do no harm: culture, technology, teamwork and design change nancy g. pratt rn, msn, svp, clinical...
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Do No Harm: Culture, Technology, Teamwork and Design Change
Nancy G. Pratt RN, MSN, SVP, Clinical Effectiveness
Sharp HealthCareFebruary 5, 2007
Sharp’s Strategic Plan for Patient Safety
CultureHumanFactors
TechnologyDesign
Develop a Culture of Safety Use Technology to Improve Safety
Address Human Factors: Teamwork and CommunicationRedesign the Processes
Develop a Culture of Safety Use Technology to Improve Safety
Address Human Factors: Teamwork and CommunicationRedesign the Processes
Reduce Reduce Harm by Harm by 50% over 5 50% over 5 yearsyears
Strategic Priorities: Patient Safety
• Implement a Culture of Safety • Anonymous reporting• Collaboration: San Diego Patient Safety Consortium• Adverse Events Program
• Teamwork and Communication• Team Resource Management• Standard Work Processes
• Use Technology to Improve Safety• Bar Coding• Electronic Safety Triggers• Electronic variance reporting • Smart Pumps – IV, PCA, Syringe
• Redesign for Safety• Human Factors Engineering• Design for Six Sigma• Product, supply, process review• JCAHO National Patient Safety Goals
Six Sigma Projects: Patient Safety
Six Sigma Projects
Status
Medication Safety Done
Pharmacy Order Cycle Time Done
SMH Discharge Project Underway
SCV Discharge to SNF Underway
SGH Discharge Project Underway
SHC Cerner CPOE Paper Lite Started
ROMACC (Reconciliation of Medications) Started
Physician gives order
RN can’t get med out of Pyxis
Fax doesn’t go through!
Pharmacist not available
Drug not available
Pharmacy informs RN med has been there for 2 hours
RN faxes & calls pharmacy again!
Onset of Complaints!
Pharmacy Tech delivers med
someplace in SICU
RN Calls pharmacy, faxes
order again!! Fills out standard
pharmacy complaint – QVR!
RN writesorder &
faxes to
Pharmacy
Alternate Actual Process
Orders by Hour
0
2
4
6
8
10
12
14
16
18
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hour
Ord
ers
0
1
2
3
4
5
6
7
8
Sta
ff i
n P
har
mac
y
Avg Number of Orders Pharmacist Staffing
PharmacyPharmacyStaffingStaffing
# Medication# MedicationOrdersOrders
Time of DayTime of Day
Pharmacy Staffing Not Matched to Medication Order Volume
Pharmacy Order Cycle Time
Pharmacy Order Cycle Time
Fax to Verification Time
Frequency
8006004002000-200
120
90
60
30
0
8006004002000-200
120
90
60
30
0
aBefore After
Well After zLast
aBefore
39.66StDev 50.53N 129
Well AfterMean 81.66StDev 185.1
Mean
N 80
zLastMean 22.60StDev 31.57N 187
81.57StDev 132.4N 155
AfterMean
Histogram (with Normal Curve) of Fax to Verification Time by Series
Panel variable: Series
After Pharmacy IT System Changed
After Initial Improves
Baseline
After Fax Server
Installed
Figure 7.5-9 Pharmacy Turnaround Time Improvement at Sharp Memorial - SICU
8254
132
40 5123 3220 12
0306090
120150
MeanTurnaround Time
MedianTurnaround Time
Std Deviation ofTurnaround Time
Min
ute
s
Pre-Intervention After Initial Improve Post Final Improve
Goal < 30 minutes
Better
Pharmacy Order Cycle Time
Med Admin Flow Map
(Ideal)
Average time~ 7 mins
RN Prompted to give med
RN interprets MAR (5Rs)
RN explains med to pt
RN washes hands
RN identifies patient
RN procures med/IV & supplies
(5Rs)
RN preps med
RN performs preadministration
assessment / checks allergies RN
prepares to admin med(final 5Rs)
RN gives med
RN documents
med
RN evals effects of med
RN washes hands
Medication Safety Project: Decrease Interruptions
Med Admin Flow Map(More real)
Average time ~ 20 mins
RN Prompted to give med
RN interprets MAR (5Rs)
RN explains med to pt
RN washes hands
RN identifies patient
RN procures med/IV & supplies
(5Rs)
RN preps med
RN performs preadministration
assessment / checks allergies
RN prepares to admin med
(final 5Rs)
RN gives med
Phone call
Need to clarify
Call MD;Wait;Get
clarification
Order is questionable
Unexpected nsg task
Can’t find med; look in 4 places;
call pharm
Wait in line
Phone call
Unexpected nsg task
Locate Missing supply
Phone call
RN documents
med
RN evals
effects of med
RN washes hands
1. Waited in line to get meds @ 9:00
2. One med grayed out – not here, one gray ed at – in refrigerator
3. Search refrigerator
4. Went to P #1, found 1 med – MVI still missing, tapped drawer to get cubie to open
5. Two meds left to find – may be in room. Crushed meds in paper cups
6. Piston syringe in room – No date – went to supply room to get another
7. Found MVI but NO med cups - ? Refrigerator MVI
8. Searched room for fiber or med cup – on bedside table – no way to administer
9. Back to med room
10.Back to room
11.Mixed meds in cup in admin – DONE 0920
Medication Delivery Total Time – 13 minutes
CR
28 1&2 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 1&2
LinenDocRm
MD
Doc
30 MDP #1
31
LeadOffice
32 1&2Supplies P #2 Kitchen Mg
33 1&2 34 35 36 37 38 3 4 5 6 7 8 9 10 11 1&2
29 1&2
Nur
se S
tatio
n #2
Kitc
hen
Util
ity H
all
What Does the Literature Tell Us? Top High Risk Situations Causing Sentinel Events
• Distractions before or during administration of meds or treatment• High alert drugs used without double-checks• Multi-tasking• Care provided under a human-error-prone situation (dark, noisy, shift
change) without appropriate compensatory actions
Reason, JT. Understanding adverse events: human factors. In VincentCA (ed) Clinical Risk Management. London: BMJ Pub; 1995
Medication Safety Action Plan
Create a standard environment for medication room design and processes
5’S’ Principles- Sort- Shine- Simplify- Standardize- Sustain
Minimize interruptions and distractions during medication administration– Respect med admin as a critical activity – Divert and discourage unnecessary calls– Encourage all disciplines to limit interruptions Create Scripting
examples for nurses– Evaluate workload demands during high volume med admin times
Medication Safety Action Plan
Develop a standard guideline for
medication preparation and administration– Avoid conversations in med room– Discourage interruptions/distractions– Verify using 7 “Rights”– Prepare and administer to 1 pt at a time– Independent double check insulin, heparin, warfarin– Use MAR or Pyxis label to verify 7 ‘R’s – Document
Grossmont - Delivered Doses by Time of DayJune 2004
0100020003000400050006000700080009000
100001100012000130001400015000160001700018000190002000021000220002300024000
Time Dose Delivered
# D
ose
s D
eliv
ered
N=114,755 doses* Only units on Clinicomp represented in data* Excludes PRN and IV meds
24 06 09 12 17 21
Number of ‘Unnecessary’ Interruptions During Med Pass: Pre and Post*
3.8 4
2.2
0.71 0.8
0
0.5
1
1.5
2
2.5
3
3.5
4
Pre (n=14) Post (n=29)
Mean Median SD*No statistical difference in number or route of meds given
p=0.000
SGH 5E Pilot Med Pass TimePre and Post*
15.1 15
5.9
11.610
4.7
0
2
4
6
8
10
12
14
16
Minutes
Pre (n=14) Post (n=29)
Mean Median SD*No statistical difference in number or route of meds given
p=0.037
Emergency Department: RME
• ED patients expect quick service and to be seen
by an ED doctor, regardless of diagnosis
• 40% of ED pts are non-emergent
• Rapid Medical Exam (RME) designed to promptly
and appropriately “treat & release”
• Issues: long waits, space, multiple entry points,
flow, communication…
ED Waits Decrease Satisfaction
89.3 90.0
86.5 86.9
80.8 80.979.6
84.385.2
<0.5h(n=10)
0.5h-1h(n=6)
1h-1.5h(n=23)
1.5h-2h(n=37)
2h-2.5h(n=59)
2.5h-3h(n=46)
3h-3.5h(n=96)
3.5h-4h(n=48)
4h +(n=404)
Hours Held in ED
Pat
ien
t S
atis
fact
ion
Overall Satisfaction (scale: 0-100) Goal 86.3
Growth of ED Visits
• 1992: 12 beds = 16,640 visits. 2006: 22 bed =45,456 visits. • 173% increase in visits since current ED was opened in 1992. • 83% increase in beds over same period.
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
FY92FY93
FY94FY95
FY96FY97
FY98FY99
FY00FY01
FY02FY03
FY04FY05
FY06
ED Outpatient Overall Satisfaction(scale 0-100)
76.6
81.1 81.8 82.5 82.2
31,62235,531
40,506 42,86745,956
FY02 FY03 FY04 FY05 FY06
Mean Volume
Lack of open ED beds creates bottlenecks. Many patients wait in front lobby area.
Bottlenecks in the ED
RME
LOBBY
PHLEBOTOMY
TRIAGE
Key Process Steps
See podium? Fill
out reg. form
Go to Triage Coordinator “behind the
glass”
Visitor?Patient?
Triage CoordinatorVisitor- send
back?
Triage: ESI? Standing Orders variable.
Respond to waiting
patient’s questions?
Patients Wait
Patients to Lab/ x-ray/ triage one/two. More
orders put in?
Patients Wait
Patients called back
to RME or to bed.
Patient and family Arrives
Security
Triage Standing Orders
RME triage criteria and bounce back
process.
RME Project Goals
1. Take vitals of all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%)
2. “Arrival noticed quickly” satisfaction = 85th percentile (baseline 18% Dec-06)
3. Establish RME triage standard to set stage for RME cycle time project
ED RME Outcomes
• Goal: Vitals on all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%). Improvements:– Guard providing safe environment– LVN assigned to check vitals – Designed EmStat report to monitor lobby patients
ED RME Outcomes
ED Outpatient Satisfaction with "Wait before arrival noticed"
19% 18%
35% 35%
80%
82.2 82.0
85.1 84.8
90.0
Dec-06(n=52)
Jan-07(n=61)
Feb-07(n=74)
Mar-07(n=64)
Apr 1-18(n=25)
%tile Rank (N=888 facilities) Mean Rating (0-100)
Goal: 80th %tile
RoMACC at Grossmont Hospital
Reconciliation of medications across the continuum of care
Project Description / Vision:
Implement a ‘Lean’ RoMACC process that demonstrates value, not just in terms of patient safety but in efficiency for practitioners.
Sponsor: Michele Tarbet
MD Partner/ Process Owner:Dr. Margaret Elizondo
Start Date: September 2006 Go Live: December 5th End Date: March 2007
Participants:
Next Sustain and Improve!Next Sustain and Improve!
Champion/Green Belt:Julie McCoyJackie Parson
Black Belt: Kurt Hanft
Process MeasureProcess Measure
RoMACC Measurement Method:
Reconciliation of medications across the continuum of care
Physician
writes the Discharge Orders and Addresses the
Discharge Reconciliation.
Unit clerk
verifies the reconciliation has been addressed
and enters a discharge order
Discharge:
Combined projectsCombined projects
RoMACC and Discharge Measurement:
% RoMACC Complete
Carecast Discharge Order Entry Compliance
Number Of Discharges
Time to Discharge a Patient
Average Time of Day a Patient Leaves.
Reconciliation of medications across the continuum of care
Continuous Improvement – Above System Goal of 75%Continuous Improvement – Above System Goal of 75%
RoMACC at Grossmont Hospital
75% System Goal
Carecast Discharge Order Entry Compliance
36%
67%84% 85%
0%
20%
40%
60%
80%
100%
1 2 3 4
%
2245 8266 7614 540010000
1 2 3 4
# o
f D
C's
RoMACC Complete
57%
85% 94% 97%
0%
20%
40%
60%
80%
100%
06 December 5th-31st
07 Jan, Feb, Mar 07 April, May, June 07 July 2-8
%
Reconciliation of medications across the continuum of care
Examples of Patient Safety Improvements:
Bar Code Implementation (Roche) Real Time Event Triggers “On Watch” (Clinicomp)Electronic Quality Variance Reporting (Peminic)Wireless Smart Pumps CQI data (Cardinal)Standardization of IV infusion concentrations (SDPSC)Enteral Tubing connections (Viasys, FDA, AHA)
Innovation with our partners: Cerner
Use Technology to Improve SafetyBar CodingElectronic Safety TriggersElectronic variance reporting Smart Pumps – IV, PCA, Syringe
System Reprogramming: Safety Achieved Quarter 1 2006
Pareto of Reprogrammings > 3X Max
010203040506070
prop
ofol
hepa
rin
MORPHIN
E sulfa
te
mida
zolam
insuli
n
oxyto
cin
VECuroniu
m
MAGne
sium
sulf (
OB)
hydr
omorpho
ne
fent
anyl
eptifi
batid
# o
f E
ven
ts
0%10%20%30%40%50%60%70%80%90%100%
Events % of Total n=145
Alaris Guardrails
Tubing Misconnections
l
Bag/Bottle of Enteral Feeding
Feeding Bag
Tubing Set
Enteral Feeding Tube
Patient Safety Strategy
• Redesign for Safety• Human Factors Engineering• Design for Six Sigma• Product, supply, process review• JCAHO National Patient Safety Goals
Patient Safety Actions
• Products:– Insulin Syringe– Dopamine Drip Bottle versus Bag– Enteral Feeding Bag versus Bottle– Heparin Flush versus Therapeutic infusion– Anesthesia Tray for Epidural – Cat Scan Contrast Injectors – IV PICC Line Cap Leaking (CLC 2000)– Insulin and Heparin Infusions – standardized– Endotracheal Tube with Sub-glotic suction
San Diego’s Health Care Leader
Gold Eureka Award, 2006
Silver Eureka Award, 2005
Bronze Eureka Award, 2004
Best Integrated Health-Care Network in California, 2007
100 Most Wired Hospitals, 1999-2006
IDG's Computerworld, 2006
Best place to work, 2004
Torch Award for Marketplace Ethics
Excellence in Patient Safety and Health Care Quality, 2006
Magnet Status
Sharp Grossmont
Malcolm Baldrige
National Site Visit, 2006
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