james m. anderson center for health systems excellence leveraging the recent advances in improvement...

James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence

Leveraging the Recent Advances in

Improvement Science to Eradicate AKI

James M. Anderson Center for Health Systems Excellence

Omni Netherlands, Downtown Cincinnati

September 28, 2012

Uma Kotagal, MBBS, MScSVP, Quality, Safety and TransformationExecutive Director, James M. Anderson Center for Health Systems Excellence


523 Bed Medical CenterAdmissions/Year – 32,981900,000 outpatient visits$143 million externally funded research$ 1.3 billion dollar endowment

12,000+ employeesSurgical Procedures – 31,000 cases (20% Inpt)17% average annual growth over past decadeNational /International partnerships and affiliates


Core Business strategy at Cincinnati Children’s

• Research-Conduct research to generate new knowledge that changes the paradigm-

• Quality Improvement-Reliably apply new and past knowledge ( evidence) to transform outcomes


Knowledge for Improvement

Profound Knowledge

Subject Matter Knowledge

Improvement

Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement.


5

Appreciation of a system

Understanding

Variation

Theory of Knowledge Psycholog

y

Value

s

Deming’s System of Profound Knowledge


Appreciation of a System

Theory of Knowledge Psychology

UnderstandingVariation

Profound Knowledge: Theory of Knowledge


Being the Best at Getting Better• Focus on the outcomes• Patients and families as Partners• Integration and alignment

• Theory of knowledge, Building a learning system• Respecting the science

• Capacity and capability• Transparency and Trust

• Learning from other industries• Prediction and management

• Executing with a sense of urgency

Source: Chart Review of Random Sample (20 Charts)Chart Updated APR 16 2012 by Tracey Bracke, AC

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.


Managing by Prediction:Patient Safety


The Elements of Prediction• MEASURABILITY OF OUTCOME – Will it be clear

if the outcome happens or not?

• VANTAGE – Is the person making the prediction in a position to observe the predictions and context?

• IMMINENCE – Is the event to occur in the next week or years away? Is the prediction before the event?

• CONTEXT – Is the context clear to the person predicting?

• PRE-INCIDENT INDICATORS (PINs) – Are there detectable pre-incident indicators that will reliably occur before the outcome?

• EXPERIENCE – Does the predictor have experience with the specific topic involved?

• COMPARABALE EVENTS – Is it possible to study outcomes similar to the one being predicted?

• OBJECTIVITY – Is the person who is predicting objective enough to believe either outcome is possible?

• INVESTMENT – To what degree is the person predicting invested in the outcome?

• REPLICABILITY – Is it practical to test the exact issue being predicted in another situation?

• KNOWLEDGE – Does the person making the prediction have accurate knowledge of the topic? Is the knowledge relevant and accurate?

The Gift of Fear and Other Survival Signals that Protect Us from Violence: Gavin De Becker, Dell Publishing, 1997


Sensitivity to Operations Beyond reducing harm:Moving toward Eliminating Harm


Eliminating Events of Harm

Active Errors

by individuals result in initiating action(s)

EVENTS ofHARM

Multiple Barriers - technology, processes, and people - designed to stop active errors (our “defense in depth”)

Latent Weaknesses

in barriers

Adapted from James Reason, Managing the Risks of Organizational Accidents, 1997

PREVENT

The ErrorsDETECT & CORRECT

The System Weaknesses


Serious Safety EventEvent that reaches the patient and results in death,life-threatening consequences, or serious physical or psychological injuryCause Analysis Level: RCA

Precursor Safety EventEvent that reaches the patient and results inminimal to no harmCause Analysis Level: ACA or RCA

Near MissEvent that almost happened - theerror was caught by one last detectionbarrierCause Analysis Level: Trend, ACA

PrecursorSafetyEvents

SeriousSafetyEvents

Near Miss

SafetyEventClassificationSEC

SM

Variation from standard of carethat results in:

© 2006, HPI, LLC


Serious Safety Event Reduction Key Driver Analysis

Outcomes Key Drivers

Intervention/Change Concepts

Reduce Serious Safety

Events0.2/10,000 Adjusted

Patient Days by 6/30/10

Lessons Learned Program

Improved Safety Governance

Error Prevention System

Cause Analysis Program

Specific Tactical Interventions

•Safety Stories•Transparency•Reinforce Culture Change•Spread story beyond organization•Patient Safety blog •Share all Action plans

•Patient Safety Oversight Group•Cabinet Leadership •CSI annual goals•CCHMC Board focus

• Error Prevention Training •Adoption of Behaviors•Safety Coaches•Procedural Safety•Simulation training•Leadership Behaviors•Situation Awareness •Family Engagement

•RCA- continuous improvement•Transition to Action•Common Cause data to drive Strategy•Effective Action Plans

• 100% UP in OR•UP for all procedures•IV infiltrate reduction•Monitor reliability pilot•Announce and Count

James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems ExcellenceOutcome Key Drivers

Interventions

Effective Error

PreventionSystem

Error Prevention training

Safety Coach program

Procedural Safety

Simulation Training

Leadership Behaviors

•Leadership training*•Staff training*•Community MD training•New staff training (achieve 95%)

•Initial pilot units*•Spread to all units*•Monthly Safety Coach support•Focused Safety Coach enhancements •Unit Level Plans

•UP in OR*•UP throughout system

•Initial focus in ED*•Expand capability of Sim Center•Pilot expansion*•In-situ across IP

•Increased event reporting•Use of Lessons Learned in microsystem•Support safety Coaches•Unit level Safety outcomes

Situation Awareness •Patient SA across IP

•Microsystem SA spread•Organization SA pilot

Family Engagement •Family Engagement Bundle spread

•MRT Activation: revise


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

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FY2005 FY2006 FY2007 FY2008 FY2009 FY2010

Ev

en

ts p

er

10

,00

0 A

dj.

Pa

tie

nt

Da

ys

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 28Feb10 by Bob Carpenter, Legal Dept. Source: Legal Dept.

Desired Direction of Change

Error Prevention Training Simulation Training Expands

Safety Coach Program

Patient SafetyTracker

Tenants ofSurgical SafetyaSSERT begins

SurgicalSafety Begins


Total Number of Times each Safety Element Failed(FY07 – Jan. 2010)

Failure Type Count% of times this failure

occurred

Coordination of Care 13 45%

Situation Awareness 13 45%

Reliable Escalation 7 24%

Family Engagement 6 21%

None of the 4 above 11 38%

SSE COMMON CAUSESRoot Cause Analyses


Identifying, Mitigating, and Escalating Patients at Risk

Situation Awareness


Journey to High Reliability: HROs

• Preoccupation with Failure

• Reluctance to Simplify Interpretations

• Commitment to Resilience

• Deference to Expertise

• Sensitivity to Operations– Find loopholes in system’s defenses, barriers and safeguards on the frontline.

Maintain Situation Awareness

Background


Situation Awareness?


• Simple Definition:– Knowing what is going on around you.– Having a notion of what is important.– Anticipation of possible future consequences

of the current situation.

Dr. Mica Endsley (1995)

What is Situation Awareness (SA)?


So how do we improve SA at CCHMC?

• Identify patients at risk.• Mitigate risk with team on unit.• Escalate risk that is not fully addressed.

Identifying, Mitigating, and Escalating Patients at Risk


Situation Awareness

3. Anticipate“Projection”

Decide

2. Recognize &Understand

“Comprehension”

Act

1. Gather Information“Perception”

↑HR, ↑diarrhea,parent concern

Recognize dehydration

Progress toshock if

untreated

Situation Awareness Process


Situation Awareness

3. Anticipate“Projection”

Decide

1. Gather Information“Perception”

2. Recognize &Understand

“Comprehension”

Act

Miss ImportantInformation

Systematically Identify High Risk Patients

Miss Context asInfo Not Integrated

Communicate EachRisk to Watchstander

WrongPrediction

Predict/Mitigate/Escalate as Team

WrongDecision!

RightDecision!

Hypotheses to Improve SA


• PEWS >5• Family raises a concern• Therapy unusual for this team• “Watcher patient”• Communication amongst team

not adequate

Prediction:Patients at Immediate

Risk


Bedside nurse

InternWatchstander

Senior Resident

WatchstanderPCF/Manager

Safety Team(MPS and SOD)

at 800, 1600 & 100

Family concerns

High risk therapies

Watcher

PEWS>5

Communication concern

MRT

Reliable escalation of riskRapid assessment and communication with primary team

Attending

Bedside Team

Microsystem Team

OrganizationTeam

Situation Awareness Model


Situation Awareness Algorithm. Illustrates the tool used during education and early phases and the specific questions and communication pathways.


Robust Planning Tool

• Elements of “Robust Plan”– Identifying the problem or

concern– Making responsible parties

aware– Forming a plan– Predicting an expected

outcome within a fixed amount of time

– Deciding on an escalation and contingency plan if outcome is not met in time

Identify the Patient, Make a Specific Plan


Process Measure Run Charts illustrating the percentage of units by week that escalate risk on ≥90% of shifts .


Process Measure Run Charts illustrating the percentage of units by week that identify ≥90% of patients at risk each shift .


Not Fully Addressed SA Bundle Concerns

0

20

40

60

80

100

120

03/2

7/10

04/0

3/10

04/1

0/10

04/1

7/10

04/2

4/10

05/0

1/10

05/0

8/10

05/1

5/10

05/2

2/10

05/2

9/10

06/0

5/10

06/1

2/10

06/1

9/10

06/2

6/10

07/0

3/10

07/1

0/10

07/1

7/10

07/2

4/10

07/3

1/10

08/0

7/10

08/1

4/10

08/2

1/10

08/2

8/10

09/0

4/10

09/1

1/10

09/1

8/10

Week Ending Date

Es

cala

tio

ns

Escalations Average Weekly Escalations Control Limits

5/2/10 Change in data collection process


0

1

2

3

4

5

6

7

8

9

10

Jan-

10

n=

704

0

Fe

b-1

0 n

=6

671

Mar

-10

n=

70

67

Ap

r-1

0 n

=6

599

May

-10

n=

66

89

Jun-

10

n=

636

1

Jul-1

0 n

=6

356

Au

g-1

0 n

=6

850

Se

p-1

0 n

=6

742

Oct

-10

n=

698

3

No

v-1

0 n

=6

443

De

c-1

0 n

=6

075

Jan-

11

n=

654

4

Fe

b 1

1

n=6

793

Mar

11

n=

73

56

Ap

r 1

1 n

=6

864

May

11

n=

699

8

Jun

11

n=

652

8

Jul 1

1

n=6

501

Au

g 1

1 n

=6

794

Se

p 1

1 n

=6

721

Oct

11

n=

727

5

No

v 1

1 n

=6

767

De

c 1

1 n

=6

662

Jan

12

n=

740

0

Fe

b 1

2

n=7

401

Mar

12

n=

79

54

Ap

r 1

2 n

=7

374

May

12

n=

735

4

Jun

12

n=

731

4

Jul 1

2

n=7

024

Au

g 1

2 n

=6

192

Ra

te p

er

10

,00

0 N

on

-IC

U B

as

e In

pat

ien

t D

ays

Rate of UNSAFE TransfersUNrecognized Situation Awareness Failure events

Per 10,000 Non-ICU Base Inpatient Days

Rate Median Goal

Updated through August 31 2012 by K. SimonJames M. Anderson Center for Health Systme s Excellence

Hospital Wide System for Safety

Floor Huddles ICU HuddlesED HuddlePeriOp Huddle

Institutional Wide Bed Huddle – Capacity Management

Individual Room / Floor / System Predictions – Capacity and Safety

Institutional Wide Safety Call

System Prediction – Mitigation Strategy

Pharmacy Security

Pt. Transport Housekeeping

3 Times - Every Day

Leadership Outcomes and Prediction MeetingCEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director

Facilities Pt Experience

Mitigate risk on unit

Escalate risk that is not fully

addressed

Predict course of most at risk

patients

Identifypatients at risk

Learn from each event

Systematically & Reliably


BEING THE BEST AT GETTING BETTER


To learn more about our work visit:

www.cincinnatichildrens.org/andersoncenter

http://www.cincinnatichildrens.org/andersoncenter

james m. anderson center for health systems excellence leveraging the recent advances in improvement...

Documents

anderson center

theory of knowledge

new knowledge

aki james

variation profound knowledge

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past knowledge evidence

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