Accelerating Momentum: National
Movement for Change
Betsy Lee, RN, BSN, MSPH
Patient Safety and Quality
Consultant
James (Jeb) Buchanan, M.D.
Fort Wayne Med Ed Program
Disclosure
Neither Betsy Lee nor James Buchanan have
relevant conflicts of financial interest to report.
Neuroscience of Learning
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State the new information
Repeat in 30 seconds
Repeat in 60-90 minute
Overnight – sleep – 1000x processing
– Dendrite formation
Review next morning - additional 10%
Increase memory retention from the normal
10% to 60%
Visual cortex 6 x
Multisensory input and emotion enhance
retention
“The Brain Rules” John Medina, PhD.
Applied Adult Learning Theory
The KSA (Knowledge, Skill, and Attitudes)
needed to master performance
improvement tools are best acquired by
participating and leading change projects
with clinical teams.
Workshop Outline
• Human Factors/System Science
• Use of learning tools and documentation
forms
• References at end for deeper dive
• Slides designed for mitigating note taking
Adult Learning Theory
Building the case for relevance
Medical Error
To Err Is Human:
Building a Safer
Health System
– 44-98,000 patients
die from errors each
year in the hospital =
one jumbo jet/day
– Institute of Medicine - 1999
Deaths From Medical Error
Using CDC Data:
#9 cause of death if use 44,000
#5 if use 98,000
Serious Harm
• 1 in 7 Medicare patients experience
serious harm secondary to medical
errors and nosocomial infections.
• 1 in 80,000 die (nearly double) the
previous 98,000 estimated deaths IOM
estimated in 1999).
November 2010 study by the Department of Health and Human
Services Office of Inspector General (Adverse events in
hospitals: National incidence among Medicare beneficiaries)
Medical Error
• Inspector General of DHHS 1/2012
– 130,000 Medicare patients/month
experience hospital adverse events
– Only 1 in 7 reported
– Of 293 investigated cases of harm
• 40 reported to hospital managers
• 28 investigated
• 5 led to change in policies/practices
January 2012 study by the Department of Health and Human
Services Office of Inspector General (Hospital incident reporting
systems do not capture most patient harm)
Medical Error
• Why errors were not reported?
– Hospital employees not understanding
what constitutes harm.
– Employees thought error was an isolated
incident and unlikely to recur.
– Employees thought error was so common
that it didn’t need to be reported.
Journal of Patient Safety
September 2013
• IOM report 1999 based on 1984 data
• Lit review – four studies stood out (data 20022008)
• 210,000 – 440,000 deaths/yr = 1/6 deaths in US
– Used IHI Global Trigger Tool
– Upper number includes Diagnostic Failure,
incomplete medical records, and originally
undetected errors with delay of months/years
before death.
• Serious harm without death 10-20x above
James, J A; New Evidence-based Estimate of Patient Harms Associated
with Hospital Care; Journal of Patient Safety; Sept 2013;Vol 9 –Issue 3:
122-128.
Medical Error
Number 3 cause of death in US
Public Interest
Van In Terre Haute, IN
LeapFrog Group; August 2013
National Quality Strategy
Aims
and
Priorities
1. Making care
safer by reducing
harm caused in
the delivery of
care.
2. Ensuring that each
person and family
are engaged as
partners in their care
3. Promoting
Effective
Communication &
Care Coordination
Healthy
People/Healthy
Communities
Better
Care
National
Quality
Strategy
4. Prevention & Treatment
of Leading Causes of
Mortality
5. Working with communities
to promote wide use of best
practices to enable healthy
living
6. Making quality care more
affordable for individuals,
families, employers, and
governments by developing and
spreading new health care
delivery models
Affordable
Care
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Partnership for Patients - Aims
• 40% Reduction in Preventable Hospital
Acquired Conditions
– 1.8 Million Fewer Injuries
– 60,000 Lives Saved
• 20% Reduction in 30-Day Readmissions
– 1.6 Million Patients Recover Without
Readmission
• Save up to $35 Billion Dollars
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National PfP Targeted Harm Categories
1) Adverse drug events
2) Birth-related injuries
a) Elimination of Early Elective Deliveries
3) Central line-associated blood stream infections
4) Catheter-acquired urinary tract infections
5) Falls with injury
6) Surgical infections and complications
7) Venous thromboembolism
8) Pressure ulcers
9) Readmissions
10)Ventilator-associated pneumonia
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PfP Additional Topics
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Leadership Systems
Patient and Family Centered Care
Culture of Safety
Teamwork and Communications
Lean Training
Innovation and Transformation
Preventing Harm Across the Board
Health Care Disparities
National Results – HHS Report
May 7, 2014
• Overall 9% reduction in harm during 2011 and 2012
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15,000 deaths prevented
560,000 patient injuries avoided
$4.1 Billion cumulative savings from the beginning of PfP
145 to 132 HACs per 1,000 discharges from 2010 to 2012
• Medicare all-cause 30-day readmissions dropped 8%
– 150,000 fewer hospital readmissions among Medicare
beneficiaries between January 2012 and December 2013
– 19 - 19.5% between 2007 and 2011 to 17.5% in 2013
Chasing Zero
• Leading national indicator datasets
(CDC, NDNQI, CMS) confirm harm
reduction from 2010 through 4th quarter
2013:
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Ventilator Associated Pneumonia - 53.2%
Early Elective Delivery - 64.5%
Obstetric Trauma Rate - 15.8%
Venous Thromboembolic Complications - 12.9%
Falls and Trauma - 14.7%
Pressure Ulcers - 25.2%
Etiology of Errors
Systems/Engineering - 80%
Human Factors - 15%
Negligence - 5%
Start of a different paradigm in
quality review
IOM Report 1999
Errors are not made by bad people, rather
bad systems.
Variation
Dartmouth Map
Variation
Quality of Care
Delivered to Medicare
Beneficiaries
– JAMA, October 4,
2000
Evidence-Based Medicine
The Quality of Health Care
Delivered to Adults in the
United States; NEJM,
6/26/03
– 30 Quality Indicators
– 55% EBM recommended
care given
– Same rate for
preventative and acute
care
Coin toss medicine
Medical Error
The Quality Chasm: A
New Health System
for the 21st Century
– Institute of Medicine - 2001
IOM 2001
Systematizing quality management has
the potential to improve health and
healthcare outcomes more than any
foreseeable tech or scientific
breakthroughs in the next 20 years,
including cures for diabetes, heart
disease and cancer.
Institute of Medicine Aims
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Safe – no patient harm
Effective – no needless deaths, pain or suffering
Patient-centered – no helplessness
Timely – no unnecessary waiting
Efficient – no waste
Equitable – for all
*Institute of Medicine. Crossing the Quality Chasm, 2001.
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How Hazardous Is Health Care?
DANGEROUS
(>1/1000)
100,000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Total lives lost per year
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
1,000,000
10,000,000
Number of encounters for each fatality
Source: Berwick, D.M.
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Four Levels of Change Required
• Changes at Level A: experience of the
patients and communities
• Changes at Level B: “microsystems” of
care
• Changes at Level C: health care
organizations
• Changes at Level D: health care
environment
Berwick DM. A user's manual for the IOM's 'Quality
Chasm' Report. Health Affairs. 2002; 21(3):80-90.
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Published in February 2013 Issue of
Health Affairs
What the Evidence Shows About
Patient Activation: Better Health
Outcomes and Care Experiences;
Fewer Data on Costs
Patients with Lower Activation
Associated with Higher Costs; Delivery
Systems Should Know Their Patients’
‘Scores’
Enhanced Support for Shared
Decision-Making Reduced Costs of
Care
for Patients with Preference-Sensitive
Conditions
Survey Shows That Fewer Than a
Third of Patient-Centered Medical
Home Practices Engage Patients in
Quality Improvement
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Patient Engagement and Adverse Events
“[T]here was an inverse relationship
between [patient] participation [in their
care] and adverse events . . .
[P]atients with high participation were
half as likely to have at least one
adverse event during the admission. ”
Source: Weingart SN et al., Hospitalized patients’ participation and its impact on quality of care
and patient safety, International Journal for Quality in Health Care 2011; 1-9.
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Nursing Education Redesign
• Quality and Safety Education for Nurses
(QSEN) - http://qsen.org/
• Competency-based approach to nursing
education supported by AACN and RWJF
• Focus on preparing future nurses with the
knowledge, skills, and attitudes (KSAs)
necessary to continuously improve the quality
and safety of the healthcare systems within
which they work
Commitment to Change
Statement
Next Accreditation System (NAS)
Feb 22, 2012
– Learn both the technical skills of being a
physician AND systems understanding for
high quality/safe care.
– Problem solve errors/causation
– Patient safety and quality improvement is
not a spectator sport / team-based.
– Effective Institutional reporting systems
NAS
• Understand and apply Human Factors and
System/Reliability Science to reduce
errors and improve quality.
• Engage residents in detection of errors
and quality improvement. (Moral agents)
• Use near misses and unsafe conditions as
educational/learning opportunities for
resident learners (Relevance).
• Feedback to GMEC for its oversight role
ACGME CLER
October 10, 2013
• Reporting of adverse events/near misses
– Not reporting to faculty who in-turn reports
(Easy Button)
• Education on patient safety
• Learning environment culture of safety
• Resident experience in patient safety
investigations and follow-up
• Clinical site monitoring of resident and
faculty engagement in patient safety
• Resident training in disclosure of patient
safety events
ACGME CLER
• Receiving feedback post reporting
• Perform Root Cause Analysis
• Know hospital’s quality and patient
safety projects and somehow
meaningfully involved
• Receive and review hospital’s quality
and patient safety measures/data
CME
• What percent of physicians after a CME
event will implement what they have
learned? 7 – 12%1,2 (JAMA 1995, AHRQ 2007)
• How long to incorporate sound EBM
into physician practices? 17 yrs3,4 (IOM 2001)
– Lacked strategy on how to implement new
knowledge
– Encountered a barrier
– Strategies, tools, and handouts at this
presentation will hopefully increase this
percent.
System Design Management
Focus on systems and not individuals.
System redesign is more efficient than
clinical education.
Patient Safety
Medical Errors
• Human error and adverse events which
may follow are problems of cognitive
psychology (human factors) and
engineering, not of medicine.
• We didn’t receive training in these in
medical school or residency.
• Easy principles
Reporting Barriers
Residents
• Don’t think report would result in any changes
being made.
• No time to report
• Don’t want to get team member in trouble
• Don’t want my name on the report
• Don’t know how to report
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Harper, M.L. & Helmreich, R.L.; 2005; Identifying barriers to the
success of a reporting system; Advances in Patient Safety; AHRQ.
Adverse Event
WHO
• An injury related to medical management, in
contrast to complications of disease. Medical
management includes all aspects of care,
including diagnosis and treatment, failure to
diagnose or treat, and the systems and
equipment used to deliver care. Adverse
events may be preventable (error) or nonpreventable.
Patient Safety
VA National Center for Patient Safety
• Patient Safety is the identification and
control of hazards/vulnerabilities that
could cause harm to patients
• Patient safety is the prevention of
inadvertant harm or injury to patients.
Residents
• 23% reported a “close call” or “near
miss” in last week for which they felt
responsible.
• Procedure and medication error most
common.
• Most common reasons: Excessive work
hours, inadequate supervision, and
handoffs
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Jagsi, R et al; 2005; Residents report on aderse events and their causes. Arch
Intern Med, 165, 2607-2613
Professional Pause
Reflect on the gap of best care not
provided; the need for physicians, nurses
and other members of the interprofessional team need to assess their
practices for the gap; and the need to
train human factors and systems science
to empower teams to close this gap.
References – CME Effectiveness
1
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician
performance: A systematic review of the effect of continuing medical education
strategies. JAMA. 1995;274:700-705.
2
Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of
Continuing Medical Education; Agency for Healthcare Research and Quality
(US); January 2007.Available at:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1b.chapter.105720).
3
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the
21st Century. National Academies Press, 2001, page 13.
4
Balas EA, Boren SA. Managing Clinical Knowledge for Health Care
Improvement. In: Bemmel J, McCray AT, editors. Yearbook of Medical
Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer
Verlagsgesellschaft mbH; 2000:65-70.