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

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

The Question

How safe is your hospital or clinic?

4

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…

Question & Key-Point #1

So why is it important to engage

patients in designing safer health care systems?

The short answer

An engaged patient =

An key ally to make your system safer

What’s the Value? Lower Cost

Question & Key-Point #2

What are the key design principles of a

patient-centered system?

3 Ideas

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10

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90

100

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

What Patients Really Want

Don’t hurt me

Help me

Be Nice to Me

13

Don Berwick, MD

The Key Design Challenge

From “What is the Matter with You?” to…

What Matters to You

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…

Step 1: Set the Aim for Patient Safety & Patient-Centered

Care in your organization

Where we want to be!

Where we are!

1. How do you bridge the gap?

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…?

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

21

Jim Reinertsen, MD

Used with Permission IHI 2012

Sometimes we cannot see what is in front of us…

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

22

Modified from M. Pugh

2. Understand the current status of Patient & Family-Centered

Care in your organization

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�

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?

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

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

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

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?

3. Make changes to achieve your aims for Safety using Patient &

Family-Centered Care

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

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)

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

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

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.

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.

Top 5 Changes You can Make Today:

Safer, Patient & Family-Centered Care on Med/Surg Units

#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?”

#2: Admission Trio Team

The Trio: Physician Nurse Pharmacist

• Interdisciplinary assessment • Single plan of care • Med reconciliation • Reduced documentation

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

8

#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

Patient’s Daily Goals

#4 Change the White Board

Patient Details

#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

Making a Change

Model For Improvement Video

4. Measure progress towards achieving your Aims for Safety

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

48

Modified from M. Pugh

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

2834

3rd Quarter, 2010 Risk Events

Q2 2010 System-wide

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

0.0

0.2

0.4

0.6

0.8

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1.2

1.4

1.6

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Oct

Nov Dec Jan

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Jul

Aug Se

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Feb

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May

Jun

Jul

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Feb

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FY2005 FY2006 FY2007 FY2008 FY2009 FY2010

Even

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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

…and whenever possible

Put a face on the data

Jim Reinertsen, MD

51 Used with Permission IHI 2012

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

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

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

Question & Key-Point #1

So why is it important to engage

patients in designing safer health care systems?

The short answer

An engaged patient =

An key ally to make your system safer

Question & Key-Point #2

What are the key design principles of a

patient-centered system?

What Patients Really Want

Don’t hurt me

Help me

Be Nice to Me

59

Don Berwick, MD

Question & Key-Point #3

How do we start to design a different

system?

Making a Change

Thank You! Kedar S. Mate Vice President Institute for Healthcare Improvement kmate@ihi.org

mailto:kmate@ihi.org�

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!