Safety Across the World International Patient Safety Symposium November 10, 2011

Safety Across the World

International Patient Safety SymposiumNovember 10, 2011

Maureen BisognanoPresident and CEO

IHI

At 2pm yesterday, the urologist's office called to say that Bob was scheduled for 8am surgery today and to make sure he was drinking only liquids. Everything was OK at their end.

At 4pm yesterday, Bob's cardiologist's office called to say that they just got a call from the anesthesiologist - the one who would be working w/the urologist - to say that the surgery cannot be performed since Bob's cardiologist did not fill out the 'approval for surgery letter' with the right terminology, and that the cardiologist is on vacation this week and cannot be contacted at all. Sonsabitches!! Bob's blood pressure shot up so high I thought he was gonna have a stroke! Bob then proceeded to leave voice mail messages for 3 people in the urologist's office, finally getting a human being to ask that the surgeon give him a call asap.

At 6:30pm, the surgeon called to say that he had just spoken to the anesthesiologist and he concurs that the surgery cannot be performed until said cardiologist returns to the office to fill out the proper paperwork and for Bob to possibly have more invasive testing before surgery, even though he's had every battery of pre-surgery tests known to man.

It seems that the person in the pre-surgery office OR the assistant to the anesthesiologist did not take the time to make sure ALL of Bob's paperwork was in order for the surgery before the 11th hour!

Bob already filled out office paperwork to take a leave of absence from work, along with a half-pay medical leave, so he's pretty mad about this last minute cancellation and so am I.

Today 11am - the very busy urologist called back to give a tentative surgery date of Tuesday, 11/08 (another 2 wks. from now)

The waiting continues, along with the emotional drain and frustration for Bob and our family. Thanks for caring.

Hi Sophie,

Of course you can tell our ongoing saga about Uncle Bob’s eventual surgery. Even though the surgeon is not in any hurry, this surgery is important to us since Bob has a large cancerous tumor growing outside his bladder PLUS a non-functioning left kidney that must be removed before it becomes dangerous in any way. And adding to these problems, Bob has high blood pressure and diabetes, along with other medical issues! I guess I definitely need to stay strong and healthy to keep this family going.

Hang in there toots.

Hugs, Aunt Rhonda

Safety in Aviation

• Design• Reliability• Checklists• Human Factors

Sully Sullenberger

Sullenberger’s Priorities

• Fly the plane• Deal with the situation• Communicate

208 seconds

Sullenberger’s Decision

“My aircraft” … “your aircraft”• All options for landing on

left side• More hours in that plane• 11 months since simulation

training…co-pilot: 1 week• Co-pilot’s first time in Airbus

Sully on Sully

• Physical stress causes increased blood pressure, increased heart rate, and narrowed vision

• Forced calm on himself• “Be the swan”• Imposed order on chaos• Chose to do only critical

things

Safety in Healthcare

• Design• Reliability• Checklists• Human Factors

• Systems knowledge

“To Err is Human” (1999)

How can we learn about our system performance?

Diagnostic Journey

• Do people die unnecessarily every day in our hospitals?

• In order for us to understand this, we need a diagnostic journey that moves out of a model for judgment and into a model for learning.

The Mortality Diagnostic – 2x2 Matrix

• Review most recent 50 consecutive deaths

• Place them into a two by two matrix based on:- Was the patient admitted for palliative care?- Was the patient admitted to the ICU?

• Focus your work initially on boxes that have at least 20% of your mortality

Diagnostic – The 2 x 2 MatrixAdmitted to the ICU?

Yes No

Admitted forPalliativeCareOnly?

Yes

No

Box #1 Box #2

Box #3 Box #4

The Mortality Diagnostic:Failure to Recognize, Plan, Communicate

• Analyze deaths in box 3 and 4 for evidence of failure to: recognize, communicate, plan

• This will help you understand the local environment

Recognize, Communicate, Plan

Failure to Recognize: Any situation in which a patient has died and there was evidence that an intervention could have been made anytime prior to the patient’s death Example: the staff was worried, change in heart rate, change in respiratory rate, change in blood pressure, change in O2 saturation or change in consciousness or neurological status that was not responded to.

Failure to Plan, such as: diagnosis, treatment, or calling a rescue team.

Failure to Communicate: Patient to staff, clinician to clinician, inadequate documentation, inadequate supervisor, leadership (no quarterback for the team), etc.

The Mortality Diagnostic:The Impact of Care

Evaluate ALL deaths in box 3 and box 4 to assess the estimated impact of our care on mortality:

*As you review the deaths in box 3 & 4, ask yourself the questions honestly (focusing on learning, not judgment):

─ Was perfect care rendered?─ If perfect care wasn’t rendered, could the outcome

of death have been prevented if the care had been better?

What number of deaths could have been prevented?

The Mortality Diagnostic:Evidence of Adverse Events

• Analyze deaths in box 3 and 4 for evidence of adverse events using the Global Trigger Tool

• This will give some further direction to local problems

Global Trigger Tool

• Review chart for triggers that are sensitive and specific for harm

• Find a trigger – Was there harm?• Not all triggers mean there was harm!

Global Trigger Tool Modules

• Cares (General) • Critical Care• Medication• Surgery• L&D• ED

Example of a trigger:Transfer to higher level of care

• Endoscopy• Post procedure somnolent and

hypotensive (BP 80) transferred to ICU• Placed on Bi-Pap• Received standard Demerol and Versed

for procedure• Given Romazicon; stayed in unit 12 hours

Global Trigger Tool Examples• Readmit within 30 days with recurrence of abscess right hip• Readmit next day w/ileus s/p exp lap for tumor• Stopped lasix-acute renal failure• Readmitted in 30 days for wound revision due to incisional

seroma• Readmit related with wound infection• Volume Depletion with altered mental status caused by Lasix -

resulted in hospital admission• ARF due to nephrotoxicity due to combination of ACE and

NSAIDS taken at home• Ischemic colitis had rt hemicolectomy. New onset CP=MI

Unresponsive, coded. Decreased loc & sats on Morphine PCA. Rec'd Narcan

Safety Initiatives

Studying Mortality

Kaiser Permanente:“Saving Lives by Studying Deaths”

Source: Lau H, Litman K. “Saving Lives by Studying Deaths: Using Standardized Mortality Ratios to Improve Inpatient Safety.” The Joint Commission Journal. 37(9): September, 2011.

• To address substantial variation across their hospitals, KP quality leaders led an efficient and effective method of investigating mortality to find patterns of harm

• Used IHI’s Global Trigger Tool and 2x2 mortality matrix, as well as other tools

• Multidisciplinary teams studied the 50 most recent inpatient deaths at 11 KP hospitals

Storytelling

• Project leaders incorporated the use of de-identified patient narratives to get at the circumstances behind the data.

• Stories were selected to share with hospital leaders to identify common issues that would help drive improvement.


Results• 10 categories of harm were identified (listed below in

order of decreasing frequency):─ Harm occurring before hospitalization─ Hospital-acquired infection─ Failure to plan─ Failure to communicate─ Other harm─ Hospital-acquired pressure ulcer─ Surgical/procedural complication─ Failure to rescue─ Medication event─ Fall

• In response, hospital leaders identified 36 quality improvement goals to pursue.


Scottish Patient Safety Program

Specific Outcome Aims for Academic and District General Hospitals

By January 2011• Mortality: 15% reduction• Adverse events: 30% reduction• Ventilator associated pneumonia: 0 or 300 days between• CL CR-BSI: 0 or 300 days between• Blood sugars w/in range (ITU/HDU): 80% or > w/in range• Staph aureus bacteraemias: 30% reduction• Crash Calls: 30% reduction• Harm from anti-coagulation: 50% reduction in ADEs• Surgical site infections: 50% reduction (clean)

The Scottish Patient Safety Program

• NHS Quality Improvement Scotland• The Scottish Government Health

Directorate• The Institute for Healthcare Improvement

Inventory national programmes and measurementsMeet with programme leader to understand programme intent, audience, historyHarmonize our metrics

Improve Safety of Hospital Healthcare Services in Scotland

Boards Accept Safety as Key

Strategic Priority for Effective

Governance

Scottish Executive Sets PSA as

Strategic Priority

Robust, evidence based proven clinical changes

IHI/QIS Team Expert at Content,

Coaching and Programme Management

Align national SPSP with

national improvement

programmes and measures

Primary Drivers

Demonstrable results to communityClear, shared measurement setVisible on all senior leader agendaPSA represents & demonstrates cohesive, united programme

Secondary DriversOwnership of agreed upon set of outcomesReview of outcomes at each meetingQuality and safety comprises 25% of agendaRecovery plans for unmet outcomesInfrastructure supports improvement and measurementInvolve patients in safety

Patient Safety Alliance Programme

Driver Diagram

International expert clinical facultyFaculty expert at improvement methods and coachingProgramme design and structure

Acceptance of pragmatic science Royal College Supports PSA Programme

.******Improve healthcare

safety by reducing:

1. Mortality by 15%

2. Adverse events by 30%

**National Priorities, Programs, Strategies

Leadership System for Safety

Care of General Ward Patients

Perioperative Care Management

Medicines Management

** Infection Prevention

Care for Acute MI Patents

Primary Drivers

Pressure UlcersCHF key processesHandoffs **Hospital at NightCommunicationFailure to Rescue *SEWS

Medicines Reconciliation**High Alert Medicines (**antioagulation ,

narcotics, insulin)Handoffs and Transitions

Secondary Drivers

MRSA + MSSA infectionsC-difficile infectionsHand hygiene and general infection

prevention

Safety as a Strategic PrioritySustainable InfrastructureEngaged and Committed Leadership

TechnicalDriver Diagram

Clean Surgical Site Infection**

AMI mortalitySeven key AMI processes

Nov-07

Jan-0

8

Mar-08

May-08

Jul-0

8

Sep-08

Nov-08

Jan-0

9

Mar-09

May-09

Jul-0

9

Sep-09

Nov-09

Jan-1

0

Mar-10

May-10

Jul-1

0

Sep-10

Nov-10

0

2

4

6

8

10

12

Scottish Patient Safety Program (SPSP)Critical Care Central Line BSI Rate

November 2007 through December 2010(Goal: 0 CL BSIs)

Cen

tral

Lin

e B

SI ra

te (B

SIs

per 1

000

cent

ral l

ine

days

)

T1 Median = 2.7

T2 Median = .71 (74% decrease)

Mar-0

8Ap

r-08

May-

08Jun

-08Jul

-08Au

g-08

Sep-0

8Oc

t-08

Nov-0

8De

c-08

Jan-09

Feb-

09Ma

r-09

Apr-0

9Ma

y-09

Jun-09

Jul-09

Aug-

09Se

p-09

Oct-0

9No

v-09

Dec-0

9Jan

-10Fe

b-10

Mar-1

0Ap

r-10

May-1

0Jun

-10Jul

-10Au

g-10

Sep-1

0Oc

t-10

Nov-1

0De

c-10

0

2

4

6

8

10

12

14

16

18

20

Scottish Patient Safety Program (SPSP)VAP Rate

March 2008 through December 2010(Goal: 0 VAPs)

VAP

Rate

(VAP

s per

100

0 ve

ntila

tor d

ays)

T1 Median = 8.4

T2 Median = 4.6 (45% decrease)

Jan-

08M

ar-0

8M

ay-0

8Ju

l-08

Sep-

08No

v-08

Jan-

09M

ar-0

9M

ay-0

9Ju

l-09

Sep-

09No

v-09

Jan-

10M

ar-1

0M

ay-1

0Ju

l-10

Sep-

10No

v-10

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Scottish Patient Safety Program (SPSP)Critical Care C. Diff Rate

January 2008 through December 2010(Goal: 50% reduction)

C. D

iff R

ate

per 1

000

patie

nt d

ays

T1 Median = 1.6

T2 Median = .44 (73% decrease)

Financial Impact of Safety Initiatives

CONFIDENTIALThis document is part of the quality assessment activities of Cincinnati Children’s Hospital Medical Center and, as such, it is a confidential document not subject to discovery pursuant to Ohio Revised Code Section 2305.25 and 2305.251. Any committees involved in the review of this document, as well as those individuals preparing and submitting information to such committees, claim all privileges and protection afforded by ORC Sections 2305.25, 2305.251 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individual or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.

Serious Safety Events per 10,000 Adj. Patient DaysRolling 12-Month Average

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Jul

Aug Se

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Se

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Se

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Se

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May

Jun

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010

Even

ts p

er 1

0,00

0 A

dj. P

atie

nt D

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 Change

36 SSE’s Prevented

Serious Safety Event PreventionHospital Wide Effort - #1 Priority

2010 Goal

Case Study - HAI• Reducing hospital

acquired infections– Our “breakthrough”

effort

Reducing Hospital Acquired Infections

Improved Medical Outcomes & Error Elimination

• Clinical initiatives to reduce Catheter Associated Bloodstream Infections (BSI), Surgical Site Infections (SSI) & Ventilator Associated Pneumonia (VAP) were initiated

• At time, our rates were close to the national averages: – BSI rate = About 2 out of every 100 children with a

catheter– SSI rate = About 1.5 out of every 100 children

receiving surgery– VAP rate = About 4 out of every 100 children placed on

a vent• Our own data suggested that maybe 15-20% of

kids in the ICU who acquired a BSI, VAP or other serious infection might be expected to die

Reducing Hospital Acquired InfectionsImproved Medical Outcomes & Error Elimination

• Interventions aimed at reducing infection rates were developed from published best practices & our own observations & thoughts

• Development of Pediatric Specific Bundles for Care Delivery

• Intense focus on Execution• Transparency of Results

– Outcomes drive Culture Change

Reducing Hospital Acquired Infections Improved Medical Outcomes & Error Elimination

• What was achieved in first 2 years: – BSI rate reduced by 60%; meaning 29 fewer

kids suffered a preventable infection– SSI rate reduced by 60%; meaning 50 fewer

kids suffered a preventable infection– VAP rate reduced 90%; meaning 70 fewer kids

suffered pneumonia in our ICU

• MOST IMPORTANTLY potentially 20 children went home from our hospital that statistically may not have been expected to be do so!

24 26 21 36 34 24 18 24 15 21 27 12 6 6 7 9 9 9 5 8 5 3 8 6 5 8 8 6 6 5 5 4 4 1 4 4 4 9 5 4

8340

8741

8546

9034

9080

8890

9324

1005

4

1045

0

1066

7

1100

7

1049

1

3861

4094

3827

3625

3706

3434

3439

3790

3757

3651

3705

3840

4180

4484

4177

4159

4353

4306

4545

4326

4834

4476

4595

4483

4620

4874

4393

4463Device

Days

Infections

This document is part of the quality assessment activities of Cincinnati Children's Hospital Medical Center and, as such, it is a confidential document not subject to discovery pursuant to Ohio Revised Code Section 2305.25 and 2305.251. Any Committees involved in the review of this document, as well as those individuals preparing and submitting information to such Committees, claim all privileges and protection afforded by ORC Sections 2305.25, 2305.251 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individual or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.

CCHMC Central Venous Catheter (CVC) AssociatedLaboratory Confirmed Bloodstream Infections (LCBIs)

0.2

1.8

1.10.9

0.9

0.8

0.90.9

1.9

2.7

1.11.41.40.8

2.22.12.4

2.5

1.51.8

1.2

1.6

1.31.5

2.6

1.81.6

1.1

2.5

2.0

1.4

2.4

1.9

3.7

4.0

2.5

3.0

2.9

1.2 0.9

0

1

2

3

4

5

6

7

8Q

3 '0

4

Q4

'04

Q1

'05

Q2

'05

Q3

'05

Q4

'05

Q1

'06

Q2

'06

Q3

'06

Q4

'06

Q1

'07

Q2

'07

Jul '

07

Aug

'07

Sep

'07

Oct

'07

Nov

'07

Dec

'07

Jan

'08

Feb

'08

Mar

'08

Apr '

08

May

'08

Jun

'08

Jul '

08

Aug

'08

Sep

'08

Oct

'08

Nov

'08

Dec

'08

Jan

'09

Feb

'09

Mar

'09

Apr '

09

May

'09

Jun

'09

Jul '

09

Aug

'09

Sep

'09

Oct

'09

Nov

'09

Dec

'09

Jan

'10

Feb

'10

Mar

'10

Apr '

10

May

'10

Jun

'10

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010

Infe

ctio

ns p

er 1

000

Dev

ice

Day

s

CVC-LCBIs Control Limits Goals [0.8 (Jul06-Jun07) / 1.0 (Jul07-Jun08) ] Baselines

Q3/04 - Revised Care Practices and Q3/04 - CHG Scrub for Line CareQ3/04 - CHG Scrub for CVC InsertionsQ4/04 - Maximal sterile barriers and CHGQ4/04 - Interventional Radiology

New CCHMC Collaborative

Began, Q1/06

CA-BSI NACHRIderived CVC bundlerolled out to hospital 3/15/07

Q2/05 - MaxPlus Cap in PICU B4 & A6Q2/05 - MaxPlus Cap on A5N2Q3/05 - MaxPlus Cap cancelled on A5N2Q3/05 - MaxPlus Caps cancelled.

3/17/09 - Microclave Cap Use Housewide

Jan09 - Microclave Cap Use ICUs

Feb09 - Microclave Cap Use HemOnc/BMT

0.8

4.0

Quantifying the Financial Impact of An Enormous QI Success

• Brilliant Hypothesis: A HAI is “Bad Business”– Clinical Outcome not as good – inability to

differentiate our product– Poor customer Value - dollars spent in treating

infection = waste– Potential high opportunity cost – bed occupied

by HAI could effect flow and ability to meet access needs of out-of-area admission

– Poor Patient Experience

• We needed a proven methodology to test and conclusively measure our hypothesis

Comparative Matched-Case Study Design

• Chart reviews to define candidates and assess whether SSI was potentially preventable

• Matched Case-Control Design– Initial OR Cost of SSI case = Control (No SSI) OR

Case– Cumulative Cost at time of discharge of Control

case = SSI Case– Match criteria: same or equivalent surgical

procedure, age, procedure date, co-morbidities– Excluded patients with cancer, immune

deficiency, neonates or over 19 yrs old• 16 Patients in final statistical analysisSparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health

Care 2007;16:219-225.

Days after surgical procedure

$0

$500,000

$1,000,000

$1,500,000

$2,000,000SSI Match

SSI ResultsAggregate Cumulative

Charges

$1,740,000

$793,000Ave LOS = 4.6 days

Ave LOS = 16.0 days

Sparling KW, Ryckman FC, Schoettker PJ et al. Qual Mngt in Health Care 2007;16:219-225.

Reducing Hospital Acquired Infections

Improved Medical Outcomes & Error Elimination

Nothing compares to the human impact of this effort & nothing is even remotely as important; but there is more:– We reduced the costs to the health care system

by $11.2 million annually– And we reclaimed 5 beds per year previously

dedicated to infections that could now be dedicated our core strategy of unique program development

Maximizing Asset Production –Revenue Production Associated with

SSISSI Patient vs. Matched No-SSI Patient

Average Daily Charges

$0

$10,000

$20,000

$30,000

$40,000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Day

Ave

rage

Dai

ly C

harg

es

SSI Match

Pre-SSI Infection

Day of Surgery

Post-SSI Infection

Low Revenue ProductionRevenue Sweet Spot

90 Day Revenue Production CycleWhen 6 Patients Develop an SSI

Bed Cycle For SSI PatientsAverage LOS for Surgery Patients With Infection = 15 Days

Total Revenue Produced in 90 Day Cycle = $622,000

$0

$10,000

$20,000

$30,000

$40,000

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

Day

Dai

ly C

harg

es

Same 90 Day Cycle of Revenue Production

If No Patients Acquire SSI (18 patient potential)

Bed Cycle For Non-SSI PatientsAverage LOS for Surgery Patients Without Infection = 4.4 Days

Total Revenue Produced in 90 Day Cycle = $892,000Annualized Incremental Revenue = $1,080,000

$0

$10,000

$20,000

$30,000

$40,000

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

Day

Dai

ly C

harg

es

Diuretic Related Harm per 100 Patients on Loop Diuretics

0

1

2

3

4

5

6J-

09F-

09M

-09

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-09

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-09

D-0

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10F-

10M

-10

A-1

0M

-10

J-10

J-10

A-1

0S

-10

HFH

Henry Ford Health System

Harm Issue Total Associated Costs Pressure Ulcer stage 2 or higher $10,624,410

Coded Procedural Complication ICD9 (998-999.99) $7,670,520UTI using coded data and AHRQ definition. $5,662,895Glucose below 40 $3,846,375Coded Acute Renal failure $2,665,680

Coded DVT/PE in both medical and surgical patients $2,365,470No Pulse Blue Alert $1,535,808Coded Medication issue $1,216,078Clostridium difficile infection $824,544Reported Fall with injury $696,527Bloodstream Infections using NHSN criteria $640,000Coded Pneumothorax using AHRQ definition $340,260SSI using NHSN criteria $280,000VAP using NHSN criteria $190,352

Total Harm-Associated Costs 2009*

*Henry Ford Hospital Only

The Leader’s Role

• Executive WalkRounds• Deep dives in safety data and stories• Signs and symbols of a just culture• Move from past tense to future tense

─Huddles─Inquiries

• Aims, prototype sites, spread plan and tempo

Thank You!

• Maureen BisognanoPresident and CEOInstitute for Healthcare Improvement20 University Road, 7th FloorCambridge, [email protected]

mailto:[email protected]

Safety Across the World International Patient Safety Symposium November 10, 2011

Documents

Transcript of Safety Across the World International Patient Safety Symposium November 10, 2011