Designing Safe Health Systems with Patients at the Center · 2014-11-12 · Designing Safe Health...
Transcript of Designing Safe Health Systems with Patients at the Center · 2014-11-12 · Designing Safe Health...
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Designing Safe Health Systems with Patients at the Center: An Interactive Workshop Kedar S. Mate, MD Vice President, Institute for Healthcare Improvement
January 2014 Doha, Qatar
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Workshop Objectives 1. Understand the value & potential benefit of taking a
patient-centered approach to patient safety 2. Have a process to produce patient-centered innovations 3. Understanding how to measure patient activation &
engagement 4. Understand the Model for Improvement and how to use
it to create more patient centered designs
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The Question
How safe is your hospital or clinic?
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If you are the patient? – What is the right number of medication
errors, infections or falls? – How long is an acceptable time to spend in
the Emergency Department waiting to be seen or admitted?
– What is the correct % of the time that you should get the right care?
Another Way to Think About How Safe…
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Question & Key-Point #1
So why is it important to engage
patients in designing safer health care systems?
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The short answer
An engaged patient =
An key ally to make your system safer
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What’s the Value? Lower Cost
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Question & Key-Point #2
What are the key design principles of a
patient-centered system?
3 Ideas
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Effectiveness: Deliver everything that will help, and only what will help. The goal is 100%
Safety: Do no harm. The goal is 0 Events
Quality: Two-sides of the coin
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What Patients Really Want
Don’t hurt me
Help me
Be Nice to Me
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Don Berwick, MD
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The Key Design Challenge
From “What is the Matter with You?” to…
What Matters to You
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Question & Key-Point #3
How do we start to design a different
system?
4 Steps
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“ Every system is perfectly designed to produce the results it gets.”
Dr. Paul Batalden
Patient Harm occurs because…
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Step 1: Set the Aim for Patient Safety & Patient-Centered
Care in your organization
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Where we want to be!
Where we are!
1. How do you bridge the gap?
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Not-So-Specific Aims
“Our hospital strives to achieve the highest levels of quality” “Memorial General Hospital aims to be in the top tier of hospitals for quality and safety”
How much….? By when…?
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Examples of Bold, Specific, System-Level Aims
“We will achieve a 50% reduction in hospital-acquired infections within 12 months, as measured by the sum of Central Line Bloodstream Infections, Ventilator-Acquired Pneumonias, and Catheter-Associated Urinary Tract Infections.” - WellStar Health System “We will cut hospital-acquired infections in half every year, on our way towards zero, as measured by the sum of C Diff, SSI, VAP and MRSA.” - Delnor Community Hospital “We will reduce Harm by 80%, as measured by Serious Safety Events, within 3 years.” – Cincinnati Children’s
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When we measure harm, eliminate the denominator… – You don’t need denominators to compare yourself to yourself,
over time – Denominators are often part of the problem (ADEs per 1000
doses, SSEs per 1000 patient days)
Denominators make the problem abstract, rather than personal
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Jim Reinertsen, MD
Used with Permission IHI 2012
Sometimes we cannot see what is in front of us…
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What makes more sense… if the right answer is 0?
Traditional Display (Rates) .005 ADEs /1000 doses 2.67 infections/1000 patient days .003 Falls with harm per/1000 patient days .00234 Mortality Rate
The Hard Count 35 Adverse Drug Events last month 220 hospital acquired infections last quarter 65 Patient falls—16 with harm last month 15 avoidable deaths
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Modified from M. Pugh
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2. Understand the current status of Patient & Family-Centered
Care in your organization
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PFCC Self-Assessment Tools IHI’s Patient- and Family-Centered Care Organizational Self-Assessment Tool.
http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/EmergingContent/PFCCOrgSelfAssess.htm
Family Voices http://www.familyvoices.org/pub/projects/fcca_UsersGuide.pdf
Institute for Family Centered Care. Strategies for leadership. Patient and Family Centered Care. A Hospital Self Assessment Inventory.
http://www.aha.org/aha/content/2005/pdf/assessment.pdf. American Hospital Association-McKesson Quest for Quality Prize® Criteria
http://www.aha.org/aha/content/2008/pdf/2009Q4Qcriteria.pdf.
http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/EmergingContent/PFCCOrgSelfAssess.htm�http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/EmergingContent/PFCCOrgSelfAssess.htm�http://www.familyvoices.org/pub/projects/fcca_UsersGuide.pdf�http://www.aha.org/aha/content/2005/pdf/assessment.pdf�http://www.aha.org/aha/content/2008/pdf/2009Q4Qcriteria.pdf�
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A Simple Assessment Exercise: Where Are You in Action and Attitude?
At this point in time, are your clinical services providing
care that is primarily
Doing To, Doing For or Doing With
your patients and families?
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You are Doing To when: We set visiting hours We control all schedules We determine what and when you eat Information is not shared in the patient’s presence Information is not easy to understand There is helplessness – when the patient/family say: – I don’t know what happens next – I don’t know who is in charge of my care – I don’t feel like you know me
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You are Doing For when: Family presence is defined by the patient We keep the patient in mind when designing programs or service lines; patients are asked to react to program or facility design There are dedicated efforts to improve the patient experience We manage patient expectations about waiting Patients have options in schedule and food Information is openly shared with patients
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You are Doing With when: Build on Doing for and move beyond Patient/family advisors are on teams to design programs and service lines that follow the patient journey All key decisions are mutual – patients/families are partners in care at every level All staff are viewed as caregivers and are skilled in respectful communication and teamwork Health Literacy is everywhere in patient care Senior leaders model that patient’s safety and well-being guide all decisions Staff, providers, leaders are recruited for values & talent; patient/family advisors involved in hiring
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To-For-With Assessment – Patients and Families
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Doing To – Patients and Families
Doing For – Patients and Families
Doing With – Patients and Families
1. Individually – Complete 1-2 examples in each category 2. Review as a group at your table 3. What do your lists tell you?
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3. Make changes to achieve your aims for Safety using Patient &
Family-Centered Care
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Change Process has two components
Ideation: A set of ideas about what changes to make – You can get these from observations – You can get these from story-telling – You can get these from others
Changing: A clear process for how to make a change
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Storytelling In lieu of doing actual observations, we will use
storytelling to describe actual experiences Recall an actual story when you knew a mistake was being made that would have an affect on you…
Who was involved? What happened?
How did individuals feel and react? Tell stories in small groups (not more than 2 minutes each)
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How might we….
Improve X, or completely re-imagine Y, or find a new way to accomplish Z. 1. ??
2. ??
3. ??
Ideas should be actionable
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Rules for Brainstorming
Chose one or two “how might we scenarios….
encourage wild ideas go for quantity – want more than 100 ideas defer judgment be visual – draw pictures one conversation at a time build on ideas of others stayed focused on topic (“how might we…” scenarios)
Write each idea on a post it note
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Matrix of Change Ideas
Difficult to Implement
Easy to Implement
Low Cost High Cost
Place concepts in matrix. Strive for easy, low-cost solutions. Translate high-cost solutions into low-cost alternatives.
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Matrix of Change Ideas
Low Impact
High Impact
Low Cost High Cost
Place concepts in matrix. Strive for high-impact, low-cost solutions. Translate high-cost solutions into low-cost alternatives.
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Top 5 Changes You can Make Today:
Safer, Patient & Family-Centered Care on Med/Surg Units
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#1 Change the Question You Ask on Intake
n engl j med 366;9 nejm.org march 1, 2012
Start Asking: “What matters to you?” as well as “What is the matter with you?”
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#2: Admission Trio Team
The Trio: Physician Nurse Pharmacist
• Interdisciplinary assessment • Single plan of care • Med reconciliation • Reduced documentation
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Organizing Care Around the Patient’s Experience
Upon admission, an interdisciplinary care team directly engages patients to develop a mutually agreeable care plan
Results: • Average length-of-stay reduced by 10%-15% • 95% of patients score satisfaction as “5/5,” improved from
68% • 25% reduction in direct and indirect costs of inpatient care • Reduced errors – eliminated medication reconciliation errors • Improved care protocol compliance
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#3 Nurse-to-Nurse Bedside Report
• Reduced CLABSI by 92%, saved $348,000
• Reduced line days by 27% • Reduced VAP by 71%,
saved $300,000 • Reduced ventilator days by
31% Ceballos K, et al. Advanced Neonatal Care. 2013 Jun 13(3):154-63
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Patient’s Daily Goals
#4 Change the White Board
Patient Details
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#5 Engage the Family • 46% of family caregivers
performed medical/nursing tasks
• 78% of family caregivers managed medications
• 53% of family caregivers served as care coordinators
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Bonus #6 Let Your Patients make a Pill Card on Hospital Day#1
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Making a Change
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Model For Improvement Video
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4. Measure progress towards achieving your Aims for Safety
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What makes more sense… if the right answer is 0?
Traditional Display (Rates) .005 ADEs /1000 doses 2.67 infections/1000 patient days .003 Falls with harm per/1000 patient days .00234 Mortality Rate
Hard Count 35 Adverse Drug Events last month 220 hospital acquired infections last quarter 65 Patient falls—16 with harm last month 15 unnecessary deaths
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Modified from M. Pugh
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Counting Noses: How do you think the Leadership & Board reacted to this report?
Falls 488 Medication Error 725 Readmission for proc/surgery site infection 11 Birth Injury 9 Difficult Delivery 42 Fetal Resuscitation 47 Maternal transfer to critical care 3 Delay in diagnosis 456 Delay in treatment 291 Mislabeled labs 327 Attempted suicide 3 Trauma to healthy tissue 117 Pressure sore 79 Complications during surgery 56 Return to OR 79 Unexpected change in condition 101
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3rd Quarter, 2010 Risk Events
Q2 2010 System-wide
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Serious Safety Events per 10,000 Adj. Patient DaysRolling 12-Month Average
0.0
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0.4
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0.8
1.0
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1.6
1.8Q
1Q
2Q
3Q
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1Q
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3Q
4Ju
lA
ug Sep
Oct
Nov Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Se
pO
ctN
ov Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Se
pO
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ov Dec Jan
Feb
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Apr
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Aug Se
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FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Even
ts p
er 1
0,00
0 A
dj. P
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ays
SSEs per 10,000 Adj. Patient Days Baseline [ 1.0 (FY05-06) ]
Fiscal Year Goals (FY07=0.75 / FY08=0.50 / FY09=0.20) Threshold for Significant Change
** The narrowing thresholds in FY2005-FY2007 reflect increasing census. Adjusted patient days for FY07 were 27% higher than for FY05.** Each point reflects the previous 12 months. Threshold line denotes significant difference from baseline for those 12 months (p=0.05).
aSSERT BeganJuly 2006
Chart Updated Through 31Aug09 by Art Wheeler, Legal Dept. Source: Legal Dept.
Desired Direction of ChangeAim: Reduce harm to children by 80% in 3
years, as measured by Serious Safety Events per 10,000 Patient Days
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…and whenever possible
Put a face on the data
Jim Reinertsen, MD
51 Used with Permission IHI 2012
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Baby Girl V. 5/12/2008
Mother’s Delay in Tx
Ursula H. 2/12/2008
Fall
Helene C. 9/5/2008
Fall
Jimmy P. 7/07/2008
Fall
Robert S. 10/13/2008
Fall
Baby Boy S. 8/1/2008
Wrong Pt. Procedure
Wade W. 7/16/2008
Delay in Tx
John B. 9/06/2008
Delay in Dx
Florita H. 7/03/2008
Delay in Tx
Joann E. 9/23/2008
Wrong Site Surgery
Joseph R. 9/08/2008
Delay in Dx.
Baseline SSER, Calendar Year 2008, 46 Events
Alvin G. 8/17/2008
Fall
Nicole S. 1/4/2008
Delay in Dx
Ms. L. 2/14/2008
Delay in Tx
Teodur C. 1/29/08, 2/12/2008
Delay in Tx
Tamika M 4/21/2008 Med Error
Nancy H. 6/18/2008 Med Error
Regina D. 12/9/2008
Wrong Site Surgery
Sandra M. 12/10/2008
Post Procedure Death
Mary D. 3/9/2008 Med Error
Margaret H. 2/6/2008
Med Error
Baby Boy G. 3/25/2008 Med Error
Lorena W. 11/10/2008
Post Procedure Death
Cynthia K. 11/10/2008 Delay in Tx
Dale W. 10/12/2008 Med Error
Eugene B. 10/27/2008, 10/28/2008
Med Error, Fall
Kathy W. 12/16/2008
Post Proced Loss of Function
Robert B. 12/2/2008
Post Procedure Death
Chantal E. 6/26/2008
Inapprop Touching
Gary B. 6/13/2008
Fall
Lester J. 9/5/2008
Fall
Calvin P. 4/4/2008
Med Error
Gwendolyn P. 10/28/2008
Wrong Implant
Douglas T. 10/18/2008 Med Error
Mary C. 12/19/2008
Fall
Lance D. 10/30/2008 Delay in Tx
Priscilla W. 8/30/2008
Delay in Tx
Kyle W. 9/13/2008
Delay in Tx
Andrea M. 6/24/2008
Wrong Procedure
Karen G. 8/5/2008
Proced Cx/Delay in Tx
Nicole H. 8/12/2008
Post-proced Cx
Virginia L. 8/12/2008
Delay in Tx
Cynthia M. 10/27/2008 Med Error
Shirley H. 12/23/08
Post Proced Death
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Beverly S. 2/4/09
Med Error
Dorothy R. 1/28/09
Delay In Treatment
24 Patients & Events – Jan-Dec,2009 vs 46 Total for 2008
Sharenda W. 2/15/09
Med Error
Edward R. 4/23/09
Wrong Side Procedure
Robert D. 5/12/09
Post Procedure Death
Donna S. 6/4/09
Retained foreign object
47% Reduction SSER from Dec. 08 Baseline 48% Reduction in # of events year to year
Lilliam C. 4/3/09
Retained foreign object
Juanita A. 5/14/09
Delay In Treatment
Yoland C. 7/7/09
Delay in Treatment
Michael F. 8/20/09
Retained foreign object
Peggy P. 7/1/09 Burn
Loueene D. 9/23/09
Fall
Karen C. 9/28/09
Delay In Treatment
Brenda R. 10/14/09
Delay In Treatment
James H. 10/25/09
Post Procedure Death
Monroe K. 5/18/09
Post Procedure Death
Alma M. 11/6/09
Fall Johnny B.
11/9/09 Fall
Jerry Y. 11/7/09
Fall
Willie B. 11/5/09
Med Error
Pauline M. 11/2/09
Fall
Ronnie D. 11/3/09
Delay in Treatment
Scott G. 9/5/09
Delay in Treatment
Helen C. 11/4/09
Delay In Treatment
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Lois R. 4/16/10
Surgical Fire
Mary B. 5/22/10
Post Procedure Cx
Lamar A. 6/3/10
Med Error
Frank S. 2/22/10
Surgery Cx
Sylvia L. 3/31/10
Delay In Dx
Bruce C. 5/25/10
Delay In Dx
Ruby B. 5/30/10
Fall
Marilyn C. 1/21/10
Med Error
Doyle L. 7/22/10
Med Error
A 78% reduction through Nov. 2010
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Question & Key-Point #1
So why is it important to engage
patients in designing safer health care systems?
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The short answer
An engaged patient =
An key ally to make your system safer
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Question & Key-Point #2
What are the key design principles of a
patient-centered system?
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What Patients Really Want
Don’t hurt me
Help me
Be Nice to Me
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Don Berwick, MD
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Question & Key-Point #3
How do we start to design a different
system?
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Making a Change
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Thank You! Kedar S. Mate Vice President Institute for Healthcare Improvement [email protected]
mailto:[email protected]�
Designing Safe Health Systems with Patients at the Center: �An Interactive WorkshopWorkshop ObjectivesThe QuestionAnother Way to Think About How Safe…Question & Key-Point #1The short answerSlide Number 7Slide Number 10Question & Key-Point #2Quality: Two-sides of the coinWhat Patients Really WantThe Key Design ChallengeQuestion & Key-Point #3Patient Harm occurs because…Slide Number 17Slide Number 18Not-So-Specific AimsExamples of Bold, Specific, System-Level AimsSometimes we cannot see what is in front of us…What makes more sense… if the right answer is 0?Slide Number 23PFCC Self-Assessment ToolsA Simple Assessment Exercise: �Where Are You in Action and Attitude?You are Doing To when:You are Doing For when:You are Doing With when:To-For-With Assessment – �Patients and FamiliesSlide Number 30Change Process has two componentsStorytelling�How might we….Rules for BrainstormingMatrix of Change IdeasMatrix of Change IdeasSlide Number 37#1 Change the Question You Ask on Intake#2: Admission Trio Team Organizing Care Around the Patient’s Experience�#3 Nurse-to-Nurse Bedside Report#4 Change the White Board#5 Engage the FamilyBonus #6 Let Your Patients make a Pill Card on Hospital Day#1Making a ChangeModel For Improvement VideoSlide Number 47What makes more sense… if the right answer is 0?Counting Noses:�How do you think the Leadership & Board reacted to this report?Slide Number 50…and whenever possibleSlide Number 52Slide Number 53A 78% reduction through Nov. 2010Question & Key-Point #1The short answerSlide Number 57Question & Key-Point #2What Patients Really WantQuestion & Key-Point #3Making a ChangeThank You!