gordon “gordy” schiff, md kathy duncan, rn critical values expedition...gordon “gordy”...

7/26/2011

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Gordon “Gordy” Schiff, MD

Kathy Duncan, RN

These presenters have nothing to disclose

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Agenda

• Welcome and Introductions

• The Expedition Process

• Overview of Critical Values Communication

• Assignment & Planning for Next Session

• Final Questions & Close

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Chat Time!

What is your goal for participating in this

Expedition?

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Join Passport to:

• Get unlimited access to Expeditions, two- to four-month,

interactive, web-based programs designed to help front-line teams

make rapid improvements.

• Train your middle managers to effectively lead quality

improvement initiatives.

• Enhance your strategic planning with customized whole systems

data and selected benchmarking information.

. . . and much, much more for $5,000 per year! •

• Visit www.IHI.org/passport for details.

• To enroll, call 617-301-4800 or email [email protected].

http://www.ihi.org/passport

mailto:[email protected]

7/26/2011

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What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for

some specific purpose

2. the group of persons engaged in such an

activity

3. promptness or speed in accomplishing

something

Where are you joining from?

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Our Expedition Director

Kathy D. Duncan, RN, Faculty, Institute for Healthcare

Improvement (IHI), is co-leader of IHI's National Learning

Network and coordinates the Improvement Map support care

processes. Previously she co-led the 5 Million Lives

Campaign National Field Team and was faculty for the

Improving Outcomes for High Risk and Critically Ill Patients

Innovation Community. Ms. Duncan was responsible for the

Prevention of Pressure Ulcers and Deployment of Rapid

Response Teams content areas for the 5 Million Lives

Campaign. She is a member of the Scientific Advisory Board

for the AHA NRCPR, NQF's Coordination of Care Advisory

Panel, and NDNQI's Pressure Ulcer Advisory Committee.

She has served in a variety of staff and management

positions, including director of critical care for a large

community hospital, where she led an initiative to decrease

ICU mortality and morbidity by reducing ventilator-associated

pneumonia and ICU length of stay.

What We Expect of You

• “All Teach, All Learn” philosophy

• Join and participate on all calls

• Participate in the listserv discussion

• Test, test, test

• Share what you’ve learned (challenges as

well as successes and insights)

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Overall Program Aim

The overall goal of the Expedition is for

participants to build the foundation of an efficient

process for communicating critical tests results

consistently and promptly.

Objectives

Upon completion of this expedition, participants will be able to:

• Identify opportunities to improve their current process of

communicating critical test results

• Identify safe practice recommendations for communicating

critical test results

• Develop a reliable process for communicating critical test

results

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7/26/2011

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Gordon “Gordy” Schiff, MD

Gordon “Gordy” Schiff, MD, Associate Director,

Center for Patient Safety Research and Practice,

Brigham and Women’s Hospital, is also Associate

Professor of Medicine at Harvard Medical School. He

is a founding member and past president of Physicians

for a National Health Program (PHNP), and he is

author of PNHP’s JAMA paper on quality health care

reform. Dr. Schiff was previously professor of medicine

at Rush University and senior attending physician at

Cook County Hospital, where he worked for more than

30 years as director of clinical quality research and

improvement for the department of medicine. During

the 1990s he was director of Cook County’s large

general medical clinic. He is clinical director of the

recently awarded TOP-MED (Tools for Optimizing

Prescribing, Monitoring and Education) CERT (Center

for Education and Research in Therapeutics) based at

the UIC College of Pharmacy.

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Outline

• Personal introduction – 3 studies

– Theophylline Potassium TSH

• Review of selected literature

– Methods Studies

• Reliability science

– Key concepts for results management

• 6 requirements to reliable test result f/up

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• -67 y.o. woman w/ hx of HBP, COPD,

asymptomatic gallstone

• -Presents acute MI

• -Develops CHF, treated w/ usual meds including

digoxin, diuretic, theophylline

• -Acute nausea vomiting abdom pain, rushed to

operating room for cholecystectomy

• -Chart review 1 yr later--theophylline level 37.0 .

Schiff Ann Intern Med 1990

Abnormal Lab Belatedly Discovered

ERROR (N=40) # %

Delay (>10 hrs) toxic level draw to MD action 20 50%

Excessively high (>1.5) doses CHF, liver dis 17 43%

Miss obvious GI,CNS,cardiac sx/signs toxicity 16 40%

Recurrent toxicity: unaware; failure adjust dose 11 28%

Dosing errors for non CHF pts 9 23%

ED rx despite pretreatment level already toxic 6 15%

Inadvertent overlap of i.v. and p.o. rx 6 15%

Interacting drugs (w/ failure to adjust dose) 5 13%

Discharged on same dose came in toxic 5 13%

Discharged w/ no noted MD awareness of toxicty 4 10%

Theophylline Toxicity, Schiff, Ann Internal Med 1991

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Potassium Prescriptions

N = 32,563

(12,825 unique patients)

Potassium Levels 5.3

N = 9,790

(4,188 patients)

Positive “Screen” = Match Found in Both Databases N=1,781 Prescriptions (701 Unique Patients)

Last K 5.3 N=498 1.53%

No Error N=1107

Same Day K 5.3 N=276 0.84%

Detailed Review all Potassium Levels

Schiff, Am J Med 2000

NAME UNITNO DATE RESULT GENERIC_NM QUANTITY

JEFFERSON, RUTH 116996 09/06/95 5.2

JEFFERSON,RUTH 116996 09/11/95 POTASSIUM CHLORIDE 100

JONES, BILL 122441 03/11/95 6.0

JONES, BILL 122441 03/20/95 POTASSIUM CHLORIDE 60

SMITH, MARY 125565 05/16/95 5.3

SMITH, MARY 125565 05/16/95 POTASSIUM CHLORIDE 30

SMITH, MARY 125565 11/19/95 7.0

STOKES,WILL 137995 01/03/95 POTASSIUM CHLORIDE 30

STOKES,WILL 137995 01/03/95 5.3

CULLEN, CORA 148341 03/30/95 5.3

CULLEN, CORA 148341 04/01/95 POTASSIUM CHLORIDE 14



PABST, POLLY 155103 01/11/95 5.3

PABST, POLLY 155103 04/12/95 POTASSIUM CHLORIDE 240

KENNEDY,JOE 156828 02/22/95 5.6

KENNEDY,JOE 156828 03/06/95 POTASSIUM CHLORIDE 240

KENNEDY,JOE 156828 04/05/95 4.9

KENNEDY,JOE 156828 05/09/95 6.6


KENNEDY,JOE 156828 05/23/95 5.2


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NAME UNITNO DATE RESULT GENERIC_NM QUANTITY

JEFFERSON, RUTH 116996 09/06/95 5.2

JEFFERSON,RUTH 116996 09/11/95 POTASSIUM CHLORIDE 100

JONES, BILL 122441 03/11/95 6.0

JONES, BILL 122441 03/20/95 POTASSIUM CHLORIDE 60

SMITH, MARY 125565 05/16/95 5.3

SMITH, MARY 125565 05/16/95 POTASSIUM CHLORIDE 30

SMITH, MARY 125565 11/19/95 7.0

STOKES,WILL 137995 01/03/95 POTASSIUM CHLORIDE 30

STOKES,WILL 137995 01/03/95 5.3

CULLEN, CORA 148341 03/30/95 5.3




PABST, POLLY 155103 01/11/95 5.3

PABST, POLLY 155103 04/12/95 POTASSIUM CHLORIDE 240

KENNEDY,JOE 156828 02/22/95 5.6


KENNEDY,JOE 156828 04/05/95 4.9

KENNEDY,JOE 156828 05/09/95 6.6


KENNEDY,JOE 156828 05/23/95 5.2


Potassium

Level

Most

Recent

Value High

Same

Day High Total %

5.3 137 27 164 24.30% 674 62.30%

5.4 86 23 109 16.20% 510 47.10%

5.5 48 22 70 10.40% 401 37.10%

5.6 51 19 70 10.40% 331 30.60%

5.7 32 11 43 6.40% 261 24.10%

5.8 24 17 41 6.10% 218 20.10%

5.9 13 5 18 2.70% 177 16.40%

6.0 16 6 22 3.30% 159 14.70%

6.1 11 8 19 2.80% 137 12.70%

6.2 10 3 13 1.90% 118 10.90%

6.3 9 3 12 1.80% 105 9.70%

6.4 3 7 10 1.50% 93 8.60%

6.5 4 3 7 1.00% 83 7.70%

6.6 8 2 10 1.50% 76 7.00%

6.7 2 2 4 0.60% 66 6.10%

6.8 4 1 5 0.70% 62 5.70%

6.9 1 3 4 0.60% 57 5.30%

>7.0 39 14 53 7.90% 53 4.90%

Total 498 176 674 100.00%

= or > K+ Level

N %

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TSH > 20

470

Rx Outside Pharmacy

17

On Thyroxine

390

Baby

3 +/-Awareness

4

Hyperthyroid Rx

17

Lost F/up; Died

27

Missed Dx

Hypothyroidism

12

Hypothyroid

63

No Rx

19

No Thyroxine

80

(5.7%)

(0.9%) (2.6%)

Schiff Arch Intern Med 2005

Year

N % N %

Total TSH done 22,076 24,524

Unique patients 17,467 19,293

TSH levels > 20 1,334 744

TSH > 20 unique patients 470 512

On thyroxine 390 415

No thyroxine 80 17.0% 97 18.9%

Hyperthyroid Rx 17 3.6% 20 3.9%

Rx outside pharmacy 17 3.6% 34 6.6%

No Rx 19 4.0% 16 3.1%

Lost F/up or died 27 5.7% 27 5.3%

Babies 3 3

Awareness but failed F/up 4 2

Missed Dx hypothyroidism 12 2.6% 11 2.1%

2000 2001

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Year

N % N %

Total TSH done 22,076 24,524

Unique patients 17,467 19,293

TSH levels > 20 1,334 744

TSH > 20 unique patients 470 512

On thyroxine 390 415

No thyroxine 80 17.0% 97 18.9%

Hyperthyroid Rx 17 3.6% 20 3.9%

Rx outside pharmacy 17 3.6% 34 6.6%

No Rx 19 4.0% 16 3.1%

Lost F/up or died 27 5.7% 27 5.3%

Babies 3 3

Awareness but failed F/up 4 2

Missed Dx hypothyroidism 12 2.6% 11 2.1%

2000 2001

Every system is perfectly

designed to deliver the

results it does

Don Berwick IHI

Perfectly designed system to “miss” 12 patients a year (and lose another 27 follow-up)

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Poon Arch Intern Med 2004

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Poon Arch Intern Med 2004

2.5 Missed Results per MD

= 25,000 “ Harvard CRICO MD’s

150,000 Missed Tests/Yr

Methods to Measure

Failed Test Result Follow-up • MD survey- how often missing results

• Chart review: failure, delay in documenting result

• Patient survey- whether aware of result

• Failure follow-up action as signal

• Tracer studies-working backward from dx

• Action suggesting unaware of result – Linking pharmacy data

• Malpractice studies

• PRO Citations

• Lab Frustrations

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Methodologic Issues • Time frame; abnormal criteria

• Type of result (Lab, x-ray, other)

• Inpatient vs. outpatient vs. ED – Labs at discharge

• Failure to document vs. failure to act

• MD notification by lab vs. Pt notification by MD

• Recall biases

• Generalizability: VA, academic centers

• Denominators

• Notification vs. Action

• Lost letters; unopened electronic messages

• Follow-up action in future

Casalino Arch Intern Med 2009

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Singh Arch Intern Med 2009

Lack of

Timely f/up Timely F/up

N=92

(7.7%)

N=1104

(92.3%)

Acknowledged 71 (77.2) 908 (82.2)

Not

Acknowledged 21 (22.8) 196 (17.8)

Acknowledged Alerts for Abnormal Imaging Exams

No Better in Timely Follow-up

Singh Arch Intern Med 2009

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Gordon Ann Intern Med 2009

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Reliability Science 10 Key Improvement Concepts

1. Situational awareness and anticipation of needs

2. Need for closed-loop

3. Attention to hand-offs and teamwork

4. Continuous flow systems w/out batching

5. Doing everything “just-in-time”

6. Culture of stopping to fix problems

7. Forcing functions, simplification, standardization

8. Visual cues- facilitate work, ensure probs not hidden

9. Use only reliable thoroughly tested technology

10.Go see for self to thoroughly understand

(Genchi Genbutsu)

Schiff, JAMA 2011

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High Reliability Results Management

1. Track tests from ordering to completion to

receipt/acknowledgement and action on

results.

2. Standardized approach for all test areas to

define and flag clinically significant

abnormal results

3. Eliminate ambiguities regarding how to

return a result or who to contact

4. Patients should be informed about all

test results, even normals

5. Importance of tracking and system

oversight monitoring

6. Advanced systems to support clinicians

in result management activities

High Reliability Results Management

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Questions?

• Raise your hand

or

• Use the chat box

The Model for Improvement

Critical Values Reporting and

Communication

July 26, 2011

7/26/2011

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Fundamental Questions for Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in an improvement?

Langley, G.J., Nolan, K.M., Nolan, T.W, Norman, C.L., & Provost, L.P.

(2009). The improvement guide: A practical approach to enhancing

organizational performance (2nd Ed.). San Francisco: Jossey-Bass.

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

From:: Associates in

Process Improvement

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The PDSA Cycle

for Learning and Improvement

PlanAct

DoStudy

- Objective- Questions and predictions (Why?)- Plan to carry out the cycle(who, what, where, when)- Plan for Data collection

- Carry out the plan- Document problems and unexpected observations- Begin analysis of the data

- Complete the analysis of the data - Compare data to predictions - Summarize what was learned

- What changes are to be made?

- Next cycle?

Source:

Improvement

Guide p 60

Repeated Use of the Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D


How will we know that a change is an improvement?

What change can we make that will result in improvement?

Model for Improvement

Source: Improvement Guide, p 10

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Successful Cycles to Test

Changes

• Plan multiple cycles for a test of a change

• Think a couple of cycles ahead

• Initially, scale down size of test (# of patients, clinicians,

locations)

• Test with volunteers

• Do not try to get buy-in or consensus for test cycles

• Be innovative to make test feasible

• Collect useful data during each test

• In latter cycles, test over a wide range of conditions

Developing the team’s

Aim Statement

Question #1: What are we trying to accomplish?

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• Defines the aim of the

improvement effort.

• Time specific and

measureable.

Aim Example

• Reduce adverse drug events (ADEs) in

critical care by 75% within 1 year.

• Increase the number of surgical cases

between cases with a surgical site

infection by 50% within 1 year.

• Reduce the average length of stay for

Medical ICU patients by 50% within 9

months.

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Tips for Creating Aim Statements

• State the aims clearly (What do you

want to accomplish? How good, by

when?)

• Define location or population

• Set stretch goals

• Include numerical goals/targets

Homework: Due Next week

• Assess Current work

• State your Aim

─Simple

─What, Where, By when

• State 2 measures

─“How do you know you have made an

improvement?”

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Things to Consider in Aim Setting

• What happens to results that return after patient

discharged?

• Who is responsible and what is process for incidental

finding on pre-op CXR ?

• What happens when the ordering MD does not answer

page for panic result?

• How are cross coverage test result issues handled?

• When is the PCP vs. specialist responsible for results of

tests specialist orders?

• What does it mean to have a test “acknowledged?”

• How are patients informed of test results; how

documented?

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Things to Consider in Aim Setting

• How do you insure that proper follow-up occurs (“repeat

in 6 mos”) ?

• What happens when test result is returned to an MD and

he/says “this is not my patient?”

• Are there ways to know when a “normal” result (e.g. INR)

is not normal?

• Are there ways to link test results to drugs (elevated

CPK on statin) ?

• How easy do you make it for your clinicians, in and

outpatient, to manage results?

• How do you handle results that return to the ED for a

patient who has been admitted?

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Volunteers…….

1.__________

2.__________

3.__________

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Upcoming Sessions

• Session 2: August 2, 2:00 PM – 3:00 PM ET

Topic: Getting Started

• Session 3: August 23, 2:00 PM – 3:00 PM ET

Topic: Developing Your Aim Statement

• Session 4: September 6, 2:00 PM – 3:00 PM ET

Topic: Testing Process Changes

• Session 5: September 20, 2:00 PM – 3:00 PM ET

Topic: Safe Practice Recommendations

• Session 6: October 4, 2:00 PM – 3:00 PM ET

Topic: Participant Report-outs and Continuing

Your Work

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gordon “gordy” schiff, md kathy duncan, rn critical values expedition...gordon “gordy”...

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