1 welcome to the nqf safe practices for better healthcare 2009 update webinar: creating...

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Welcome to theNQF 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:

www.safetyleaders.orgOnline Access Password: Webinar1 (case-sensitive)

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Charles Denham, MDChairman, TMIT;

Co-chairman, NQF Safe Practices Consensus Committee;

Chairman, Leapfrog Safe Practices Program

Safe Practices WebinarOctober 22, 2009

Welcome and Safe PracticeOverview

Toll-free Call-in number: 1-866-764-6260

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Panelists

Peter Angood

Charles Denham: Welcome and Safe Practice Overview

Timothy McDonald: Looking Forward: Principles Applied

Lucian Leape: Looking Back: Lessons Learned

Peter Angood: The National Quality Forum Perspective

Rebecca Martins: Opportunities for Patient and Family Involvement Rebecca Martins

Lucian LeapeTimothy McDonald


Charles Denham

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Practice Line-Up Changes:

• From 30 to 34 Practices• Culture Practice Elements

Broken Up into 4 Practices• 2 Practices Discontinued• 4 Medication Management

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:

• Format Structure Preserved • Lightly Edited Text of Most

Practices• New Practices• Updated References• Corrections and Clarification• Care Setting Clarification Using

CMS Classification• Measures To Be Considered (in

formulation)• Soft Copy Document Hyperlinks• Crosswalk Tables • Glossary

Changes of 2006 Version to 2009 Update

10Toll-free Call-in number: 1-866-764-6260

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Harmonization – The Quality Choir


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Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition- & Site-Specific Practices

Consent & Disclosure

Culture

Workforce

Consent and Disclosure


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CHAPTER 7: Hospital-Associated Infections• Hand Hygiene• Influenza Prevention• Central Venous Catheter-Related Blood Stream

Infection Prevention • Surgical-Site Infection Prevention• Care of the Ventilated Patient and VAP • MDRO Prevention• UTI Prevention

Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition-, Site-, and Risk-Specific Practices

Consent & Disclosure

Wrong-siteSx Prevention

Press. Ulcer Prevention

DVT/VTE Prevention

Anticoag. Therapy

VAP Prevention

Central V. Cath.BSI Prevention

Sx-Site Inf.Prevention

Contrast Media Use

Hand HygieneInfluenza

Prevention

Pharmacist Systems Leadership:High-Alert, Std. Labeling/Pkg., and Unit-Dose

Med. Recon.

Culture

CPOE

Read-Back & Abbrev.

Discharge System

PatientCare Info.

LabelingStudies

Culture Meas.,FB., and Interv.

Structuresand Systems

ID and Mitigation Risk and Hazards

Team Trainingand Team Interv.

Nursing Workforce

ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care

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

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

CHAPTER 8:• Wrong-Site, Wrong-Procedure, Wrong-Person

Surgery Prevention • Pressure Ulcer Prevention• DVT/VTE Prevention• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention• Organ Donation• Glycemic Control• Falls Prevention• Pediatric Imaging

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Informed Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver

Consent and Disclosure

2009 NQF Report

Care of Caregiver

MDROPrevention

UTIPrevention

FallsPrevention

OrganDonation

GlycemicControl

New

MaterialChanges

No MaterialChanges

Legend:

PediatricImaging

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LEADERSHIP STRUCTURES and SYSTEMS

Values

Systems

Structures

Behaviors

Outcomes

Culture Measurement, Feedback, and Intervention

Teamwork Training and Skill Building

Identification and Mitigation of Risks and Hazards

Leadership Structuresand Systems

Patients and Community

NQF 34 Safe Practices

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Looking Forward:Principles Applied

Timothy McDonald, MD, JDChief Safety and Risk Officer for Health

Affairs;Professor, Anesthesiology and Pediatrics,

University of Illinois

Safe Practices WebinarOctober 22, 2009Toll-free Call-in number: 1-866-764-6260

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#5 Informed Consent#6 Life-Sustaining Treatment#7 Disclosure#8 Care of the Caregiver

National Quality Forum Safe Practices


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#5 Informed Consent

NQF SP #5


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Only 24% of consent forms contained the four elements considered essential for informed consent. Designed more to protect institution than inform patient.


Background to Current Problem

Arch Surg 2000; 135:26-33

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Average reading comprehension was 6th grade; Educational materials – 11th to 14th grade;Informed consent written materials – written at college-level


Background to Current Problem

J Fam Pract 1990; 31(5):533-8

The gap between patient reading comprehension and the readability of patient education materials. Davis, Crouch et al.

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• 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.

NQF SP #5


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• Informed Consent: Additional Specifications - Informed consent documents for use with the patient should be written at or below the 5th-grade level. - Shared decision-making: the patient and the family should be engaged in a dialogue about the nature and scope of the procedure. - A qualified medical interpreter or reader should be

provided to assist patients with limited English proficiency, limited health literacy, and visual or hearing impairments. - The risk that is associated with high-risk elective cardiac procedures and high-risk procedures with the strongest volume-outcomes relationship should be conveyed.

NQF SP #5


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• 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

Informed Consent: Looking Forward


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NQF SP #6


#6 Life-Sustaining Treatment

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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 wishesFins 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

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Ethical Principles


• Beneficence• Non-maleficence• Patient autonomy• Truth telling• Ethical dilemmas – when principles

conflict

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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

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NQF SP #7


#7 Disclosure

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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

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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

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Patient Harm?

Inappropriate care?

Yes

Yes

No

No

“Near misses”

Activation of Crisis Management Team

Hard-wiring NQF SP #7A Comprehensive Approach to Adverse Patient Events

Process ImprovementConsider “Care for Caregiver”

Error Investigationhold bills?

Full Disclosure withRapid Apology and Remedy

PatientCommunicationConsult Service

Data Base Unexpected Event reported toSafety/Risk Management

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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”

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#8 Care of the Caregiver

NQF SP #8


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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 2006 Sep 6;296(9):1071-8.

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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, supportive medical care, and the opportunity to fully participate in event investigation and risk identification and mitigation activities that will prevent future events.

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Patient Harm?

Inappropriate care?

Yes

Yes

No

No

“Near misses”

Activation of Crisis Management Team

Hard-wiring NQF SP #8A Comprehensive Approach to Adverse Patient Events

Process ImprovementConsider “Care for Caregiver”

Error Investigationhold bills?

Full Disclosure withRapid Apology and Remedy

PatientCommunicationConsult Service

Data Base Unexpected Event reported toSafety/Risk Management

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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

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Looking Back:Lessons Learned

Lucian Leape, MDChair, Lucian Leape Institute; Adjunct

Professor of Health Policy, Harvard School of Public Health

Safe Practices WebinarOctober 22, 2009Toll-free Call-in number: 1-866-764-6260

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1. Know what happened2. Receive an apology3. Be assured the hospital is doing all it

can to prevent a recurrence

Making Disclosure Happen:What Do Patients Want?


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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

Why Are Disclosure and Apology

So Difficult?


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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


Why Are Disclosure and Apology

So Difficult?

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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.

We Have Serious Hang-ups About Being Open and

Apologizing


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• 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

Bad Advice from Lawyers


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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

The Malpractice Myth


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1999:136 2003: 812000: 122 2004: 912001: 121 2005: 852002: 88 2006: 61

2008: 14

The Malpractice Myth


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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)

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• 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

The Doctor is the Second Victim


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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

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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


The Power of ApologyFor 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)

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www.macoalition.org

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The National Quality ForumPerspective

Peter B. Angood, MD, FRCS(C), FACS, FCCMSenior Advisor, Patient Safety,

National Quality Forum



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Top 5 Issues for CEOs


1. Safety and Quality2. Revenue Enhancement3. Capital Enhancement4. Technology Investment5. 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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• 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.

Changing USA Demographics


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• 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.

Changing USA Demographics


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“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.”

Communication is the Cornerstone of Patient

Safety


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• 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

To That End:


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© 1997, Russell Consulting, Inc. Used with permission.

Cultural(values, beliefs, and norms)

Behavioral(what groups and individuals do)

Infrastructure(management systems,measurements, and rewards)

Physical(processes, tools, and structures)

Mostdifficult

Longterm

Abi

lity

to in

flue

nce

or

cha

nge

Dur

abili

ty o

f th

e ch

ange

Easiest Shortterm

The Four Levels of Every Organization

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The Nature of Change*

* Leading Change Training, Jeff and Linda Russell, 2003

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 introducedisruptions• 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?

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LookingBack

LookingForward

Chaos

Stability

Comfortand Control

Inquiry,Experimentation,

and Discovery

Learning,Acceptance, and

Commitment

Fear, Anger,and Resistance

Leader Actions

Create aFelt Needfor Change

Stabilizeand Sustainthe Change

Revise andFinalize the

ChangePlan

Introducethe Change

4

3

2

1

* Leading Change Training, Jeff and Linda Russell, 2003

What are Your Tasks…as a Change Leader?

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Diffusion of InnovationsDefinition:• 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 Patientand Family Involvement

Rebecca Martins Founder, www.voice4patients.com


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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)

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