mcdonald san fran hen wave 2 - registration123.com · • data tracking and analysis • education...
TRANSCRIPT
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© 2008 The Board of Trustees of the University of Illinois
Creating and sustaining a culture of improvement:importance of patient and family engagement
Timothy McDonaldVice President for Quality and Safety
University of Illinois Hospital and Health Sciences System
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How ? has always felt about lawyers
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The Problem
Institute of Medicine: 1999 report that shook the medical world
Making Matters Worse
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Safety Culture and the response to a hospital associated condition
• LH 46 y.o. patient undergoes C‐section– Begins routinely– Complications with bleeding ensue– Case lasts 2 hours– Discharged home – Returns to ED 6 months later with abdominal pain– Taken to OR for exploratory laparotomy– Sponge found upon exploration– Surgeon suggests to team that it would be inappropriate to tell patient of finding of sponge
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What next?
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What about open, honest and effective communication?
• Barriers • Benefits
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Taking a “Principled Approach”
• Benefits– Maintain trust– Learn from mistakes– Improve patient safety– Employee morale– Psychological well‐being– Accountability– Money– Less litigation
• Barriers– Culture– No institutional support– Loss of job– Reputation– “Shame and blame”– Loss of control– Loss of license– Fear of lawyers, litigation– Non‐standard process– Money
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2005 UIC Board approves“communication‐ resolution” program
• Comprehensive• Integration of safety, risk, quality and credentials
• Linkage to claims and legal – deal with the fears• Longitudinal patient safety education plan
– UGME– GME– CME
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Need a process for execution
• Reporting• Investigation• Initial communication with patient/family• Identification of preventive measures• Resolution• Follow‐up and ongoing data collection• Education of event/improvements
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A Comprehensive Response to Patient Incidents: The Seven Pillars. McDonald et al Quality and Safety in Health Care, Jan 2010
• Reporting• Investigation• Communication• Apology with remediation• Process and performance improvement• Data tracking and analysis• Education – of the entire process
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Driven by the Power of:Patient and Family Engagement
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The Seven Pillars:A Patient and Family‐Centered Comprehensive Approach to the
Prevention and Response to Patient Safety EventsLD.04.04.05
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
RI.01.02.01
Process and Performance Improvement
Data Base
PatientCommunicationConsult Service
24/7Immediately
AvailableRI.01.02.01
Yes
Yes
No
No
“Near misses”
Activation of Crisis Management Team
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October 7, 2011
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Another communicating openly and resolving early
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October 7, 2011
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Process improvement: Significant change in national guidelines
• July 1, 2012 ASA• Specifically, in section 3.2.4 of the Standards for Basic Anesthetic Monitoring, the ASA states, "...During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.
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Back to the case investigation
• What do you want to know?
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Designing process improvement strategies
• Must understand the problem in order to design solutions
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Choosing your AIM:“No Thing Left Behind”
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Designing process improvement strategies
• Must understand the problem in order to design solutions– Changes– Measurement– Feedback – Rapid cycle
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Patient presents with a retained instruments: a ‘never’ event
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Scope of the Problem
• 1 in 1000 vs 1 in 5000 surgical cases• Potentially catastrophic• Res Ipsa Loquitur: “the thing speaks for itself”• Media Nightmare• JC sentinel, NQF and CMS “never event”
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A standard process for intraop instrument/sponge management
Surgery
Count beforefinal closure
CorrectCount?
IntraopX-ray
CountBeforeIncision
NO! ToPACU
Yes
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Back to RCAs: common causes associated with the “standard process” for managing intraop
instruments/sponges
• Relies entirely on human counting processes– The human factor – normalized deviance in counting process
• Lack of consistency in count vs. no need to count• Inability to count: emergencies• Count was correct or not done in most claims related to
retained foreign objects• Some procedural objects not routinely counted (OR towels etc)• Relies on human factor for detection on x-ray• Relies on effective communication
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A standard process for intraop instrument/sponge management
Surgery
Count beforefinal closure
CorrectCount?
IntraopX-ray
CountBeforeIncision
NO!To
PACU
Yes
Potential PointsOf Failure
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“Evidenced-based” medicine and retained objects
January 16, 2003
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Risk factors for retained objects
• Emergency open cavity surgery• Unexpected change in surgical procedure• BMI > 35• No count of sponges or instruments• “Case-controlled analysis of medical
malpractice claims may identify and quantify risk factors…”
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UIC data for additional risks or common causes from UIC RCAs
• Extending beyond change of shift• Greater than 6 hours in duration• Multiple (>1) surgical services involved• When indication for x-ray was unclear
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Radiologist must know about “other indications” via order for x-ray
• Must communicate results to team• Team must take action if positive for potential
retained object.
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Identifying areas for improvement
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Implementing a modified process
Surgery
Count beforefinal closure
CorrectCount?
IntraopX-ray
CountBeforeIncision
No!
Yes
OtherIndication?
NoYes!To
PACU or ICUCommunication
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Steps needed to create a highly reliable process
• Standardized process for “counting” before during and after procedures
• Assessment of “high risk status”• Ordering x‐ray for incorrect count or other• Listing x‐ray indication as “potential retained object”• Obtaining x‐ray in a timely fashion• Communicating result as a “critical result”• Appropriate following up
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Areas of “culture” pushback
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Steps needed to create a highly reliable process
• Standardized process for “counting” before during and after procedures
• Assessment of “high risk status”• Ordering x‐ray for incorrect count or other• Listing x‐ray indication as “potential retained object”• Obtaining x‐ray in a timely fashion• Communicating result as a “critical result”• Appropriate following up
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Steps needed to create a highly reliable process
• Standardized process for “counting” before during and after procedures: nursing, surgeons
• Assessment of “high risk status”: surgeons• Ordering x‐ray for incorrect count or other: surgeons, nursing• Listing x‐ray indication as “potential retained object”: nursing,
surgeons• Obtaining x‐ray in a timely fashion: radiology, nursing, surgeons• Communicating result as a “critical result”: radiology, nursing
surgeons• Appropriate following up
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How to overcome barriers
• Engage all stakeholders• Brainstorm ideas• Create the will to change• Plan small steps of execution• Celebrate wins• Engage patients and families in the process
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• There is a way to get our bearings. When you're in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?‐Don Berwick, MD May, 2012
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Resources for Patient and Family Engagement
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Identify key metrics for measurement
• Options?
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Identify key metrics for measurement
• Options?• Audit high risk patients• X‐ray compliance• PDSA with feedback• Continuous engagement of stakeholders
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Data
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Benefits of the project?
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Lessons learned in past 50 months
• 14 objects identified in “correct count” cases• 2 neck case• 1 OB case• 1 ortho case• 1 chest• 9 abdominal cavity• No claims since implementation• One health system – 0 retained objects in last 530
days
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A “near-miss” in OB: the reason we do this!
• 28 year old primigravid• Worrisome FHR; scalp electrode placed• 2 hours later emergent c-section• Emergency abdominal surgery indication for x-ray• Intraop x-ray taken after closure of abdomen• Patient taken to PACU
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OB x-ray after surgery
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OB x-ray after surgery
Scalp electrode remnant
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Gratified Patient: Improved Process