Quality & Safety
at Hadassah
A Progress Report
Mayer Brezis, MD MPH
Professor of Medicine,
Center of Quality & Safety
Chairman, Quality & Safety Committee
Yoel Donchin, MD, Nurit Porat, RN
Quality & Safety at Hadassah
• Students Projects
• Institution-wide Projects
• Educational Activities
• National Impact
Making Health
Care Safer: A
Critical Analysis
of Patient Safety
Practices
Evidence Report
Agency for
Healthcare
Research &
Quality
www.ahrq.gov/
clinic/ptsafety
Venous Thromboembolism
in Neurosurgery
Dr. G. Rosenthal, S. Goldman RN, Prof. F. Umanski,
Prof. D. Varone, Dr. Y Weiss
Departments of Neurosurgery, Hematology, Central
Management, Center for Quality & Safety
Hadassah University Hospital
Jerusalem, Israel
• 58 year-old woman underwent
resection of meningioma
• On post-op day 2, sudden onset
of respiratory distress
• Chest CT demonstrates massive
pulmonary embolism
• Vena cava filter inserted &
anticoagulation initiated
• On post-op day 6 sudden onset
of severe headache and vomiting
Post-op CT
Follow-up CT
Cases of Cases
thrombo-embolism
of VTE
12
10
10/239
4%
8
6
4
10
2
0
•5 months (2003)
•10 cases of
thromboembolism
5/75
•7 vena cava filters
7%
0/94
inserted
0%
•Extended ICU
&
5
hospital stays
0
Control
1st Control
Intervention
2nd Control
Cases of Cases
thrombo-embolism
of VTE
12
10
8
6
4
2
0
July 2003:
10/239
Introduction of
4%
intermittent pneumatic
compression devices
10
0/94
0%
5/75
7%
5
0
Control
1st ControlIntervention
Intervention 2nd Control
Cases of Cases
thrombo-embolism
of VTE
12
10
10/239
4%
8
6
4
2
0
10
0/94
0%
5/75
7%
5
0
Control
1st ControlIntervention
Intervention 2nd Control
Cases of Cases
thrombo-embolism
of VTE
12
10
10/239
4%
8
6
4
2
0
10
0/94
0%
5/75
7%
5
0
Control
Control
Control
Intervention
1st ControlIntervention
Intervention 2nd
Control
Conclusion:
Quality can
reduce morbidity
& save costs
Quality indicators for the
management of
myocardial infarction
M. Cohen, Dr. A. Pollack, Prof. A. Weiss, Prof. C. Lotan
Intensive Cardiac Units, Division of Cardiology &
Department of Medicine, Mt. Scopus & Ein Kerem
Hadassah University Hospital
Jerusalem, Israel
Quality indicators for myocardial
infarction, Hadassah vs. US data
Hadassah (%) 89 90 50 83 69
44’
102’
Peterson R, JAMA 2004;291:195
Hadassah
Quality in Health Care
• Evidence-based
• System-minded
themake
HowWill
can we
pathology
result
sure the patient
gets
thelost?
result?
get
98
p<0.05
Percent of
96
patients
94
0%
1%
having
92
received the 90
failed
result of their 88
malignancy
4%
P.skin
Topol,
RN, Dr. A. Zlotogorski, Prof.
A. Ingbar, Dr.
biopsy
reports
Will the pathology result
get lost?
86
A. Mali, T. Friedman,
RN, M. Benhur, N. Porat, RN
2001
2002
2003
Departments
of Dermatology,
Pathology,
Information
A
clinic-based intervention
(led by the
head nurse,
involving
Systems,
Nursing
and Quality & Safety Committee
both
physicians
& patients)
An institution-wide intervention: electronic alerts sent to
physician’s computer whenever a pathology report is ready
This quality
improvement
project, awarded
prize of best poster
at the meeting of
the Israeli Society
for Quality in
Medicine, is posted
at the dermatology
clinic as a reminder
for both patients,
nurses and
physicians
Quality & Safety Committee
Subcommittee for Medication Errors
Specific
labels for
lines to
patients - to
avoid mix up
Interactive software to learn
prescribing for new physicians
Screen from software asking:
“Would you approve this prescription?”
Quality in Health Care
• Evidence-based
• System-minded
• Patient-centered
Palliative Care in General Internal
Medicine: A successful pilot
intervention among elderly
patients with life threatening
illness and impaired cognition
S. Gottsman, RN, MA et al.
Head Nurse, Medicine B, Mt Scopus
Intervention
Staff-initiated meetings with
relatives, to communicate
information on patient’s condition;
to listen to their questions and to
their preferences based on
patient’s prior wishes – if any had
been expressed; and finally to
attempt shared goal setting and
decision making
Control ward – no intervention
Percent of relatives agreeing
with negative statements
Control
“Staff did not really consider my opinions”
60
13*
“I felt not involved in decision making”
57
23*
“It upset me that I did not know what was
happening”
43
10*
“I did not receive explanations about
alternatives”
57
20*
“Relative’s problems were not explained”
53
3*
“I felt uncomfortable with asking questions”
“I was not asked to participate in decisions”
53
10*
60
17*
“I felt alone and without support”
43
17*
“I felt pressured to make decisions”
27
7*
Intervention
Emerging methods for quality evaluation
Is the X-ray interpretation by
the junior staff on duty correct?
Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A.
Shaham, R. Hefez, Dr. D. Shaham
Departments of Surgery, Radiology, and
Center for Quality & Safety
Frontal bone fracture
Hip fracture
Validity of X-ray Interpretations in Trauma
Sensitivity
(%)
Specificity
(%)
Positive
predictive
value (%)
Chest
92
93
79
97
(n=54)
Neck
(n=19)
(65-100)
(82-98)
(52-94)
(88-100)
100
100
100
100
(5-100)
(85-100)
(5-100)
(85-100)
Pelvis
60
100
100
92
(n=27)
(18-93)
(87-100)
(37-100)
(75-99)
CT’s
94
95
94
95
(n=75)
(81-99)
(85-99)
(81-99)
(85-99)
mean & 95% CI (confidence interval)
Negative
predictive
value (%)
Reliability of X-ray
Interpretation on Duty
mean & 95%
confidence
intervals
Surgery
Pulmonary
Inter-observer variability
Resident vs. Specialist
Percent
Kappa
agreement Coefficient
77%
0.60 (0.4-0.8)
95%
0.84 (0.7-1.0)
A Senior Resident in Radiology Concluded:
“We need to look at ourselves”
Summary & Conclusion
•Students Projects
•Institution-wide Projects
•Educational Activities
•National Impact
Diverse projects attempt to make
healthcare at Hadassah more
patient-centered, more evidencebased and more system-minded.
Increased accountability by
department heads for quality and
safety may be a key to further
successes.
How would an open disclosure
policy about mistakes affect
hospital image in public’s eyes?
60
40
%
20
0
MD
student
Zivan Beer
Improve
Damage
No
Image Change Image
Publ
How would an open disclosure
policy about mistakes affect
hospital image in public’s eyes?
N=115
N=570
p<0.001
MD
student
Zivan Beer
Improve
Damage
No
Image Change Image
New position statement by the Ethics
Board of the Israeli Medical Association
supports transparency (May 2004)
IMA Ethics Board
Position Paper
“The physician
has an
obligation to
disclose to the
patient that a
mishap has
happened”