1
Proposed Resources for Partnership for
Patients
Terri Conner, Ph.D.
Nybeck Analytics
Partnership for Patients

2
 In the U.S.
– 7% of patients suffer a medication error
–
–
On average, every patient admitted to the ICU suffers an adverse event
44,000 – 98,000 people die in hospitals each year as the result of medical errors
– An additional 100,000 deaths from health-care associated infections
– Cost of HAI is $28-33 billion

3
 25% of in-patient surgeries are followed by a complication, many leading to:
– Prolonged LOS
– Re-admission
– Death
 50% of all hospital adverse events are linked to surgery
– At least 50% of adverse surgical events are preventable

4

5
 To achieve significant reductions in surgical site infection and surgical complication rates
– Reducing complications reduces readmissions
 To achieve significant improvements in safety culture

6
 Harm is preventable
– Many HAIs and complications are preventable, and should be viewed as defects
 Technical and adaptive work
– Focus on systems; not on individuals
– Engage frontline staff to identify and fix local opportunities to improve

7
 Informed by science
– Medical best evidence
– Social science
 Led by clinicians and supported by management
 Guided by measures

8
 No single SSI prevention bundle
– Dive deeply into SCIP measures to identify local defects
– Emerging evidence
 Bowel prep
 Antibiotic redosing
 Chlorhexidine skin prep
 Capitalize on frontline wisdom to identify local opportunities to improve

9
SUSP
 Technical component
– TRIP: Translating Evidence into Practice
 Adaptive component
– CUSP: Comprehensive Unit-based Safety
Program

10
 Michigan Keystone ICU program
– Reduction in central line-associated blood stream infections
– Reduction in ventilator-associated pneumonias

11
TRIP: Translating Evidence Into
Practice
 Summarize the evidence
 Identify local barriers to implementation
 Measure performance
 Ensure all patients get the evidence
–
4 E’s Model

12
4 E’S MODEL TO HELP IMPLEMENT
PATIENT SAFETY INTERVENTIONS




Engage
– How does this make the world a better place?
Educate
– What do we need to know?
Execute
–
–
What do we need to do?
What keeps me from doing it?
– How can we do it with our resources and culture?
Evaluate
– How do we know we improved safety?

Comprehensive Unit-based Safety Program
An intervention to learn from mistakes and improve safety culture
13
A good approach whenever there is a gap between evidence-based practice and current practice on your unit.

 Shared attitudes, values, goals, practices, behaviors
14
 Culture influences behavior
– Participation in quality improvement efforts
– Communication
 Breakdown in communication contributes to nearly all adverse events.

15
CUSP: COMPREHENSIVE UNIT-
BASED SAFETY PROGRAM
 Safety practices part of daily work
 Implemented at the unit level
 Led by clinicians
 Structured program, yet flexible

16
 Assemble Safety Team
– Multidisciplinary
– Different levels of experience
– Encourage joining team at any phase of the program

17
 Team Members – frontline staff
– Project Leader (Unit Champion)
– Nurse Manager
– Physician Champion
– Senior Hospital Executive
–
–
Patient Safety Coordinator
Epidemiology / Infection Control
– Coach

18
 Measure Safety Culture
– Before CUSP implementation, and then every 12-18 months
–
Use AHRQ’s The Hospital Survey on Patient Safety Culture
(HSOPS)
– All clinical and non-clinical providers
– Report results to the unit and senior hospital executive

19
1.
Science of safety training
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from defects
5.
Implement teamwork tools

STEP 1: SCIENCE OF SAFETY
TRAINING
20
 Goals
– Magnitude of patient safety problem
– Foundation for investigating safety defects
–
Providers’ involvement significantly affects patient safety

21
STEP 1: SCIENCE OF SAFETY
TRAINING
 Learning Objectives
– Safety is a property of the system
– Use strategies to improve system performance
 Standardize work
 Create independent checks for key processes
 Learn from mistakes
– Apply strategies to both technical work and team work
– Teams make wise decisions with diverse and independent input

STEP 1: SCIENCE OF SAFETY
TRAINING
22
 Training Session
– 3part “Improving Safety” presentation by Dr. Peter Pronovost
 Part 1: http://www.youtube.com/watch?v=GOJJHHm7lnM
 Part 2 http://www.youtube.com/watch?v=wpzb7nM6oFQ&feature=related
 Part 3 http://www.youtube.com/watch?v=6BnXs4KtER8&feature=related
– Instruct staff on reporting of safety concerns
– Describe executive safety rounds

23
 Eyes and ears of patient safety
 Ongoing process
 Disseminate Staff Safety Assessment Form
 Combine results and prioritize defects

24
 Anything you do not want to have happen again.
 Many HAIs are preventable. They should be viewed as defects.

25
 Staff Safety Assessment Form
– Purpose: Tap into your knowledge and experiences at the frontlines of patient care to find out what risks are present on your unit that do or could jeopardize patient safety.
– All health care providers in the unit complete this form.
– 2-item questionnaire

26
 Staff Safety Assessment Form
1.
Please describe how you think the next patient in your unit/clinical area will be harmed.
2.
Please describe what you think can be done to prevent or minimize this harm.

27
 Combine Results
– Group into common types of defects
 Communication
 Medication process
 Patient falls
 Supplies
– Frequency distributions
 Example: communication, 57%

28
 Prioritize safety concerns
– Obtain input from CUSP team senior executive
– Prioritize based on
 Likelihood of causing patient harm
 Severity of harm
 How common is the problem
 Likelihood it can be solved by implementing a daily work process

29
Four Key Questions
1.
What happened?
2.
Why did it happen?
3.
4.
What will you do to reduce the chance it will recur?
How do you know that you reduced the risk that it will happen again?

30
 Reconstruct the timeline and explain what happened
 Put yourself in the place of those involved, in the middle of the event as it was unfolding
 Try to understand what they were thinking and the reasoning behind their actions/decisions
 Try to view the world as they did when the event occurred

31
SYSTEM FAILURES
 Arise from managerial and organizational decisions that shape working conditions



Often results from production pressures
Damaging consequences may not be evident until a “triggering event” occurs
Develop lenses to see the system factors that lead to the event

32
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?
 Prioritize most important contributing factors
 Prioritize most beneficial interventions
 Safe design principles
– Standardize what we do
– Create independent check
– Make it visible
 Safe design applies to technical and team work

33
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?
 Develop list of interventions
 For each intervention:
– Rate how well the intervention solves the problem or mitigates the contributing factors for the accident
– Rate the team belief that the intervention will be implemented and executed as intended
 Select top interventions (2 to 5) and develop intervention plan
– Assign person, task follow-up date

34
HOW DO YOU KNOW RISKS WERE
REDUCED?
 Did you create a policy or procedure?
 Do staff know about policy or procedure?
 Are staff using the procedure as intended?
– Behavior observations, audits
 Do staff believe risks were reduced?

35
 Summarize and Share Findings
– Learning from Defects Tool
–
 Detailed form for each incident or identified defect
Case Summary Form
 Summarize the case
 Identify system failures
 Identify opportunities for improvement
 List actions taken to prevent future harm
– Share your findings

36
Key Points
– Focus on systems, not people
– Prioritize
– Go mile deep and inch wide, rather than mile wise and inch deep
– Pilot test
– Learn from 1 defect a quarter
– Answer the four questions

37
Staff Safety Assessment
Safety Issues Worksheet
Status of Safety Issues
Learning from Defects Tool
Case Summary Form
Briefings/Debriefings
SSI Investigation
Audits

38
Used to identify defects in the unit
1.
Please describe how you think the next patient in your unit/clinical area will be harmed.
2.
Please describe what you think can be done to prevent or minimize this harm.

39
Identified Issue
1.
2.
3.
Potential/
Recommended
Solution
Resourc es
Needed
Resources
Not
Needed

Date
Safety Issue
New and Ongoing
Contact Status Goal
New and Ongoing
Contact Status Date Safety Issue Goal
40
Date Safety Issue
Completed
Contact Status Goal

41






Explain what happened.
Check off the factors that negatively or positively contributed to the incident.
Describe how you will reduce the likelihood of this defect happening again by completing the tables.
Develop interventions, and choose 2-5 to implement.
–
–
–
What will be done?
Who will lead the intervention?
When is follow-up?
Describe how you know you have reduced the risk.
Summarize your findings using the Case Summary Form.

42
Form Sections
 Safety tips
 Case summary
 System failures
 Opportunities for improvement
 Actions taken to prevent harm

43
 Dominant tool for SUSP
 Growing evidence
– Better team performance
– Better safety culture
– Reduction in delays
 Adapted to local hospital and OR
 Adapted to surgery type

44
 Look into factors that may be systematically contributing to SSIs

45
 Skin prep audits
 Antibiotic audits

46
 Mislabeled specimens
 Wrong sided surgery
 Retained foreign objects

47