Quality & Safety Quality & Safety at Hadassahat Hadassah

A Progress ReportA Progress Report Mayer Brezis, MD MPHMayer Brezis, MD MPH

Professor of MedicineProfessor of Medicine , ,Center of Quality & SafetyCenter of Quality & Safety

Chairman, Quality & Safety CommitteeChairman, Quality & Safety Committee

Yoel Donchin, MD, Nurit Porat, RNYoel Donchin, MD, Nurit Porat, RN

• Students ProjectsStudents Projects

• Institution-wide ProjectsInstitution-wide Projects

• Educational ActivitiesEducational Activities

• National ImpactNational Impact

Quality & Safety at HadassahQuality & Safety at Hadassah

Making Health Making Health Care Safer: A Care Safer: A

Critical Analysis Critical Analysis of Patient Safety of Patient Safety

PracticesPracticesEvidence ReportEvidence Report

Agency for Agency for Healthcare Healthcare Research & Research &

QualityQualitywww.ahrq.gov/www.ahrq.gov/clinic/ptsafetyclinic/ptsafety

Venous Venous Thromboembolism in Thromboembolism in

NeurosurgeryNeurosurgery

Dr. G. Rosenthal, S. Goldman RN, Prof. F. Dr. G. Rosenthal, S. Goldman RN, Prof. F. Umanski, Prof. D. Varone, Dr. Y Weiss Umanski, Prof. D. Varone, Dr. Y Weiss

Departments of Neurosurgery, Hematology, Departments of Neurosurgery, Hematology, Central Management, Center for Quality & SafetyCentral Management, Center for Quality & Safety

Hadassah University HospitalHadassah University HospitalJerusalem, IsraelJerusalem, Israel

•58 year-old woman underwent 58 year-old woman underwent resection of meningiomaresection of meningioma

•On post-op day 2, sudden On post-op day 2, sudden onset of respiratory distressonset of respiratory distress

•Chest CT demonstrates Chest CT demonstrates massive pulmonary embolismmassive pulmonary embolism

•Vena cava filter inserted & Vena cava filter inserted & anticoagulation initiatedanticoagulation initiated

•On post-op day 6 sudden onset On post-op day 6 sudden onset of severe headache and of severe headache and vomitingvomiting

Post-op CT Follow-up CT

10

05

0

2

4

6

8

10

12

1st Control Intervention 2nd Control

Cas

es o

f VTE

10/239 4%

0/94 0%

5/75 7%

Control

Cases o

f th

rom

bo-

em

bolism•5 months (2003)•10 cases of thromboembolism•7 vena cava filters inserted•Extended ICU & hospital stays

10

05

0

2

4

6

8

10

12

1st Control Intervention 2nd Control

Cas

es o

f VTE

10/239 4%

0/94 0%

5/75 7%

July 2003: Introduction of

intermittent pneumatic

compression devices

Cases o

f th

rom

bo-

em

bolism

Control

Intervention

10

05

0

2

4

6

8

10

12

1st Control Intervention 2nd Control

Cas

es o

f VTE

10/239 4%

0/94 0%

5/75 7%

Cases o

f th

rom

bo-

em

bolism

Control

Intervention

10

05

0

2

4

6

8

10

12

1st Control Intervention 2nd Control

Cas

es o

f VTE

10/239 4%

0/94 0%

5/75 7%

Control InterventionControl

Intervention

Cases o

f th

rom

bo-

em

bolism

Control

Quality can Quality can

reduce reduce

morbidity & morbidity &

save costssave costs

ConclusionConclusion::

Quality indicators for Quality indicators for the management of the management of myocardial infarctionmyocardial infarction

M. Cohen, Dr. A. Pollack, Prof. A. Weiss, Prof. C. M. Cohen, Dr. A. Pollack, Prof. A. Weiss, Prof. C. Lotan Lotan

Intensive Cardiac Units, Division of Cardiology & Intensive Cardiac Units, Division of Cardiology & Department of Medicine, Mt. Scopus & Ein Kerem Department of Medicine, Mt. Scopus & Ein Kerem

Hadassah University HospitalHadassah University HospitalJerusalem, IsraelJerusalem, Israel

Quality indicators for myocardial infarction, Hadassah vs. US data

HadassahHadassah ((%%) 89 90 50 83 69 44’ 102’

Peterson R, JAMA 2004;291:195

HadassahHadassah

• Evidence-basedEvidence-based

• System-mindedSystem-minded

Quality in Health CareQuality in Health Care

Will the pathology

result get lost?

86

88

90

92

94

96

98

2001 2002 2003

Percent of patients having

received the result of their skin biopsy

p<0.05

A clinic-based intervention (led by the head nurse, A clinic-based intervention (led by the head nurse, involving both physicians & patients)involving both physicians & patients)

An institution-wide intervention: electronic alerts sent to An institution-wide intervention: electronic alerts sent to physician’s computer whenever a pathology report is physician’s computer whenever a pathology report is ready ready

4%

failed malignancy reports

0%1%

Will the pathology result get lost?

P. Topol, RN, Dr. A. Zlotogorski, Prof. A. Ingbar, Dr. A. Mali, T. Friedman, RN, M. Benhur, N.

Porat, RN

Departments of Dermatology, Pathology, Information Systems, Nursing and Quality &

Safety Committee

How can we make sure the

patient gets the result?

This quality improvement

project, awarded prize of best poster at the

meeting of the Israeli Society for

Quality in Medicine, is

posted at the dermatology clinic as a reminder for

both patients, nurses and physicians

Quality & Safety Committee Quality & Safety Committee Subcommittee for Medication Subcommittee for Medication

ErrorsErrors

Quality & Safety Committee Quality & Safety Committee Subcommittee for Medication Subcommittee for Medication

ErrorsErrors

Specific Specific labels for labels for lines to lines to

patients - to patients - to avoid mix avoid mix

upup

Screen from software asking: “Would you approve this

prescription?”

Interactive software to learn prescribing for new physicians

• Evidence-basedEvidence-based

• System-mindedSystem-minded

Quality in Health CareQuality in Health Care

• Patient-centeredPatient-centered

Palliative Care in General Palliative Care in General Internal Medicine: A successful Internal Medicine: A successful

pilot intervention among pilot intervention among elderly patients with life elderly patients with life threatening illness and threatening illness and

impaired cognitionimpaired cognition

S. Gottsman, RN, MA et al.S. Gottsman, RN, MA et al.Head Nurse, Medicine B, Mt Head Nurse, Medicine B, Mt

ScopusScopus

Staff-initiated meetings with relatives, to communicate information on patient’s

condition; to listen to their questions and to their

preferences based on patient’s prior wishes – if any had been

expressed; and finally to attempt shared goal setting

and decision making

Intervention

Control ward – no intervention

“Staff did not really consider my opinions”6013*

“I felt not involved in decision making” 5723*

“It upset me that I did not know what was happening”4310*

“I did not receive explanations about alternatives” 5720*

“Relative’s problems were not explained”533*

“I felt uncomfortable with asking questions”5310*

“I was not asked to participate in decisions”6017*

“I felt alone and without support”4317*

“I felt pressured to make decisions”277*

Control

InterventionPercent of relatives agreeing with negative

statements

Is the X-ray interpretation by the junior staff on duty correct?

Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham

Departments of Surgery, Radiology, and Center for Quality & Safety

Emerging methods for quality evaluation

Frontal bone fracture

Hip fracture

Sensitivity )%(

Specificity

)%(

Positive predictive

value)%(

Negative predictive

value)%(

ChestChest (n=54)(n=54)

92(65-100)

93(82-98)

79(52-94)

97(88-100)

Neck Neck (n=19)(n=19)

100(5-100)

100(85-100)

100(5-100)

100(85-100)

PelvisPelvis (n=27)(n=27)

60(18-93)

100(87-100)

100(37-100)

92(75-99)

CT’sCT’s(n=75)(n=75)

94 (81-99)

95(85-99)

94(81-99)

95(85-99)

Validity of X-ray Interpretations in Trauma

mean & 95% CI (confidence interval)

Reliability of X-ray Reliability of X-ray Interpretation on DutyInterpretation on Duty

mean & 95% mean & 95% confidence confidence intervalsintervals

Inter-observer variabilityInter-observer variability

Resident vs. SpecialistResident vs. Specialist

Percent Percent agreementagreement

Kappa Kappa CoefficientCoefficient

SurgerySurgery77%77%0.600.60 ((0.4-0.80.4-0.8))

Pulmonary Pulmonary EmbolismEmbolism95%0.84 (0.7-1.0)(0.7-1.0)

A Senior Resident in Radiology Concluded:

“We need to look at ourselves”

•Students ProjectsStudents Projects•Institution-wide ProjectsInstitution-wide Projects•Educational ActivitiesEducational Activities•National ImpactNational Impact

Summary & Summary & Conclusion Conclusion

Diverse projects attempt to make healthcare at Hadassah more

patient-centered, more evidence-based and more system-minded.

Increased accountability by department heads for quality and

safety may be a key to further successes.

How would an open disclosure policy about mistakes affect

hospital image in public’s eyes?

Damage Damage ImageImage

No No ChangChang

ee

ImproveImprove ImageImage

MD student

Zivan Beer

How would an open disclosure policy about mistakes affect

hospital image in public’s eyes?

p<0.001

Damage Damage ImageImage

No No ChangChang

ee

ImproveImprove ImageImage

MD student

Zivan Beer

N=570

N=115

Risk Risk

management:

management: Extreme

Extreme honesty may be

honesty may be

the best policy

the best policy

(The V.A. Experience)

(The V.A. Experience)

Annals of Internal

Annals of Internal

Medicine ‘99

Medicine ‘99

New position statement by the Ethics Board of the Israeli Medical

Association supports transparency (May 2004)

““Tell the tru

th

Tell the tru

th

and tell it fast”

and tell it fast”

N. Augustine. Crisis Management

N. Augustine. Crisis Management

Harvard Business Review (2000)

Harvard Business Review (2000)

“The physician has an obligation to disclose to the patient

that a mishap has

happened”

IMA Ethics BoardPosition Paper