mazda Miata AKA Fishbone diagram Brainstorming Tool Tool for uncovering and describing factors that influence an outcome 3 steps: 1.

Identify the problem - A concise problem statement - i.e. Long Wait times in Clinic 2. Create headers for the fish skeleton - Need to be mutually exclusive and comprehensive - i.e. People, Policy, Methods, Materials, Other 3. Investigate each of the headers for more concrete examples - i.e. understaffing at the pharmacy would fall under Man Power

Fishbone Example: Long Wait Times in Primary Care Clinic

People Policy Nursing understaffed Each physician likes things done differently HIPAA limits abilities of front desk personel Allscripts communication rather than verbal Redundancy- pts filling out same forms and questions multiple times Not enough exam rooms Too many steps in the process- precheckin, checkin, nursing intake etc..

Outdated new patient questionnaires Methods Materials Long wait times in walk-in clinic

Examples of PDSAs….

What changes for next cycle?

Can the change be implemented Set objective Ask questions Make predictions Plan how to answer Collect data ACT PLAN STUDY Complete the analysis Compare data to predictions Summarize what was learned DO Carry out the plan Collect the data Begin analysis of the data

PLAN: Project Charter

      Problem Statement: There are discrepancies between physician MRI screening questionnaires and MRI tech screening questionnaires Primary Metric: Mean # of discrepancies per chart Project Goals/Objectives: Reduce mean # of discrepancies per chart by 70% and increase the likelihood of a single chart making it through the process without a discrepancy Scope: Inpatients receiving MRIs Monday-Friday Team  Champion: Dr. Lezama   What is the impact to:  Customers: improved MRI safety, decreased # of redundant forms  Process Owner: Dr. Joseph Parise Members: Dr. Emily Lorch, Dr. Alex Reiss (Hospitalist Chief) Carolyn Eubanks (MRI tech supervisor), Gwen Patterson (MRI tech), MRI clerk, Lynn Martinez (CPRS) Company: improved MRI safety, improved efficiency

Process Level 1

MD orders MRI

PLAN: Process Mapping

MD fills out questionnaire MD order/ questionnaire prints out at MRI clerk station MRI tech #1 fills out questionnaire MRI tech #2 reviews both questionnaires Tech calls nurse for quick screening

Process Level 2

Order placed Pop-up with questionnai re MD reads questionnai re on computer screen MD goes to find patient MD questions patient MD reviews chart MD goes back to computer and fills out questionnai re

PLAN: Fishbone Diagram

Methods Possible to bypass form Not windows compatible Not enough computers Too many questions Not available in paper form Materials People Staffing issues- not enough techs Lack of knowledge Least experienced on the team Redundancy Pt sedated by the time they get to MRI Limited resident hours Policy Discrepancies between MRI forms

PLAN: 35% of the MRI forms had at least 1 discrepancy….

80% of the defects are in 6 fields: welding, joint, back/joint surgery, contrast allergy, Kidney or liver disease, stents

DO: Old Form

DO: New Form

DO: Educational Component

C A N C E L C ochlear implant A neurysm clip i N fusion pump C ardiac pacemaker E ye metal L imb prosthesis I M R M orbid obesity R enal insufficiency I nsane

STUDY: Binomial Analysis



Prior to the changes 35% of charts had at least 1 discrepancy between the tech form and the MD form



Following our interventions, 3% of the charts had at least 1 discrepancy

Study: Fischer’s Exact



Test and CI for Two Proportions

   Sample X N Sample p 1 35 100 0.350000

2 3 30 0.100000

    Difference = p (1) - p (2) Estimate for difference: 0.25

95% CI for difference: (0.107649, 0.392351) Test for difference = 0 (vs not = 0): Z = 3.44 P-Value = 0.001

 Fisher's exact test: P-Value = 0.011

Plan for Control Chart

Week No. of Defects No. of MRIs week 1 week 2 week 3 2 3 4 100 83 90 week 4 week 5 1 2 week 6 1 101 80 90

Another Example of a PDSA: Inpatient Medicine

PLAN

: Thoracentesis samples sent in wrong tube - Trace process from inpatient medicine floors, Interventional Radiology - Fishbone diagram- pH and CBC were primary problems (consistent with pareto’s law)

DO

: Modify the Medicine Order Set

STUDY

: Following the intervention review what % of thoracentesis tubes were sent incorrectly

ACT

: Educate IR about our new order set If intervention doesn’t work, how can we modify it

Another Example of a PDSA: Outpatient Medicine

   

PLAN

: Identify a quality measure to target  i.e. documentation of goals of care, flu shots, colonoscopy screening Each resident reviews their current processes and success rate with regard to the measure  What % of patients have appropriate documentation  What are some barriers to meeting this measure • May need flow diagram, fishbone, FMEA

DO

: Develop an intervention (or action)    Resident or staff education Make forms more available EMR modifications

STUDY

: Following the intervention review what % of patients have appropriate documentation

ACT

: If intervention works, spread the word!

If intervention doesn’t work, how can we modify it

Logistics

     Initiative needs to come from the TOP Need to appoint a “QI/PS” team leader Allocate time should start with “protected time” for both the attendings and the residents  Suggestions: • Noon-conference • Morning report • • • Rounds Outpatient block Orientation Part didactics but mostly active learning Evaluation and feedback are important so that it seems like a “real” part of the curriculum

Goals for the Future

      Other specialties and disciplines: surgery, OB/GYN, psychiatry, dermatology, nursing etc..

Teach the teacher dry run of our SGIM workshop “A Toolbox for Teaching Patient Safety” Integration into orientation for both MS III and PGY1s Integration into basic clinical months (rather than isolated electives) Collaboration with other departments here at USF: psychology, engineering, public health Collaboration with other universities

Resources

  Patient Safety 

Wachter, R. M.

(2012). Understanding patient safety. New York, McGraw Hill Medical.

 

Reason, J. T

.

(1997). Managing the risks of organizational accidents. Aldershot, Hants, England ; Brookfield, Vt., USA, Ashgate.

National Patient Safety Center:

James Bagian

) http://www.patientsafety.gov/curriculum/index.html

(Dr.   Agency for HealthCare Research and Quality: http://webmm.ahrq.gov/

Dr. Fabri’s

Course here at USF: Patient Safety and Human Error Quality Improvement      Nolan, K. M. and M. W. Schall (2007). Spreading improvement across your health care organization. Oak Brook, Ill. Cambridge, MA,

Joint Commission

Resources ; Institute for Healthcare Improvement.

Berwick, D. M.,

A. B. Godfrey, et al. (1990). Curing health care : new strategies for quality improvement : a report on the National Demonstration Project on Quality Improvement in Health Care. San Francisco, Jossey-Bass.

Ogrinc, G.,

L. A. Headrick, et al. (2004). "Teaching and assessing resident competence in practice-based learning and improvement." J Gen Intern Med

19

(5 Pt 2): 496-500.

American Society for Quality: http://asq.org/conferences/six-sigma/

Dr. Fabri

National Meetings SGIM- Patient Safety/QI Workshop, Precourse Orlando May 5-9th Society for Hospitalist Medicine Institute for HealthCare Improvement