Matters Patient Safety Matters Matters Challenges and Opportunities 2006 San Antonio 2005 11th...

Patient Safety Matters Matters

MattersMatters Challenges and Opportunities

2006

San Antonio 2005

11th European Forum 2006. Prague.

WONCAWONCAAHRQResource Center

How we see and deal with these matters And why are others Interested in our work?

We are aboutWe are aboutPlacing Patient Safety at Placing Patient Safety at

the of Medical the of Medical EducationEducation

andandPracticePractice

CONTENT OF THIS AND THE OTHER THREE CONTENT OF THIS AND THE OTHER THREE PRESENTATIONSPRESENTATIONS

•Our Mission, Driving principles, Premises, and Implications•The Burden of Lack of Safety on the Nation

•The Opportunity

•Our approach to lightening the Burden

Main Areas of our Activity Education/training Safety Practice Enhancement Formation of Culture & TRM

Co

vere

d i

n t

he

oth

er t

hre

e p

rese

nta

tio

ns

Covered in this presentation

Our Innovative Approaches

•Culture of safety

Singh: April 2005

Current Situation

Singh: April 2005

FearFear

Kill the messenger(denial; shift the blame)

Filter the data(game the system)

Micromanage(Barking up the wrong tree)

Scherkenbach’s Cycle of Fear, 1991

1

Current Strategies for identifying safety problems:

Error reports• Can provide rich information• Under-reporting is the norm• Gradual shift towards a culture of safety will help

improve rates of reporting• Promising work is being done in this area

• Errors reports are a valuable source of info but do not yet provide the whole picture

© Gurdev Singh 2007

2

Current Strategies for identifying safety problems:

Practice Profiles• Many physicians ignore them• Disregard uniqueness of individual practices• A cause of division between ‘winners’ and ‘losers’ • A cause of poor morale

Audits• Useful, objective way of measuring performance• Most are based on documentation – a limited view• Tend to focus on a specific area


Need for Change in Strategy

SS


Various Various (overlapping)(overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety are:for Improving in Patient Safety are:

Punitive action directed against individualsPunitive action directed against individuals

Avoid



Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.

Can help considerably

Various (Various (overlapping)overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety are:for Improving in Patient Safety are:



Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.Process RedesignProcess Redesign

Helps even more

Various Various (overlapping)(overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety for Improving in Patient Safety

are:are:



Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.Process RedesignProcess RedesignTechnical and Technological Technical and Technological

System EnhancementSystem Enhancement

These lead to significant

improvements

Various Various (overlapping)(overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety are:for Improving in Patient Safety are:



Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.Process RedesignProcess RedesignTechnical and Technological Technical and Technological

System EnhancementSystem EnhancementCultural ChangesCultural Changes

These are the most effective

andsustainable

and theyaugment the above

four

Various (Various (overlapping)overlapping) Possible Possible Strategies for Improving in Patient Strategies for Improving in Patient

Safety are:Safety are:


Scherkenback’s Cycle of Fear, 1991

Culture of SafetyCulture of SafetyWill helpWill help

break this Cycle break this Cycle

withwith

Self-empowered Self-empowered and and

Self-motivated Self-motivated teamsteams

Kill the messenger

(denial; shift the blame)

Filter t

he data

(gam

e the syste

m)

Micromanage

(bark at the wrong tree)


© Gurdev Singh 2007© Gurdev Singh 2007

So how do we form

theSafety

Culture ?


Adopt Systems (Holistic)Approach: Address

fragmentation and decentralization to capture

and understand

complexity of the system,to create a shared Common vision




and understand

complexity of the system,to create a shared

Common vision Make SAFETY Leadership’s Priority and every ones’

responsibility. Provide adequate and competent human resources

and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis

and system redesign




and understand


Common vision Make SAFETY Leadership’s

Priority and every ones’responsibility. Provide adequate and competent human resources


and system redesign

Design the System for Recovery, making errors

visible and detectable, making it hard to carry out irreversible

actions but easy to reverse inadvertent actions, as well

as building barriers and redundancies




and understand


Common vision

Make SAFETY Leadership’s Priority and every ones’



and system redesign

Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible



Adopt Proactive Approach by adopting

prospective tools of systems analysis (FMEA ) and exploiting

technology (e.g. EMR with inductive and deductive decision

support systems)




and understand


Common vision




and system redesign







support systems)Create Non-hierarchical Teams; built on mutual respect, trust, collaboration, cooperation

and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.




and understand





and system redesign




support systems)

Create Non-hierarchical

Teams; built on mutual respect, trust, collaboration, cooperation


Facilitate Accurate and Timely Information

e.g exploiting relational databases and decision support systems for safe healthcare with particular

attention to care transitions







and understand


Common vision




and system redesign







support systems)







Create Learning Environment in which error reporting (preferably voluntary) is non-punitive, confidential and accessible to all staff and patients with no restrictions on format


Create Learning Environment in which error reporting (preferably voluntary) is non-punitive,

confidential and accessible to all staff and patients with no restrictions on format



and understand





and system redesign







support systems)




Create Awareness of the Value of Quality that

leads to patient and staff job satisfaction, that energizes and

empowers the workers to improve Quality, leading ultimately to

increased profitability (i.e. use Humanistic approach to safety

management)





Framework of Interactive Contributors to the Construct of Culture of Patient Safety



and understand


Common vision Make SAFETY Leadership’s Priority and every ones’



and system redesign







support systems)Create Non-hierarchical



Create Awareness of the Value of Quality that leads to patient and staff job

satisfaction, that energizes andempowers the workers to improve

quality leading ultimately to increased profitability (i.e. use Humanistic approach to safety

management)










and understand


Common vision




and system redesign







support systems)Create Non-hierarchical



Create Awareness of the Value of Quality that leads to patient and staff job

satisfaction, that energizes andempowers the workers to improve

quality leading ultimately to increased profitability (i.e. use Humanistic approach to safety

management)






Manifestation ofSafety Climate:Expressing itself in

Measurable Attitudes

and Perceptions

Framework of Interactive Contributors to the Construct of Culture of Patient Safety: Manifesting as Safety Climate, which Expresses itself (partly) in Measurable Attitudes and

Perceptions with Numerous Cybernetic loops with the Culture.© Gurdev Singh 2007

That is all very well but we have limited $$$$$

G and R Singh 2008

TRM/crm

P4P

P a y e r

Empowered ProvidersForm Self-empowered and

Motivated Team•Receptive to external data

•Provides preparedness for P4P•It is prospective

•Internal measurements – privacy•Makes info. useful at the point of care

•Patient centered•Forms culture of Safety/Quality

•Cost effective quality improvement •Can improves patient satisfaction

•Increase clinician satisfaction•Provides change management tools

•May reduce malpractice•….

Resistant ProvidersNot enthusiastic

•Resistance to external data•Resistance to change

•Culture of blame•Avoidance of high-risk patients

•Concern with ‘indicators’•Unintended –ve consequences

•May undermine wholesome/multi- disciplinary approach•Compromises Clinician-Patient

Relation•May not address co-morbidities

•……

Top Down

Bottom Up

Large proportion of all the organizations (outside H.Care)that were earlier adopters of P4P have already dropped it !

The four laws of economic incentives Top Down

1. Salary Do as little as possible for as few people as possible

2. Capitation Do as little as possible for as many people as possible

3. FFS Do as much as possible, whether or not it helps the patient

4. Quality p4p Carry out a limited range of highly commendable$$tasks, but nothing else

$$$$$$$$$$$

From Martin Rowland Singh: April 2005

The Transcendent Law of economic incentive:Bottom Up

Create Adaptive Practices with Self-empowered and

Self-motivated Teams Embedded in a Culture of Safety

This approach has received AHRQ support (R21 and R18) Singh 2005

Affordable Excellence in Quality

Why not ask them what they see?

ALL workers“Swimming in the Water”

can each see various partsat various times

Humanistic=Pursuit ofExcellence

95%

5%

Co

mp

/Su

pp

lem

enta

ry

REPORTSPROFILES

AUDITS=Mechanistic

Let us adopt an eclectic approach

This is

Team Resource Management(=CRM)

This is Prospective

• Treat each ‘practice/setting’ as a unique micro-system to help it thrive; through trust, mutual respect and collaboration between all ‘agents’ (“strange attractors” that produce order in disorder/uncertainty).

• Culture of safety has to be established that encourages empowerment, ownership, and raises morale–shift from blame culture.

G and R Singh

Proposed cyclical approach:

1. Assess/MeasureBaseline

Safety state

2. IdentifyMost significant

System Problems-

Overall view of methodology for safety improvement(based on FMEA)

3. Establish team based feasible

solutions to prioritized hazards

4. Implement team based solutions

A, G and R Singh

acc

ess

Assessment

Plan

Implementation

Review& Learn

1A

1P

1I1F

1RPATIENTBeliefsPreferencesFamily, FriendsCommunity

1: Office

Feedback

Macro-System of Primary Care Office Domain

Based on understanding of:

G and R Singh 2001

Medication Management Micro-system

Patient/Caregiver

Script

Office

Patient/Caregiver Medication

Home

Pharmacist

Patient/Caregiver

Pharmacy

Nurse

Doc

Recept.

Lab

Phone/Fax

Chart

and understanding of:

Int. to

H.

Org.

0

100

1stQtr

3rdQtr

Assessment

Plan

Implementation

Macro-System

Feedback

Review &Learn

Chart/EMR

Micro-System

SEMI-P Instrument

R & G Singh: Jan. 2003

Anonymous Error Survey Example page

Hazard Matrix

1002420.50Severe (=100%)

204.800.400.10Moderate (=20%)

51.200.100.03Mild(=5%)

10.240.020.01Minimal (=1%)

FrequentOccasionalUncommonRemoteSeverity (s)

Probability (p)

G and R Singh

1. Assess/MeasureBaseline

Safety state

2. IdentifyMost significant

System Problems-

Overall view of Methodology for Safety Enhancement

3. Establish team based feasible


4. Implement team based solutions

G and R Singh

Prioritization

Prioritization is Based on HAZARD RATINGHazard = Probability x Severity

h = p x s

The survey yields qualitative perceptions of probability and severity – these must first be converted to quantitative data:

PROBABILITY (p): its numerical value was derived from the descriptive perception by taking into account the number of patients seen in the corresponding descriptive period

SEVERITY (s): its numerical value was obtained by adopting a risk aversive attitude

-

2. IdentifyMost significantSystem Problems

2

G and R Singh

Results2. IdentifyMost significantSystem Problems

-

All the compiled results and analysis from the first step were circulated to all the staff. Sample :

8.54Doesn’t provide accurate info about meds taken

11.37Delay in seeking medical attention

13.13Masks symptoms by inappropriate self-treatmentPatient

(Assessment)

2.04Reading from wrong chart

3.53Incomplete/not-updated chart

3.90Failure to update chart adequatelyNurse-Chart

Interaction

1.67Inadequate patient education about disease

1.74Inadequate patient education about treatment

1.81Misunderstanding b/c patient in a hurryNurse-Patient

Interaction

1.38Not using available resources for help

3.05Nurse fatigued, stressed, ill

10.95Nurse in a hurry

Nurse

1.71Receptionist fatigued, stressed, ill

2.10Long wait in office

2.33Misfiled Record

Reception

Mean Hazard Score

ItemArea

2

G and R Singh

0

10

20

30

40

50

60

70

80

90

100

Severe Moderate Mild Minimal

Qualitative Severity of Consequence

Qua

ntita

tive

Sev

erity

of

Con

sequ

ence Risk Preferring

Indifference to risk

Risk Averse adopted

Very high risk aversiveness

Conversion of descriptive/qualitative to quantitative values of severity ‘s’

G and R Singh

e.g.ResultsS

SFollowing the initiation of this onFollowing the initiation of this on--going process, a number of going process, a number of

other quality improvement interventions have been designed other quality improvement interventions have been designed and implemented that are not directly related to the Survey and implemented that are not directly related to the Survey results, but may results, but may reflect a shift in the Culture and a greater reflect a shift in the Culture and a greater awareness of the importance of medical errorsawareness of the importance of medical errors. Examples of . Examples of some of these quality improvement measures include:some of these quality improvement measures include:

• The development of a look up table for drawing up doses of parenteral Morphine.

• Better tracking of patients receiving Coumadin therapy, and their blood test results.

• Revision to the policy on Administration of Medications and Immunizations by nursing staff

• Revisions to the Medication Refill Policy and a change in the format of the Medication List kept in the chart to improve its clarity..

4. Implementation of Team-based solutions

-4

G and R Singh

e.g. Results 3. Establish team-based feasible


In subsequent weeks the team devised feasible solutions to hazards identified in THEIR practiceincorporating proven safety principles and practices

Description of the solutions to hazards in First Priority list follows:

1. Patient delays seeking medical attention / masks signs by inappropriate self-treatment.A plan was made for the Medical staff to create patient educationmaterials that can be included in New Patient introductory materials, and also can be handed to specific patients at the discretion of the providers.Specifically it was decided to focus on the problem of patients delaying seeking attention or inappropriately self treating Chest Pain(that might represent an acute cardiac event) and Neurological symptoms (that might represent a stroke).

3

G and R Singh

Results3. Establish team-

based feasible solutions to

prioritized hazards

Cont..

Description of the solutions to hazards in First Priority list follows:

3. Nurse Provider Interaction: Misunderstanding because nurse in a hurry:Two solutions were devised. Firstly, the Providers agreed to utilize a Flag system (which was already in place outside each exam room) which allows them to alert the Nurse that there are Orders for the Nurse to carry out. Secondly, the providers agreed to always give orders in a written form so as to avoid misunderstandings and potential errors.

3

G and R Singh

G and R Singh 2004

0

100

1stQtr

3rdQtr

Assessment

Plan

Implementation

Macro-System

Feedback

Review &Learn

SEMI-P Instrument

Chart/EMR

Micro-System

SEMI-P InstrumentSEMI-P Instrument

Informed by important safety principles, Informed by important safety principles, strategies andstrategies and

equipment featuresequipment features

CO

ST

CO

ST

LOW SAFETY

HIGH SAFETY

DECREASING RISK/HAZARD RATINGn

Hazard Rating of the System = severity of consequence (S) x probability of occurrence (P)0

n n n

= (S) x (P) = Hazard Factor = HF; where n is the number of entities and processeso o o

INTERPLAY BETWEEN SAFETY-BASED QUALITY AND COSTS IN THE WHOLE SYSTEM UNDER STUDY

OBJECTIVE

TOTAL COST = Cp + Cs

Cs = Costs of safety investments and maintenance of the system

Cp = Tangible and intangible costs of harm to patients andstaff in the system

Achieved through

prioritized cost-effective interventions in the system

Achieved through communication, patient education and stress management

G and R Singh

PREMISEPREMISE

Office Staff “Swimming in the Water”

can each see various partsat various times

REPORTS

PLUSREPORTS

PLUS

Survey of Errors and Consequences Leads toSurvey of Errors and Consequences Leads toThe Design of Targeted Interventions by the The Design of Targeted Interventions by the

Energized Self Empowered Clinic TeamEnergized Self Empowered Clinic Team

Why not ask them what they see?

Error Reportsare the

Tip of the IcebergThey allow us to look at the tip in great detail

Supported by the US AHRQ

Enabled by HIT

Our past experiences with

this methodology

•FM Practices•Post-operative pain management

•Falls management•SNF

SS

G and R Singh

Our experience with this approach:Our experience with this approach:• Filling out the survey:Filling out the survey:

– Helps make everyone more aware / conscious of problemsHelps make everyone more aware / conscious of problems– Helps make people more safety consciousHelps make people more safety conscious

• Seeing the results:Seeing the results:– Helps people to see other peoples’ perspectivesHelps people to see other peoples’ perspectives– Helps in identifying priorities for improvementHelps in identifying priorities for improvement

R & G Singh: Aug. 2002

Advantages of this Humanistic Advantages of this Humanistic Approach:Approach:

• Creates awareness among the staff of the Creates awareness among the staff of the value of qualityvalue of quality• Leads to improvement in patient and staff Leads to improvement in patient and staff satisfactionsatisfaction• Energizes the empowered workers to maintain and continually Energizes the empowered workers to maintain and continually

improve qualityimprove quality• Has potential to reduceHas potential to reduce litigation litigation• Can lead ultimately to Can lead ultimately to increased profitabilityincreased profitability..

Findings of Strategic Planning InstituteFindings of Strategic Planning Institute “ “Relative perceived service quality”Relative perceived service quality”

R & G Singh: Aug. 2002

FORTUNE June, 2006

FOR

About 2 trillion

Likely to provide the biggest

Our Aspiration

Transfer approach across all the domains

Matters Patient Safety Matters Matters Challenges and Opportunities 2006 San Antonio 2005 11th...

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