safety across the world international patient safety symposium november 10, 2011
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Safety Across the World International Patient Safety Symposium November 10, 2011. Maureen Bisognano President and CEO IHI. - PowerPoint PPT PresentationTRANSCRIPT
Safety Across the World
International Patient Safety SymposiumNovember 10, 2011
Maureen BisognanoPresident and CEO
IHI
At 2pm yesterday, the urologist's office called to say that Bob was scheduled for 8am surgery today and to make sure he was drinking only liquids. Everything was OK at their end.
At 4pm yesterday, Bob's cardiologist's office called to say that they just got a call from the anesthesiologist - the one who would be working w/the urologist - to say that the surgery cannot be performed since Bob's cardiologist did not fill out the 'approval for surgery letter' with the right terminology, and that the cardiologist is on vacation this week and cannot be contacted at all. Sonsabitches!! Bob's blood pressure shot up so high I thought he was gonna have a stroke! Bob then proceeded to leave voice mail messages for 3 people in the urologist's office, finally getting a human being to ask that the surgeon give him a call asap.
At 6:30pm, the surgeon called to say that he had just spoken to the anesthesiologist and he concurs that the surgery cannot be performed until said cardiologist returns to the office to fill out the proper paperwork and for Bob to possibly have more invasive testing before surgery, even though he's had every battery of pre-surgery tests known to man.
It seems that the person in the pre-surgery office OR the assistant to the anesthesiologist did not take the time to make sure ALL of Bob's paperwork was in order for the surgery before the 11th hour!
Bob already filled out office paperwork to take a leave of absence from work, along with a half-pay medical leave, so he's pretty mad about this last minute cancellation and so am I.
Today 11am - the very busy urologist called back to give a tentative surgery date of Tuesday, 11/08 (another 2 wks. from now)
The waiting continues, along with the emotional drain and frustration for Bob and our family. Thanks for caring.
Hi Sophie,
Of course you can tell our ongoing saga about Uncle Bob’s eventual surgery. Even though the surgeon is not in any hurry, this surgery is important to us since Bob has a large cancerous tumor growing outside his bladder PLUS a non-functioning left kidney that must be removed before it becomes dangerous in any way. And adding to these problems, Bob has high blood pressure and diabetes, along with other medical issues! I guess I definitely need to stay strong and healthy to keep this family going.
Hang in there toots.
Hugs, Aunt Rhonda
Safety in Aviation
• Design• Reliability• Checklists• Human Factors
Sully Sullenberger
Sullenberger’s Priorities
• Fly the plane• Deal with the situation• Communicate
208 seconds
Sullenberger’s Decision
“My aircraft” … “your aircraft”• All options for landing on
left side• More hours in that plane• 11 months since simulation
training…co-pilot: 1 week• Co-pilot’s first time in Airbus
Sully on Sully
• Physical stress causes increased blood pressure, increased heart rate, and narrowed vision
• Forced calm on himself• “Be the swan”• Imposed order on chaos• Chose to do only critical
things
Safety in Healthcare
• Design• Reliability• Checklists• Human Factors
• Systems knowledge
“To Err is Human” (1999)
How can we learn about our system performance?
Diagnostic Journey
• Do people die unnecessarily every day in our hospitals?
• In order for us to understand this, we need a diagnostic journey that moves out of a model for judgment and into a model for learning.
The Mortality Diagnostic – 2x2 Matrix
• Review most recent 50 consecutive deaths
• Place them into a two by two matrix based on:- Was the patient admitted for palliative care?- Was the patient admitted to the ICU?
• Focus your work initially on boxes that have at least 20% of your mortality
Diagnostic – The 2 x 2 MatrixAdmitted to the ICU?
Yes No
Admitted forPalliativeCareOnly?
Yes
No
Box #1 Box #2
Box #3 Box #4
The Mortality Diagnostic:Failure to Recognize, Plan, Communicate
• Analyze deaths in box 3 and 4 for evidence of failure to: recognize, communicate, plan
• This will help you understand the local environment
Recognize, Communicate, Plan
Failure to Recognize: Any situation in which a patient has died and there was evidence that an intervention could have been made anytime prior to the patient’s death Example: the staff was worried, change in heart rate, change in respiratory rate, change in blood pressure, change in O2 saturation or change in consciousness or neurological status that was not responded to.
Failure to Plan, such as: diagnosis, treatment, or calling a rescue team.
Failure to Communicate: Patient to staff, clinician to clinician, inadequate documentation, inadequate supervisor, leadership (no quarterback for the team), etc.
The Mortality Diagnostic:The Impact of Care
Evaluate ALL deaths in box 3 and box 4 to assess the estimated impact of our care on mortality:
*As you review the deaths in box 3 & 4, ask yourself the questions honestly (focusing on learning, not judgment):
─ Was perfect care rendered?─ If perfect care wasn’t rendered, could the outcome
of death have been prevented if the care had been better?
What number of deaths could have been prevented?
The Mortality Diagnostic:Evidence of Adverse Events
• Analyze deaths in box 3 and 4 for evidence of adverse events using the Global Trigger Tool
• This will give some further direction to local problems
Global Trigger Tool
• Review chart for triggers that are sensitive and specific for harm
• Find a trigger – Was there harm?• Not all triggers mean there was harm!
Global Trigger Tool Modules
• Cares (General) • Critical Care• Medication• Surgery• L&D• ED
Example of a trigger:Transfer to higher level of care
• Endoscopy• Post procedure somnolent and
hypotensive (BP 80) transferred to ICU• Placed on Bi-Pap• Received standard Demerol and Versed
for procedure• Given Romazicon; stayed in unit 12 hours
Global Trigger Tool Examples• Readmit within 30 days with recurrence of abscess right hip• Readmit next day w/ileus s/p exp lap for tumor• Stopped lasix-acute renal failure• Readmitted in 30 days for wound revision due to incisional
seroma• Readmit related with wound infection• Volume Depletion with altered mental status caused by Lasix -
resulted in hospital admission• ARF due to nephrotoxicity due to combination of ACE and
NSAIDS taken at home• Ischemic colitis had rt hemicolectomy. New onset CP=MI
Unresponsive, coded. Decreased loc & sats on Morphine PCA. Rec'd Narcan
Safety Initiatives
Studying Mortality
Kaiser Permanente:“Saving Lives by Studying Deaths”
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
• To address substantial variation across their hospitals, KP quality leaders led an efficient and effective method of investigating mortality to find patterns of harm
• Used IHI’s Global Trigger Tool and 2x2 mortality matrix, as well as other tools
• Multidisciplinary teams studied the 50 most recent inpatient deaths at 11 KP hospitals
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Storytelling
• Project leaders incorporated the use of de-identified patient narratives to get at the circumstances behind the data.
• Stories were selected to share with hospital leaders to identify common issues that would help drive improvement.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Results• 10 categories of harm were identified (listed below in
order of decreasing frequency):─ Harm occurring before hospitalization─ Hospital-acquired infection─ Failure to plan─ Failure to communicate─ Other harm─ Hospital-acquired pressure ulcer─ Surgical/procedural complication─ Failure to rescue─ Medication event─ Fall
• In response, hospital leaders identified 36 quality improvement goals to pursue.
Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.
Scottish Patient Safety Program
Specific Outcome Aims for Academic and District General Hospitals
By January 2011• Mortality: 15% reduction• Adverse events: 30% reduction• Ventilator associated pneumonia: 0 or 300 days between• CL CR-BSI: 0 or 300 days between• Blood sugars w/in range (ITU/HDU): 80% or > w/in range• Staph aureus bacteraemias: 30% reduction• Crash Calls: 30% reduction• Harm from anti-coagulation: 50% reduction in ADEs• Surgical site infections: 50% reduction (clean)
The Scottish Patient Safety Program
• NHS Quality Improvement Scotland• The Scottish Government Health
Directorate• The Institute for Healthcare Improvement
Inventory national programmes and measurementsMeet with programme leader to understand programme intent, audience, historyHarmonize our metrics
Improve Safety of Hospital Healthcare Services in Scotland
Boards Accept Safety as Key
Strategic Priority for Effective
Governance
Scottish Executive Sets PSA as
Strategic Priority
Robust, evidence based proven clinical changes
IHI/QIS Team Expert at Content,
Coaching and Programme Management
Align national SPSP with
national improvement
programmes and measures
Primary Drivers
Demonstrable results to communityClear, shared measurement setVisible on all senior leader agendaPSA represents & demonstrates cohesive, united programme
Secondary DriversOwnership of agreed upon set of outcomesReview of outcomes at each meetingQuality and safety comprises 25% of agendaRecovery plans for unmet outcomesInfrastructure supports improvement and measurementInvolve patients in safety
Patient Safety Alliance Programme
Driver Diagram
International expert clinical facultyFaculty expert at improvement methods and coachingProgramme design and structure
Acceptance of pragmatic science Royal College Supports PSA Programme
.******Improve healthcare
safety by reducing:
1. Mortality by 15%
2. Adverse events by 30%
**National Priorities, Programs, Strategies
Leadership System for Safety
Care of General Ward Patients
Perioperative Care Management
Medicines Management
** Infection Prevention
Care for Acute MI Patents
Primary Drivers
Pressure UlcersCHF key processesHandoffs **Hospital at NightCommunicationFailure to Rescue *SEWS
Medicines Reconciliation**High Alert Medicines (**antioagulation ,
narcotics, insulin)Handoffs and Transitions
Secondary Drivers
MRSA + MSSA infectionsC-difficile infectionsHand hygiene and general infection
prevention
Safety as a Strategic PrioritySustainable InfrastructureEngaged and Committed Leadership
TechnicalDriver Diagram
Clean Surgical Site Infection**
AMI mortalitySeven key AMI processes
Nov-07
Jan-0
8
Mar-08
May-08
Jul-0
8
Sep-08
Nov-08
Jan-0
9
Mar-09
May-09
Jul-0
9
Sep-09
Nov-09
Jan-1
0
Mar-10
May-10
Jul-1
0
Sep-10
Nov-10
0
2
4
6
8
10
12
Scottish Patient Safety Program (SPSP)Critical Care Central Line BSI Rate
November 2007 through December 2010(Goal: 0 CL BSIs)
Cen
tral
Lin
e B
SI ra
te (B
SIs
per 1
000
cent
ral l
ine
days
)
T1 Median = 2.7
T2 Median = .71 (74% decrease)
Mar-0
8Ap
r-08
May-
08Jun
-08Jul
-08Au
g-08
Sep-0
8Oc
t-08
Nov-0
8De
c-08
Jan-09
Feb-
09Ma
r-09
Apr-0
9Ma
y-09
Jun-09
Jul-09
Aug-
09Se
p-09
Oct-0
9No
v-09
Dec-0
9Jan
-10Fe
b-10
Mar-1
0Ap
r-10
May-1
0Jun
-10Jul
-10Au
g-10
Sep-1
0Oc
t-10
Nov-1
0De
c-10
0
2
4
6
8
10
12
14
16
18
20
Scottish Patient Safety Program (SPSP)VAP Rate
March 2008 through December 2010(Goal: 0 VAPs)
VAP
Rate
(VAP
s per
100
0 ve
ntila
tor d
ays)
T1 Median = 8.4
T2 Median = 4.6 (45% decrease)
Jan-
08M
ar-0
8M
ay-0
8Ju
l-08
Sep-
08No
v-08
Jan-
09M
ar-0
9M
ay-0
9Ju
l-09
Sep-
09No
v-09
Jan-
10M
ar-1
0M
ay-1
0Ju
l-10
Sep-
10No
v-10
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Scottish Patient Safety Program (SPSP)Critical Care C. Diff Rate
January 2008 through December 2010(Goal: 50% reduction)
C. D
iff R
ate
per 1
000
patie
nt d
ays
T1 Median = 1.6
T2 Median = .44 (73% decrease)
Financial Impact of Safety Initiatives
CONFIDENTIALThis document is part of the quality assessment activities of Cincinnati Children’s Hospital Medical Center and, as such, it is a confidential document not subject to discovery pursuant to Ohio Revised Code Section 2305.25 and 2305.251. Any committees involved in the review of this document, as well as those individuals preparing and submitting information to such committees, claim all privileges and protection afforded by ORC Sections 2305.25, 2305.251 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individual or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.
Serious Safety Events per 10,000 Adj. Patient DaysRolling 12-Month Average
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Jul
Aug Se
pO
ctN
ov Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Se
pO
ctN
ov Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Se
pO
ctN
ov Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Se
pO
ctN
ov Dec Jan
Feb
Mar
Apr
May
Jun
FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Even
ts p
er 1
0,00
0 A
dj. P
atie
nt D
ays
SSEs per 10,000 Adj. Patient Days Baseline [ 1.0 (FY05-06) ]
Fiscal Year Goals (FY07=0.75 / FY08=0.50 / FY09=0.20) Threshold for Significant Change
** The narrowing thresholds in FY2005-FY2007 reflect increasing census. Adjusted patient days for FY07 were 27% higher than for FY05.
** Each point reflects the previous 12 months. Threshold line denotes significant difference from baseline for those 12 months (p=0.05).
aSSERT BeganJuly 2006
Chart Updated Through 31Aug09 by Art Wheeler, Legal Dept. Source: Legal Dept.
Desired Direction of Change
36 SSE’s Prevented
Serious Safety Event PreventionHospital Wide Effort - #1 Priority
2010 Goal
Case Study - HAI• Reducing hospital
acquired infections– Our “breakthrough”
effort
Reducing Hospital Acquired Infections
Improved Medical Outcomes & Error Elimination
• Clinical initiatives to reduce Catheter Associated Bloodstream Infections (BSI), Surgical Site Infections (SSI) & Ventilator Associated Pneumonia (VAP) were initiated
• At time, our rates were close to the national averages: – BSI rate = About 2 out of every 100 children with a
catheter– SSI rate = About 1.5 out of every 100 children
receiving surgery– VAP rate = About 4 out of every 100 children placed on
a vent• Our own data suggested that maybe 15-20% of
kids in the ICU who acquired a BSI, VAP or other serious infection might be expected to die
Reducing Hospital Acquired InfectionsImproved Medical Outcomes & Error Elimination
• Interventions aimed at reducing infection rates were developed from published best practices & our own observations & thoughts
• Development of Pediatric Specific Bundles for Care Delivery
• Intense focus on Execution• Transparency of Results
– Outcomes drive Culture Change
Reducing Hospital Acquired Infections Improved Medical Outcomes & Error Elimination
• What was achieved in first 2 years: – BSI rate reduced by 60%; meaning 29 fewer
kids suffered a preventable infection– SSI rate reduced by 60%; meaning 50 fewer
kids suffered a preventable infection– VAP rate reduced 90%; meaning 70 fewer kids
suffered pneumonia in our ICU
• MOST IMPORTANTLY potentially 20 children went home from our hospital that statistically may not have been expected to be do so!
24 26 21 36 34 24 18 24 15 21 27 12 6 6 7 9 9 9 5 8 5 3 8 6 5 8 8 6 6 5 5 4 4 1 4 4 4 9 5 4
8340
8741
8546
9034
9080
8890
9324
1005
4
1045
0
1066
7
1100
7
1049
1
3861
4094
3827
3625
3706
3434
3439
3790
3757
3651
3705
3840
4180
4484
4177
4159
4353
4306
4545
4326
4834
4476
4595
4483
4620
4874
4393
4463Device
Days
Infections
This document is part of the quality assessment activities of Cincinnati Children's Hospital Medical Center and, as such, it is a confidential document not subject to discovery pursuant to Ohio Revised Code Section 2305.25 and 2305.251. Any Committees involved in the review of this document, as well as those individuals preparing and submitting information to such Committees, claim all privileges and protection afforded by ORC Sections 2305.25, 2305.251 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individual or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.
CCHMC Central Venous Catheter (CVC) AssociatedLaboratory Confirmed Bloodstream Infections (LCBIs)
0.2
1.8
1.10.9
0.9
0.8
0.90.9
1.9
2.7
1.11.41.40.8
2.22.12.4
2.5
1.51.8
1.2
1.6
1.31.5
2.6
1.81.6
1.1
2.5
2.0
1.4
2.4
1.9
3.7
4.0
2.5
3.0
2.9
1.2 0.9
0
1
2
3
4
5
6
7
8Q
3 '0
4
Q4
'04
Q1
'05
Q2
'05
Q3
'05
Q4
'05
Q1
'06
Q2
'06
Q3
'06
Q4
'06
Q1
'07
Q2
'07
Jul '
07
Aug
'07
Sep
'07
Oct
'07
Nov
'07
Dec
'07
Jan
'08
Feb
'08
Mar
'08
Apr '
08
May
'08
Jun
'08
Jul '
08
Aug
'08
Sep
'08
Oct
'08
Nov
'08
Dec
'08
Jan
'09
Feb
'09
Mar
'09
Apr '
09
May
'09
Jun
'09
Jul '
09
Aug
'09
Sep
'09
Oct
'09
Nov
'09
Dec
'09
Jan
'10
Feb
'10
Mar
'10
Apr '
10
May
'10
Jun
'10
FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Infe
ctio
ns p
er 1
000
Dev
ice
Day
s
CVC-LCBIs Control Limits Goals [0.8 (Jul06-Jun07) / 1.0 (Jul07-Jun08) ] Baselines
Q3/04 - Revised Care Practices and Q3/04 - CHG Scrub for Line CareQ3/04 - CHG Scrub for CVC InsertionsQ4/04 - Maximal sterile barriers and CHGQ4/04 - Interventional Radiology
New CCHMC Collaborative
Began, Q1/06
CA-BSI NACHRIderived CVC bundlerolled out to hospital 3/15/07
Q2/05 - MaxPlus Cap in PICU B4 & A6Q2/05 - MaxPlus Cap on A5N2Q3/05 - MaxPlus Cap cancelled on A5N2Q3/05 - MaxPlus Caps cancelled.
3/17/09 - Microclave Cap Use Housewide
Jan09 - Microclave Cap Use ICUs
Feb09 - Microclave Cap Use HemOnc/BMT
0.8
4.0
Quantifying the Financial Impact of An Enormous QI Success
• Brilliant Hypothesis: A HAI is “Bad Business”– Clinical Outcome not as good – inability to
differentiate our product– Poor customer Value - dollars spent in treating
infection = waste– Potential high opportunity cost – bed occupied
by HAI could effect flow and ability to meet access needs of out-of-area admission
– Poor Patient Experience
• We needed a proven methodology to test and conclusively measure our hypothesis
Comparative Matched-Case Study Design
• Chart reviews to define candidates and assess whether SSI was potentially preventable
• Matched Case-Control Design– Initial OR Cost of SSI case = Control (No SSI) OR
Case– Cumulative Cost at time of discharge of Control
case = SSI Case– Match criteria: same or equivalent surgical
procedure, age, procedure date, co-morbidities– Excluded patients with cancer, immune
deficiency, neonates or over 19 yrs old• 16 Patients in final statistical analysisSparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health
Care 2007;16:219-225.
Days after surgical procedure
$0
$500,000
$1,000,000
$1,500,000
$2,000,000SSI Match
SSI ResultsAggregate Cumulative
Charges
$1,740,000
$793,000Ave LOS = 4.6 days
Ave LOS = 16.0 days
Sparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health Care 2007;16:219-225.
Reducing Hospital Acquired Infections
Improved Medical Outcomes & Error Elimination
Nothing compares to the human impact of this effort & nothing is even remotely as important; but there is more:– We reduced the costs to the health care system
by $11.2 million annually– And we reclaimed 5 beds per year previously
dedicated to infections that could now be dedicated our core strategy of unique program development
Maximizing Asset Production –Revenue Production Associated with
SSISSI Patient vs. Matched No-SSI Patient
Average Daily Charges
$0
$10,000
$20,000
$30,000
$40,000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Day
Ave
rage
Dai
ly C
harg
es
SSI Match
Pre-SSI Infection
Day of Surgery
Post-SSI Infection
Low Revenue ProductionRevenue Sweet Spot
90 Day Revenue Production CycleWhen 6 Patients Develop an SSI
Bed Cycle For SSI PatientsAverage LOS for Surgery Patients With Infection = 15 Days
Total Revenue Produced in 90 Day Cycle = $622,000
$0
$10,000
$20,000
$30,000
$40,000
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Day
Dai
ly C
harg
es
Same 90 Day Cycle of Revenue Production
If No Patients Acquire SSI (18 patient potential)
Bed Cycle For Non-SSI PatientsAverage LOS for Surgery Patients Without Infection = 4.4 Days
Total Revenue Produced in 90 Day Cycle = $892,000Annualized Incremental Revenue = $1,080,000
$0
$10,000
$20,000
$30,000
$40,000
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Day
Dai
ly C
harg
es
Diuretic Related Harm per 100 Patients on Loop Diuretics
0
1
2
3
4
5
6J-
09F-
09M
-09
A-0
9M
-09
J-09
J-09
A-0
9S
-09
O-0
9N
-09
D-0
9J-
10F-
10M
-10
A-1
0M
-10
J-10
J-10
A-1
0S
-10
HFH
Henry Ford Health System
Harm Issue Total Associated Costs Pressure Ulcer stage 2 or higher $10,624,410
Coded Procedural Complication ICD9 (998-999.99) $7,670,520UTI using coded data and AHRQ definition. $5,662,895Glucose below 40 $3,846,375Coded Acute Renal failure $2,665,680
Coded DVT/PE in both medical and surgical patients $2,365,470No Pulse Blue Alert $1,535,808Coded Medication issue $1,216,078Clostridium difficile infection $824,544Reported Fall with injury $696,527Bloodstream Infections using NHSN criteria $640,000Coded Pneumothorax using AHRQ definition $340,260SSI using NHSN criteria $280,000VAP using NHSN criteria $190,352
Total Harm-Associated Costs 2009*
*Henry Ford Hospital Only
The Leader’s Role
• Executive WalkRounds• Deep dives in safety data and stories• Signs and symbols of a just culture• Move from past tense to future tense
─Huddles─Inquiries
• Aims, prototype sites, spread plan and tempo
Thank You!
• Maureen BisognanoPresident and CEOInstitute for Healthcare Improvement20 University Road, 7th FloorCambridge, [email protected]