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Measuring Progress in Patient Safety
Peter Pronovost, MD, PhD, FCCM Johns Hopkins University BNVBBVB
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Exercise Please answer each question with a score of 1 to 5
Exercise Please answer each question with a score of 1 to is below average, 3 is average and 5 is above average How smart am I How hard do I work How kind am I How tall am I How good is the quality of care we provide
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Improving Sepsis Care (n= 19 ICUs)
36% Reduction (NS) 69% Reduction (p < 0.001)
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Improving Sepsis Care (n= 19 ICUs)
36% Reduction (NS) 69% Reduction (p < 0.001)
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x Central Mandate Scientifically Sound Feasible Local Wisdom
Safety efforts are where the x is. We need to migrate to be more scientifically sound and tap into local wisdom
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Context Have we created a culture of safety?
Conceptual model for measuring safety Process Outcome Structure How often do we harm? Have we reduced the likelihood of harm? How often do we do what we are supposed to? IT Context Have we created a culture of safety? Adapted from Donebedian
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Keystone ICU Safety Dashboard
2004 2006 How often did we harm (BSI) 2.8/1000 How often do we do what we should 66% 95% How often did we learn from mistakes 100s % Needs improvement in Safety climate Teamwork climate 84% 82% 43% 42% Pronovost JAMA 2007
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Pronovost BMJ 2008
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Comprehensive Unit-based Safety Program (CUSP)
Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter and implement teamwork tools The intervention we used to improve culture and learn from mistakes is the comprehensive unit based safety program. Your role in the csicu was as the executive who adopted that unit. You can tell some of the defects you surfaced. Pronovost J, Patient Safety, 2005
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What can be measured as a valid rate?
Rate requires Numerator- event Denominator- those at risk for event Surveillance for events and those at risk Minimal and Known Error Random error Systematic error
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Sources Variation in Safety measures
True variation in Safety V data quality/definition/methods of collection V case mix V historical rates Chance
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Measuring Preventable Harm
Measure rate or counts directly High sensitivity low specificity Estimate observed/expected (O/E) Low sensitivity and specificity Link process and outcome High specificity and moderate sensitivity
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Process Measures Validity of the construct
Validity of how we measure construct
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It is Ok to have non-rate measures
Self reported measures are generally not valid as rates A common mistake is interpreting a non-rate measure as a valid rate
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Learning from Mistakes
What happened? Why did it happen (system lenses) What could you do to reduce risk How to you know risk was reduced Create policy/process/procedure Ensure staff know policy Evaluate if policy is used correctly Pronovost 2005 JCJQI
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Pronovost Health affairs in press
Identify Hazards ( 3. Mitigate Risks 2. Analyze & Prioritize Hazards 4. Evaluate Effectiveness of Risk Reduction Patient Safety Learning Communities Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control. Pronovost Health affairs in press
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GYN/OB JHOC Medicine Neurosciences Oncology Ophthalmology
FAC: Fetal Assessment Center/OB Ultrasound GSS - Shared Specialty Suite Asthma & Allergy - Allergy & Clinical Immunology BRU GSS - Medical Oncology GSS - Wilmer 110 GSS - GYN/OB 420 JHOPC - Express Testing Asthma & Allergy - Pulmonary EMU IPOP Clinic - HIPOP Location GSS - Wilmer Laser Center GSS - GYN/REI JHOPC - OR Asthma & Allergy - Rheumatology JHOPC Neurosciences IPOP Clinic - IPOP Location WECP & ER HAL-2 JHOPC - PACU Blalock 4 - Endoscopy MEY 8 (12) Weinberg OPD - 1st Floor Wilmer OR JHOPC GYN/OB WM - Shared Specialty Suite Blalock 5 Echo Lab (2) MEY 9 (5) Weinberg OPD - 2nd Floor Wilmer PACU MCE Cardiac CT NCCU7 WGA 5 (5) Wilmer White Marsh NEL-2 Nursery CCP-5 (5) WGB 5 Wilmer: Other - E Balt Divisions NEL-2 Obstetric OR CCU-5 (7) WGC-5 (3) Wilmer: Other - Satellites NEL-2 PACU CVC WGD 5 Nelson Harvey 2 CVIL- CardioVascular Interventional Lab OSL-2 Dialysis Unit OSL-3 Nursery GSS - Internal Medicine OSL-3 HAL-5 (5) WGB-4 HAL-8 (7) Hospitalist Unit (5) JHOPC - Exec Health & Travel Clinic JHOPC - Medicine Clinics
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CAST Each contributing factor rate Each Intervention rate
importance of the problem and contributing factors in causing the accident importance of the problem and contributing factors in future accidents Each Intervention rate How well the intervention solves the problem or mitigates the contributing factors for the accident Rates the team belief that the intervention will be implemented and executed as intended
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“The way we do things around here”
What is Culture*?: “The way we do things around here” here 1 attitude = opinion…everyone’s attitude = culture *aka Climate
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Executive Perceptions vs. Frontline Perceptions:
Executives overestimate: Teamwork Climate 4X Safety Climate 2.5X Executive Confidence vs. Executive Accuracy: -Often wrong but rarely in doubt… -Currently no incoming data-streams -Halo Effects -Frontline data fills the gap
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* Statistically Significant
6 of 7 domains have shown statistically significant improvements since 2006. * Statistically Significant 28
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71 Teamwork Climate 2008 67 Teamwork Climate 2007 64 Teamwork Climate 2006 62 Teamwork Climate 2005 This illustrates the teamwork domain scores (safety on the next slide) for each of the 150+ units across the organizaiton. It is important to notice the variability…even with an organizational domain score of 71. It also shows how many units are below the danger zone threshhold (60%). 29
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60 Safety Climate 2006 65 Safety Climate 2007 70 Safety Climate 2008 59 Safety Climate 2005 30
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#4. “I Would Feel Safe Being Treated Here As A Patient.”
% of respondents within an ICU that agree
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#3. “Nurse Input Is Well Received In This ICU.”
% of respondents within an ICU that agree
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#26. “In This ICU, It Is Difficult To Speak Up If I Perceive A Problem With Patient Care.”
% of respondents within an ICU that agree
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#32. “Disagreements In This ICU Are Resolved Appropriately (i. e
#32. “Disagreements In This ICU Are Resolved Appropriately (i.e. not who is right, but what is best for the patient).” % of respondents within an ICU that agree
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Questions for Reflection
How do you know you are safer? How will you become more efficient in your measurement efforts? How will you better tap into local wisdom?
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Focus and Execute
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