Temple University Hospital
House Staff Orientation
High Value Care
Rebecca Armbruster, DO, MS
Interim Associate Chief Medical Officer
Medical Director-Resource Management
Temple University Hospital
June/July, 2014
PART ONE
High Value Care
What is it?
The Triple Aim
Population
Health
Patient
Experience
Per Capita
Cost
Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)
Value Proposition
High value health care =
high quality outcomes / low cost
High value can only occur if:
• The culture supports communication,
collaboration and consistently safe care
• Frontline employees and physicians (including
house staff) are engaged at every level
• The entities of the health system are aligned
from Board to bedside
TUHS Value Construct
HighConstruct
Value Care, Every Patient, Every Day
Quality
Culture
Engineering
And
Design
Execution
And
Diffusion
Infrastructure: Integrated Care Across The Continuum
Electronic Communication and Health Information
Adopted from the Mayo Clinic Value Construct Model, 2012
High Value Care
Are we consistently delivering it?
Wrapping Your Head Around
the Problem of Medical Errors
• To Err is Human –
the landmark
report of the IOM
in 1999 – up to
98,000 people die
each year in the
U.S. from medical
errors.
The Numbers are Staggering
• Every day and a half a fully loaded 747 would have to fall
from the sky before the airline passenger loss of life
would surpass that of hospitals
Adverse Events at TUH
• Wrong site surgery
• Retained sponge
• Medication errors
• Falls
• Infections
• Death
SERIOUSLY?
Healthcare
QUALITY
begins with
PATIENT
SAFETY
Kenneth Kaiser, MD, MPH
National Quality Forum
•
•
•
•
•
Freedom from injury
Consistent care 24 x 7 x 365
Seamless transitions/handoffs
Informed, satisfied patients
Transparency in care and
data
• Open, honest, non- punitive
reporting
• A culture obsessed with
safety
Defining Quality
• No needless deaths
• No needless pain or suffering
• No unwanted waits
• No helplessness
• No waste
For Anyone….
Institute for Healthcare Improvement
The Six Dimensions of Quality
• Patient Safety
• Patient Centeredness
• Timeliness
• Effectiveness
• Efficiency
• Equity
From the IOM: Crossing the Quality Chasm (2001)
Why So Many Errors?
• Why are hospitals unsafe?
• Why are errors made?
• Can they be prevented?
Humans Make Errors
You are sitting on the unit entering orders after rounds
There are a series of orders for different patients
Midway through, your cell phone goes off. You take the
call. Distraction
You turn back to the ordering tasks and pull up Mr.
Jones. You order 100mg of methadone orally. The
medication is administered to Mr. Jones.
Two hours later you get a call from the nurse, that Mr.
Smith wants to know where his methadone is.
You realize at that point that you ordered methadone on
the wrong patient. Human Error
Human Factors
• Human information processing is influenced
by multiple factors:
– Attention – may be limited in duration or focus
– Memory constraints – working memory is limited
– Automaticity – consistent, over-learned responses
may become automatic, and completed without
conscious thought
– Situation awareness – a person’s perception of
elements in the environment may affect their
processing of information
(Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science 1974; 185:1124-31)
Human Factors and Bias
• Pattern matching instead of careful reasoning
• What has worked before is used when there is uncertainty
• Availability heuristic – giving undue weight to facts that come
readily to mind, and ignoring that which is not immediately
present
• Confirmation bias – once a decision is reached, there is a
tendency to seek evidence to support it
• Selectivity – focus of attention on what is logically important vs.
what is psychologically salient
• Frequency gambling – betting on the condition that occurs most
frequently
Human Error
• An unsafe act is “an error or a
violation committed in the presence
of a potential hazard”
• Two categories: errors and
violations
(James Reason, Human Error, 1990)
Errors and Violations
Errors
An action does
not go as
intended
Violations
An action goes
as intended,
but it’s the wrong
action
A deliberate
deviation
from an operating
procedure, standard or rule
(James Reason, Human Error, 1990)
Lapse
Slip
Mistake
Human Factors
Humans will always make mistakes
regardless of training, experience and
determination
Human infallibility is impossible
Those who build systems that depend on
the absence of human error will fail
John Nance. Why Hospitals Should Fly. 2008, page 45
Systems are Designed to
Prevent Errors from Reaching
the Patient
• What is a system?
– A series of actions that, when followed, provides for
the delivery of safe care to every patient, every
time
• Codified in policies, procedures, standard order sets,
check lists
– A series of redundancies that provides multiple
check points
• An order is written, checked by the pharmacy, checked by
the nurse, reconciled with the medication list
Redundant Processes
(James Reason)
Each layer is a defense against potential error impacting the outcome
Failure at Every Level
Circumstances in which planned actions fail to achieve the desired outcomes
Culture of Safety
• Shared perceptions and actions around what is good, right,
important, valued, supported, rewarded and expected
• Culture is shaped by the alignment of people and systems;
attitudes; knowledge; practices; leadership; trust;
accountabilities; and a commitment to safety
• Culture is linked to outcomes – strong culture decreases
medication errors, hospital acquired UTI’s, nurse turnover and
absenteeism, nurse satisfaction, malpractice claims, back
injuries, patient satisfaction, needle sticks
Halligan, M. and A. Zecevic. Safety culture in healthcare: a review of concepts, dimensions, measures and progress.
Qual Saf Health Care/. 2011. doi:101136/bmjqs.2010.040964.
High Value Care
Evidence-Based care delivered
efficiently, at the highest standard
in the absence of error or adverse
event by a team that has created a
culture to support superior
outcomes.
High Value Care
How is this accomplished?
KNOW THE SYSTEM
High Value Care
Communication
Care Delivery
Hospital Acquired Conditions
Risk Management
Breakout Sessions
•
•
•
•
319A
319B
319C
319D
Risk Management
Care Delivery
Quality and Hospital Acquired Conditions
Communication
A-F
8:15 - 8:30
G-K
L-R
S-Z
High Quality Care – Part I
8:40 - 9:10
319A
319D
319C
319B
9:15 - 9:45
319B
319A
319D
319C
9:45 – 10:00
Break
10:00 - 10:30
319C
319B
319A
319D
10:35 - 11:05
319D
319C
319B
319A
11:15 - 11:30
High Quality Care – Part II
PART TWO
High Value Care
THE TOP TEN
House Staff Orientation:
TOP TEN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient safety and quality of care are the top priorities
Humans make errors
Systems are designed to prevent those errors from reaching the
patient (processes, policies, best practices)
Systems only work in the presence of individual accountability
The majority of errors occur because of lack of communication
Teamwork is vital – it takes a village - use the resources and
expertise available (Nurses, CM, RM, PT, Pharmacy, etc.)
Basic medication safety rules, consent, documentation
Universal protocol
Infection prevention
The patient and the patient’s well being must be at the center of
everything you do – it’s about the patient experience and the clinical
outcomes
Adopted from: Tsilimingras, et.al. The Challenge of Developing a Patient Safety
Curriculum for Medical School. Med Sci Edu 2012;22(2):65-72.
Keep the Patient at the Center
of Everything You Do
Attendings
House Staff
Extenders
Pharmacists
Therapists
Nutritionists
Infection
Preventionists
Nursing
PATIENT
Performance
Improvement
Patient Safety
Facilitators
Case Managers
Social Workers
Transport
Supply Chain
EVS
Facility
The National Agenda: The
Triple Aim
Population
Health
Patient
Experience
Per Capita
Cost
Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)
Get Involved in Quality and Safety
Accountable Care
Unit:
Huddles
Multidisc Rounds
Mini RCA’s
Throughput
Patient Satisfaction
Core Measures
Infection Control
RESIDENT
INTEGRATION
INTO
QUALITY
House Staff
Quality
Council
& Program Level
PI/QI
Medical Staff
Committees:
Patient Safety
Performance
Improvement
Peer Review
PATIENT
SAFETY
You Are The Key to
Preventing Medical Errors
AND
Providing Safe, Quality
Patient Care