Temple University HospitalHouse Staff Orientation
High Value Care
Susan L. Freeman, MD, MS
Chief Medical Officer
Temple University Health System
June/July, 2013
PART ONEHigh Value Care
What is it?
The Triple Aim
Population
Health
Per Capita Cost
Patient Experience
Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)
Value PropositionHigh value health care =
high quality outcomes / low costHigh value can only occur if: • The culture supports communication,
collaboration and consistently safe care• Frontline employees and physicians (including
house staff) are engaged at every level• The entities of the health system are aligned
from Board to bedside
Quality Construct
Electronic Communication and Health Information
High Value Care, Every Patient, Every Day
CultureExecution
And Diffusion
Engineering
AndDesign
Infrastructure: Integrated Care Across The Continuum
TUHS Value Construct
Adopted from the Mayo Clinic Value Construct Model, 2012
High Value Care
Are we consistently delivering it?
Wrapping Your Head Around the Problem of Medical Errors
• To Err is Human – the landmark report of the IOM in 1999 – up to 98,000 people die each year in the U.S. from medical errors.
The Numbers are Staggering
• Every day and a half a fully loaded 747 would have to fall from the sky before the airline passenger loss of life would surpass that of hospitals
Adverse Events at TUH
•Wrong site surgery•Retained sponge•Medication errors•Falls• Infections•Death
SERIOUSLY?
HealthcareQUALITY
begins with PATIENT SAFETY
Kenneth Kaiser, MD, MPHNational Quality Forum
• Freedom from injury• Consistent care 24 x 7 x 365• Seamless transitions/handoffs• Informed, satisfied patients• Transparency in care and
data• Open, honest, non- punitive
reporting• A culture obsessed with
safety
Defining Quality
•No needless deaths•No needless pain or suffering•No unwanted waits•No helplessness•No waste
For Anyone….
Institute for Healthcare Improvement
The Six Dimensions of Quality
•Patient Safety•Patient Centeredness•Timeliness•Effectiveness•Efficiency•Equity
From the IOM: Crossing the Quality Chasm (2001)
Why So Many Errors?
•Why are hospitals unsafe?•Why are errors made?•Can they be prevented?
Humans Make ErrorsYou are sitting on the unit entering orders after rounds
There are a series of orders for different patients
Midway through, your cell phone goes off. You take the call.
You turn back to the ordering tasks and pull up Mr. Jones. You order 100mg of methadone orally. The medication is administered to Mr. Jones.
Two hours later you get a call from the nurse, that Mr. Smith wants to know where his methadone is.
You realize at that point that you ordered methadone on the wrong patient.
Distraction
Human Error
Human Factors
• Human information processing is influenced by multiple factors:– Attention – may be limited in duration or focus– Memory constraints – working memory is limited– Automaticity – consistent, over-learned responses
may become automatic, and completed without conscious thought
– Situation awareness – a person’s perception of elements in the environment may affect their processing of information
(Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science 1974; 185:1124-31)
Human Factors and Bias
• Pattern matching instead of careful reasoning• What has worked before is used when there is uncertainty • Availability heuristic – giving undue weight to facts that come
readily to mind, and ignoring that which is not immediately present
• Confirmation bias – once a decision is reached, there is a tendency to seek evidence to support it
• Selectivity – focus of attention on what is logically important vs. what is psychologically salient
• Frequency gambling – betting on the condition that occurs most frequently
Human Error
•An unsafe act is “an error or a violation committed in the presence of a potential hazard”
•Two categories: errors and violations
(James Reason, Human Error, 1990)
Errors and Violations
Errors
An action does not go as intended
An action goes as intended,
but it’s the wrongaction
MistakeLapseSlip
Violations
A deliberate deviation
from an operatingprocedure, standard or rule
(James Reason, Human Error, 1990)
Human Factors
Humans will always make mistakes regardless of training, experience and determination
Human infallibility is impossibleThose who build systems that depend on
the absence of human error will fail
John Nance. Why Hospitals Should Fly. 2008, page 45
Systems are Designed to Prevent Errors from Reaching
the Patient• What is a system?
– A series of actions that, when followed, provides for the delivery of safe care to every patient, every time
• Codified in policies, procedures, standard order sets, check lists
– A series of redundancies that provides multiple check points
• An order is written, checked by the pharmacy, checked by the nurse, reconciled with the medication list
Redundant Processes (James Reason)
Each layer is a defense against potential error impacting the outcome
Failure at Every Level
Circumstances in which planned actions fail to achieve the desired outcomes
Culture of Safety
• Shared perceptions and actions around what is good, right, important, valued, supported, rewarded and expected
• Culture is shaped by the alignment of people and systems; attitudes; knowledge; practices; leadership; trust; accountabilities; and a commitment to safety
• Culture is linked to outcomes – strong culture decreases medication errors, hospital acquired UTI’s, nurse turnover and absenteeism, nurse satisfaction, malpractice claims, back injuries, patient satisfaction, needle sticks
Halligan, M. and A. Zecevic. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. Qual Saf Health Care/. 2011. doi:101136/bmjqs.2010.040964.
High Value Care
Evidence-Based care delivered efficiently, at the highest standard in the absence of error or adverse event by a team that has created a
culture to support superior outcomes.
High Value Care
How is this accomplished?
KNOW THE SYSTEM
High Value Care
Communication
Care Delivery
Hospital Acquired Conditions
Risk Management
Breakout Sessions• 319A Risk Management• 319B Care Delivery• 319C Quality and Hospital Acquired Conditions• 319D Communication
A-G H-L M-P R-Z
8:10 - 8:30 Auditorium
8:35 - 9:05 319A 319D 319C 319B
9:10 - 9:40 319B 319A 319D 319C
9:45 - 10:15 319C 319B 319A 319D
10:20 - 10:45 319D 319C 319B 319A
10:50 - 11:00 Auditorium
PART TWOHigh Value Care
THE TOP TEN
House Staff Orientation:TOP TEN
1. Patient safety and quality of care are the top priorities
2. Humans make errors
3. Systems are designed to prevent those errors from reaching the patient (processes, policies, best practices)
4. Systems only work in the presence of individual accountability
5. The majority of errors occur because of lack of communication
6. Teamwork is vital – it takes a village - use the resources and expertise available (Nurses, CM, RM, PT, Pharmacy, etc.)
7. Basic medication safety rules, consent, documentation
8. Universal protocol
9. Infection prevention
10. The patient and the patient’s well being must be at the center of everything you do – it’s about the patient experience and the clinical outcomes
Adopted from: Tsilimingras, et.al. The Challenge of Developing a Patient Safety Curriculum for Medical School. Med Sci Edu 2012;22(2):65-72.
Keep the Patient at the Center of Everything You Do
PATIENT
AttendingsHouse StaffExtenders
Nursing
Case ManagersSocial Workers
TransportSupply Chain
EVSFacility
Performance Improvement Patient Safety
Facilitators
PharmacistsTherapists
NutritionistsInfection Preventionists
The National Agenda: The Triple Aim
Population Health
Per Capita Cost
Patient Experience
Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)
Get Involved in Quality and Safety
Medical Staff Committees:
Patient SafetyPerformance ImprovementPeer Review
House StaffQuality Council
& Program LevelPI/QI
Accountable CareUnit:
HuddlesMultidisc Rounds
Mini RCA’sThroughput
Patient SatisfactionCore MeasuresInfection Control
RESIDENTINTEGRATION
INTOQUALITY
PATIENT SAFETY
You Are The Key to Preventing Medical Errors
ANDProviding Safe, Quality
Patient Care