Surgical Unit-Based Safety Program

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Surgical Unit-Based Safety
Program
Proposed Resources
for Partnership for
Patients
Terri Conner, Ph.D.
Nybeck Analytics
1
Partnership for Patients
HOSPITALIZATIONS ARE RISKY

In the U.S.
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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
SURGERY IS RISKY

25% of in-patient surgeries are followed by a
complication, many leading to:
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
50% of all hospital adverse events are linked
to surgery
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Prolonged LOS
Re-admission
Death
At least 50% of adverse surgical events are
preventable
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PROJECT GOALS

To achieve significant reductions in surgical
site infection and surgical complication rates
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Reducing complications reduces readmissions
To achieve significant improvements in
safety culture
IMPORTANT POINTS

Harm is preventable
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Technical and adaptive work
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Many HAIs and complications are preventable,
and should be viewed as defects
Focus on systems; not on individuals
Engage frontline staff to identify and fix local
opportunities to improve
SUSP
Not Just a Checklist Program

Informed by science
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
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Medical best evidence
Social science
Led by clinicians and supported by
management
Guided by measures
SUSP INTERVENTIONS
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No single SSI prevention bundle
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Dive deeply into SCIP measures to identify local
defects
Emerging evidence
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Bowel prep
Antibiotic redosing
Chlorhexidine skin prep
Capitalize on frontline wisdom to identify
local opportunities to improve
HOW WILL WE GET THERE?
SUSP
 Technical component
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Adaptive component
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TRIP: Translating Evidence into Practice
CUSP: Comprehensive Unit-based Safety
Program
SUCCESSFUL EFFORTS

Michigan Keystone ICU program
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Reduction in central line-associated blood stream
infections
Reduction in ventilator-associated pneumonias
TRIP: Translating Evidence Into
Practice
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Summarize the evidence
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Identify local barriers to implementation
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Measure performance
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Ensure all patients get the evidence
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4 E’s Model
4 E’S MODEL TO HELP IMPLEMENT
PATIENT SAFETY INTERVENTIONS
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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?
CUSP
Comprehensive Unit-based Safety Program
An intervention to learn from mistakes and
improve safety culture
A good approach whenever there is a gap
between evidence-based practice and current
practice on your unit.
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CUSP: EMPHASIS ON CULTURE

Shared attitudes, values, goals, practices,
behaviors
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Culture influences behavior
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Participation in quality improvement efforts
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Communication
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Breakdown in communication contributes to nearly all
adverse events.
CUSP: COMPREHENSIVE UNITBASED SAFETY PROGRAM
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
Safety practices part of daily work

Implemented at the unit level
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Led by clinicians
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Structured program, yet flexible
PRE-CUSP STEPS

Assemble Safety Team
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Multidisciplinary
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Different levels of experience
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Encourage joining team at any phase of the
program
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PRE-CUSP STEPS
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Team Members – frontline staff
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Project Leader (Unit Champion)
Nurse Manager
Physician Champion
Senior Hospital Executive
Patient Safety Coordinator
Epidemiology / Infection Control
Coach
PRE-CUSP STEPS
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Measure Safety Culture
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Before CUSP implementation, and then every 12-18 months
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Use AHRQ’s The Hospital Survey on Patient Safety Culture
(HSOPS)
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All clinical and non-clinical providers
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Report results to the unit and senior hospital executive
CUSP STEPS
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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

Goals
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Magnitude of patient safety problem
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Foundation for investigating safety defects
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Providers’ involvement significantly affects patient
safety
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STEP 1: SCIENCE OF SAFETY
TRAINING
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Learning Objectives
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Safety is a property of the system
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Use strategies to improve system performance
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Standardize work
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Create independent checks for key processes
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Learn from mistakes
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Apply strategies to both technical work and team work
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Teams make wise decisions with diverse and independent input
STEP 1: SCIENCE OF SAFETY
TRAINING
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Training Session
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3-part “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
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Instruct staff on reporting of safety concerns
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Describe executive safety rounds
STEP 2: IDENTIFY DEFECTS
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
Eyes and ears of patient safety
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Ongoing process
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Disseminate Staff Safety Assessment Form
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Combine results and prioritize defects
WHAT IS A DEFECT?
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
Anything you do not want to have happen again.

Many HAIs are preventable. They should be viewed
as defects.
STEP 2: IDENTIFY DEFECTS
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Staff Safety Assessment Form
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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.
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All health care providers in the unit complete this form.
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2-item questionnaire
STEP 2: IDENTIFY DEFECTS
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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.
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STEP 2: IDENTIFY DEFECTS

Combine Results
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Group into common types of defects
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Communication
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Medication process
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Patient falls
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Supplies
Frequency distributions
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Example: communication, 57%
STEP 2: IDENTIFY DEFECTS
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Prioritize safety concerns
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Obtain input from CUSP team senior executive
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Prioritize based on
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Likelihood of causing patient harm
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Severity of harm
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How common is the problem
Likelihood it can be solved by implementing a daily work process
STEP 4: LEARN FROM DEFECTS
Four Key Questions
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1.
What happened?
2.
Why did it happen?
3.
What will you do to reduce the chance it will recur?
4.
How do you know that you reduced the risk that it will
happen again?
WHAT HAPPENED?
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Reconstruct the timeline and explain what happened
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Put yourself in the place of those involved, in the middle of the
event as it was unfolding
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Try to understand what they were thinking and the reasoning
behind their actions/decisions
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Try to view the world as they did when the event occurred
WHY DID IT HAPPEN?
SYSTEM FAILURES
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
Arise from managerial and organizational decisions that shape
working conditions
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Often results from production pressures
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Damaging consequences may not be evident until a “triggering
event” occurs
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Develop lenses to see the system factors that lead to the event
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?
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Prioritize most important contributing factors
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Prioritize most beneficial interventions
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Safe design principles
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Standardize what we do
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Create independent check
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Make it visible
Safe design applies to technical and team work
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?
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Develop list of interventions
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For each intervention:
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Rate how well the intervention solves the problem or
mitigates the contributing factors for the accident
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Rate the team belief that the intervention will be
implemented and executed as intended
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Select top interventions (2 to 5) and develop intervention plan
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Assign person, task follow-up date
HOW DO YOU KNOW RISKS WERE
REDUCED?
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Did you create a policy or procedure?
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Do staff know about policy or procedure?
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Are staff using the procedure as intended?
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Behavior observations, audits
Do staff believe risks were reduced?
STEP 4: LEARN FROM DEFECTS
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Summarize and Share Findings
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Learning from Defects Tool
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Detailed form for each incident or identified defect
Case Summary Form
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Summarize the case
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Identify system failures
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Identify opportunities for improvement
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List actions taken to prevent future harm
Share your findings
STEP 4: LEARNING FROM
DEFECTS
Key Points
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Focus on systems, not people
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Prioritize
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Go mile deep and inch wide, rather than mile wise and inch
deep
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Pilot test
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Learn from 1 defect a quarter
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Answer the four questions
STEP 5: TEAM WORK TOOLS
Staff Safety Assessment
Safety Issues Worksheet
Status of Safety Issues
Learning from Defects Tool
Case Summary Form
Briefings/Debriefings
SSI Investigation
Audits
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STAFF SAFETY ASSESSMENT
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.
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SAFETY ISSUES WORKSHEET
Identified Issue
1.
2.
3.
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Potential/
Recommended
Solution
Resourc
es
Needed
Resources
Not
Needed
STATUS OF SAFETY ISSUES
New and Ongoing
Date
Date
Safety Issue
Safety Issue
Contact
New and Ongoing
Contact
Status
Status
Goal
Goal
Completed
Date
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Safety Issue
Contact
Status
Goal
LEARNING FROM DEFECTS
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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.
CASE SUMMARY FORM
Form Sections
Safety tips
Case
summary
System
failures
Opportunities
Actions
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for improvement
taken to prevent harm
BRIEFINGS / DEBRIEFINGS
Dominant
Growing
tool for SUSP
evidence
–Better
team performance
–Better safety culture
–Reduction in delays
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Adapted
to local hospital and OR
Adapted
to surgery type
SSI INVESTIGATION TOOL
Look
into factors that may be systematically
contributing to SSIs
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AUDITS
Skin
prep audits
Antibiotic
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audits
OTHER TOOLS
Mislabeled
Wrong
sided surgery
Retained
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specimens
foreign objects
SUSP IS A CONTINUOUS
JOURNEY!!
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