quality, safety and cme - wild apricot€¦ · online psa reporting starts psas prioritized: red...

© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center

Quality, Safety and CMEAligning an Institutional Patient Safety Program

with CME

Bruce A. Nitsche, M.D., ABIMDirector of CME

Virginia Mason Medical CenterSeattle ,Washington


Virginia Mason Medical Center

• Multispecialty group practice of more than 470 physicians- Founded in 1920

• Acute care hospital with over 300 beds

• Regional clinic network throughout the Seattle metropolitan area

• Benaroya Research Institute

• Virginia Mason Institute

• GME programs in Internal Medicine, Radiology, Anesthesiology, and Surgery

Our Strategic PlanOur Strategic Plan

© 2012 Virginia Mason Medical Center


Virginia Mason Production System

• Modeled after “Toyota Production system”

• Adopted in 2002

• Lean production

• Zero defects

• “Stopping the line”


“I’m not much of a gardener, but my friends who are tell me how

essential it is to till the soil first to prepare it for planting. That’s the idea

behind “nemawashi,” which loosely translates to “preparing the soil for

planting” in Japanese. It’s also a key concept of the Toyota Production

System and our Virginia Mason Production System. We need to do the

work up front to make sure our teams are prepared to participate in

improvement and important change before it happens.”

“The power of nemawashi is in creating a sense of readiness within

teams and helping them understand the need for improvement, how

their work will be impacted and why. This preparation is important to

get everyone’s best thinking and engagement as changes occur. Like

most things in life, it takes time to do it right.”


Patient Safety Alert System

• Empower all staff to “speak up”

� Safe to report mistakes

� If reported, they will be corrected

� Reporters will be praised

� 24/7 hotline with administrator on call

� Reviewed monthly by Quality and Safety Committee


PSA Coding

• Harm: no risk 0, minor to moderate 1-2,

major risk 3

• Care Process rate: infrequent 1, weekly/monthly 2, hourly/daily 3

• Resources to resolve: one mgr 1, multiple

dept 2, system wide 3

• Liability: none 0, moderate 1-2, major 3

Yellow 2-4, Orange 5-7, Red 8-12

Dec. 2011 3-PDedicated

Patient Safety

Team created

March 2007

April 2009 Yellow PSA

standard work

improvements

Passing of

Mary L. McClinton

November 2004

Nov. 2008 PSA taxonomy

improvement work

starts

June 2011

Yellow PSA

Genba Kaizen

Quick Entry Form

Taxonomy

Timeline of Patient Safety Improvements

Toyota Production System

introduced to VM2001

PSA System

starts tracking

non-clinical

incidents2003

August 2002

PSA System starts

tracking clinical

incidents

January 2005

Online PSA

reporting starts

PSAs prioritized:

Red (high),

Orange (medium),

Yellow (low)

Red PSA standard

work improvementsFeb. 2007

June 2002

Virginia Mason

Production System

established

CEO mandates

Patient Safety Alert

(PSA) System

2000

600 Red

2,745 Orange

26,622 Yellow

243 Other issues

30,210 PSA incidents (clinical care gaps)Sept 1, 2002-Sept

30, 2012


Patient Safety Alert System

• Empower all staff to “speak up”

� Safe to report mistakes

� If reported, they will be corrected

� Reporters will be praised

� 24/7 hotline with administrator on call

� Reviewed monthly by Quality and Safety Committee


Quality and Safety Committee at VMMC

• Voting Members

• Jim Bender, MD Alvin Calderon, MD Robert Caplan, MD, Chair Joan Ching RN

• Ruth Conn, MD Mark Cook, MD William DePaso, MD Michael Dudas, MD

• Farrokh Farrokhi, MD Cathie Furman, RN Fred Govier, MD Donald Guinee, MD

• Dan Hanson, MD Richard Hert, MD Andrew Jacobs, MD Dana Kahn, PharmD

• Steve Kirtland, MD Dawna Kramer, MD Dana Kahn, PharmD Stephen Lavine , MD

• Rick Ludwig, MD Ravi Moonka, MD, Vice Chair Brian Owens, MD Stephen Rupp, MD

• Donna Smith, MD Julianna Yu, MD

• Nonvoting Members

• Jim Bouey Celeste Derheimer* RN David Dreis, MD* Twiggy Lee, MD

• Michael Myint, MD* Bruce Nitsche, MD Christine Palermo, MD

• Karina Uldall, MD Roger Woolf*, PharmD


Jim Bender, MD Medical Director of InformaticsDavid Dreis, MD Clinical Decision Support Richard Hert, MD GH Pulmonary/Critical

Michael Myint, MD*Infectious Disease Jim Bouey*Community MemberCeleste Derheimer, RN*QA and Safety Andrew Jacobs, MD Chief Medical OfficerBruce Nitsche.MD*CME Director Alvin Calderon, MD HospitalistMichael Dudas, MD Chief Pediatrics Dana Kahn, PharmD PharmacyStephen Olivar, MD GH Anesthesiology Robert Caplan, MD ChairFarrokh Farrokhi, MD Neurosurgery Steve Kirtland, MD Hospital Chief of Staff Brian Owens, MD GME Director Joan Ching, RN Nursing QACathie Furman, RN Senior VP Quality and Safety Dawna Kramer, MD RadiologyAlison Porter, MD*Housestaff President Mark Cook, MD GHC OB/GYNFred Govier, MD Chief of Surgery Twiggy Lee, MD Chief Medicine Resident

Stephen Rupp, MD Anesthesiology Ruth Conn, MD*Pediatrics

Donald Guinee, MD Pathology Rick Ludwig, MD Pacific Medical CentersDonna Smith, MD Medical Director Hospital William DePaso, MD Assist Chief Medicine

Dan Hanson, MD Hospitalist Care Ravi Moonka, MD Vice Chair/SurgeonJackie Valentine, RPh Patient Safety Karina Uldall, MD*Psychiatry


How

• ACCME push to align CME and Quality

• “IGRA” questionaire sent to all staff in

February of 2012

• “Invited” to join Quality and Safety

Committee

• Development of educational “intervention”

• In the spirit of continous process

improvement-refining the intervention


Educational Intervention

• 154 enduring material presentations online

at VMMC– 1580 views = 10 views average

(Marshal Kaplan,MD hepatology lecture 22

views; Lucian Leape, MD lecture on safety

17 views)

• First 2 “PSA Pointers”- 616 views….nearly

70% watching to end with first viewing


Questionaire on TB

• True or False-The new IGRA test can

distinguish active TB from Latent TB.

• A patient has a positive PPD but a negative IGRA—what is next step?

• Do you feel comfortable interpreting

IGRA’s and PPD’s?


PSA Pointers

Education with a Mission ― OUR

Mission

Welcome to PSA Pointers, a series of quick, succinct educational presentations designed for the busy practitioner. Each PSA Pointer is based on an actual Patient Safety Alert in which a knowledge gap played a role. We tell the story and highlight the educational lesson learned in less than 5 minutes through a MediaSite presentation. To begin, click the link and log in to MediaSite using your VM network log-in.

PSA Pointer: A case involving misinterpretation of a test

Duration: 4.5 minutes

When we discover new ways to improve care, we share and spread the lessons.

Bruce A. Nitsche, M.D.

Medical Director of CME

Bob Caplan, M.D. Medical Director of

Quality

Missed an issue? View the complete PSA

Pointer catalog.

Organizations may not certify activities for AMA PRA Category 2 Credit™.

A physician may individually assess the educational value for each learning

experience in which he or she participates to determine if it is appropriate to claim AMA

PRA Category 2 Credit™.

PSA Pointer: A case involving misinterpretation of a test

Duration: 4.5 minutes


PSA Pointer survey on IGRA Testing




PSA Pointers

Education with a Mission ― OUR

Mission

Welcome to PSA Pointers and the first in a series of quick, succinct educational presentations designed for the busy practitioner. Each PSA Pointer will be based on an actual Patient Safety Alert in which a knowledge gap played a role. We will tell the story and highlight the educational lesson learned in less than 5 minutes through a MediaSite presentation. To begin, click the link and log in to MediaSite using your VM network log-in.

PSA Pointer: A case of an adverse medication reactionDuration: 4:28

When we discover new ways to improve care, we share and spread the lessons.

Bruce A. Nitsche, M.D.

Medical Director of CME

Bob Caplan, M.D. Medical Director of

Quality

Organizations may not certify activities for

AMA PRA Category 2 Credit™. A physician may individually assess the educational value for each learning

experience in which he or she participates to determine if it is appropriate to claim AMA

PRA Category 2 Credit™.

PSA Pointer: A case of an adverse medication reactionDuration: 4:28


Additional examples of topics

• Baclofen use in patient with renal

insufficiency

• Disclosure of unintentional outcomes

• Delayed diagnosis of pulmonary embolism

• Delay in identification of patient with

sepsis thereby a delay in initiation of

sepsis protocol

• Delirium

quality, safety and cme - wild apricot€¦ · online psa reporting starts psas prioritized: red...

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