partnering for quality creating reliability for healthcare peter pronovost, md, phd johns hopkins...
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Partnering for QualityCreating Reliability for Healthcare
Peter Pronovost, MD, PhDJohns Hopkins University
Objectives
• To understand the need for creating reliability in healthcare
• To understand a model for creating reliability in healthcare
• To consider how to organize patient safety efforts
• To explore a vision for the future of patient safety
RAND Study Confirms Continued Quality Gap
10.5Alcohol dependence
22.8Hip fracture
40.7Urinary tract infection
45.2Headaches
45.4Diabetes mellitus
48.6Hyperlipidemia
53.0Benign prostatic hyperplasia
53.5Asthma
53.9Colorectal cancer
57.2Orthopedic conditions
57.7Depression
64.7Hypertension
68.0Coronary artery disease
68.5Low back pain
Percentage of
Recommended Care Received
Condition
McGlynn et al, NEJM 2003; 348(26):2635-2645
Central Mandate
Local Wisdom
Scientifically Sound Feasible
xx
Concurrent Retrospective
Automatic Desired state
Manual ICU data system
Current state
Data Collection for Safety and Quality
ExercisePlease answer each question with a score of 1 to 5.
1 is below average, 3 is average and 5 is above average
• How smart am I
• How hard do I work
• How honest am I
• How kind am I
• How tall am I
• How good is the quality of care we provide
More than 5 years after IOM report
• No significant improvements
-40% say quality of care is worse than 5 years ago
- 38% feel it is the same
- Only 10% feel it has improved
• How do we know patients are safer?
Model to Improve Reliability of Care• Pick an important clinical area• Identify what should we do?
– principles of evidence-based medicine• Measure if you are doing it• Understand the process and context of work• Ensure patients get what they should
– Engage– Educate– Execute (reduce complexity, create redundancy, learn from
defects)• Evaluate whether outcomes are improved
Health Services Research, 2006; Circulation (in press)
Creating Reliable Health Care
Executive Leaders
Team Leaders
Staff
Engage(adaptive)
How Do I Make the World a Better Place?
Educate(technical)
What Do I Need to Know?
Execute(adaptive)
What Do I Need to Do?
Evaluate(technical)
How Will I Know I Made a Difference?
© Quality and Safety Research Group, Johns Hopkins University
Ensure patients get what they should
• Summarize strategies in toolkit
• Engage– Make harm visible– Watch Josie video– Partner with other discipline experts– Tell stories– Post performance
Ensure patients get what they should
• Educate on evidence supporting the intervention – original literature, concise summaries and slide
presentations – conference calls, newsletters, printed educational materials
• Execute – Simplify the system: protocols, order sets etc– Create redundancies: daily goals and others– Learn from defects
• Evaluate– Validated tools and dedicated data collection
Evaluate whether outcomes are improved
• Rigorous methods to minimize risk of inaccurate conclusions
• When inferences are made about the benefits of an intervention without acknowledging limitations, it is likely the inferences will be accepted as truth
• Consumers may believe the claims/ could be hazardous, at a minimum is misleading
Understand the process and context of work
• Observe staff performing the interventions to identify where the process may break down
• “Walk the process” to identify barriers in providing the intervention
• Listen to staff concerns regarding the intervention and identify what they stand to gain or lose from the improvement effort
Organizing Safety work
• Evaluating Progress in Patient Safety
• Translating evidence into practice (TRIP)
• Identifying and mitigating hazards
• Improving culture and communication
• Linking organizational characteristics to patient safety
As Leaders, How Can We Improve the Quality of Our Studies?
• First, have a clear and articulated QI plan (including hypothesis/objective, study design, sample size and explicit intervention and outcome measures)
As Leaders, How Can We Improve the Quality of Our Studies?
• Second, use data collection forms and procedures that have been tested for reliability
• Third, provide adequate training, supervision and quality assurance for individuals collecting the data and using the tools
As Leaders, How Can We Improve the Quality of Our Studies?
• Fourth: ensure data collected is appropriately managed to minimze the risk for data entry errors and support accurate analysis
• Fifth: Make certain you have the requisite knowledge and skill to appropriately describe, conduct and report the analyses.– If you don’t have the in-house resources, partner
with someone who does (local college or community resources)
As Leaders, How Can We Improve the Quality of Our Studies?
• Finally, Ensure that limitations and potential biases are transparently reported for all quality improvement projects
Vision for improving the effectiveness and efficiency of patient safety efforts
• Develop GAAP safety scorecard
• Create TRIP programs
• Create CAST in healthcare
• Understand how to improve culture and communication
• Link organizational characteristics to outcome
1. Identify Hazards
2. (
3.
3. Mitigate Risk
2.Analyze & Prioritize Hazards
4. Evaluate Effectiveness of Risk Reduction
Patient Safety Learning Communities
Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger level s of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control.
(Design, Pilot Test, Implement)
Requirements
• Build Capacity
• Create learning communities
• Develop sustainable financial model
Next Steps
• Commit to TPSC Collaborative
• State wide learning from Mistakes
• State wide Safety Culture Assessment and improvement
• Capacity Building
• Share what you learn globally