1. Does Patient Centered Care Enhance Quality and Safety?
Human Factors, System Issues
System Solutions
© 2010 Planetree, Inc.

2. Objectives of Presentation
Provide concepts of how the Planetree philosophy can support system changes to enhance a culture of quality and safety
Understand safety implications related to human performance
Discuss how a patient centered approach can enhance patient and family involvement and patient safety
Present outcome measures to demonstrate that a Planetree patient centered environment not only supports a culture of quality but also improves patient and employee satisfaction, and the bottom line

3. What Started Safety Awareness?
To Err is Human – IOM
Study showed adverse events happen in 2.9 to 3.7 percent of hospitalizations
Extrapolated over 33.6 million admissions per year = 44,000-98,000 deaths due to medical error per year
Poor communication and a lack of teamwork was identified as a root cause of most safety problems

4. 11 Years After the IOM “To Err is Human…” Report: What Has Changed?4

5. Safety Hazard Probabilities (events per million opportunities)
Acquiring HIV from 1 unit of transfused blood 0.7
All heads on 20 coin tosses
Death of commercial airline passenger
Death: general anesthesia
Death: motor vehicle
Preventable hospital deaths
Orlikoff,J. Orlikoff and Associates, Inc. Chicago, IL. Jan. 2010

6. Cost of Medical Errors in U.S.
$17 billion costs associated with preventable errors (IOM, 1999)
In the past, third party payers have paid regardless of outcome – changed as of 10/2008!
Central Line associated bloodstream infections resulted in an average loss per case of $26,839 in 2006
Shannon et al, “Economics of Central-Line Associated Bloodstream Infections” American Journal of Medical Quality Supplement to Vol.21, No.6 Nov/Dec 2006
Run thru these next few slides to emphasize what’s happening… do they know their numbers for these events?

7. National Health Expenditures per Capita, 1980– 2007
Data: OECD Health Data 2009 (June 2009).

8. What are the “Other” Cost of Errors?
Errors may be career ending events
Caregivers don’t intend to harm
Trust issues and safety concerns on part of the consumers and payers
Frustrated consumers
Silence often surrounds issues which may result in malpractice claims
Sensational negative media coverage

9. News Headlines
SEPT. 2006: “HOSPITAL CHANGES PROCEDURES AFTER PREEMIE DEATHS”:
Three preemies die after they receive adult doses of heparin at a hospital in Indianapolis
NOV. 2007: “HOSPITAL REPEATS WRONG-SIDED BRAIN SURGERY”:
“For the third time this year, doctors at Rhode Island Hospital have operated on the wrong side of a patient’s head – an action that has brought about censure from the state Department of Health and a $50,000 fine.”
SEPT. 2010: “BABY DIES AT SEATTLE CHILDREN’S HOSPITAL AFTER OVERDOSE”:
…a hospital nurse gave her 10 times the proper dose of a medication, calcium chloride. Five days later, on Sept. 19, after suffering a brain hemorrhage, the baby died.

10. State of Colorado
Local TV news coverage on prevention of central line infections
Discussed use of central line bundle
Shortly thereafter, legislators in the State received a “slew” of s from constituents demanding use of the central line bundle be made into law!

11. Put it in Perspective
25% of US patients state they have experienced a medical error - 50% of those resulting in serious harm
42% of health care workers (HCW) state they have been personally involved in a medical error
HCW’s state they fear becoming a patient
Seek the best MD – not the MD on call
Seek out high volume places for complicated surgeries
Seek out clinicians with at least 10 years experience (experienced but not burned out)
Avoid hospitalization in July – new interns, medical and nursing students (now proven by research)

12. What is Patient Safety Freedom from accidental injury through:
Systems and processes that decrease the likelihood of mistakes
and
Systems and processes that increase the likelihood of prompt identification and correction of errors and mistakes before they cause harm to a patient

13. What is High Quality Care?
IOM defines quality as:
“The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
High quality (evidence based) medicine allows for variation based on patient need, not on physician preferences (patient focused)

14. Evidence Based Care Bundles Hospital Infections are Preventable!
FACT - 80,000 CLABIs per year, cause about 28,000 deaths
In 103 ICUs in Michigan median CLABI rate per 1,000 catheter days declined from 2.7 to ZERO
HOW? - It’s simple
Hand washing;
Full Barrier precautions;
Chlorhexidine use;
Avoid using the femoral site;
Removing unneeded catheters.
Provonost, et al. New England Journal of Medicine, Dec 28, 2006.

15. IHI- 5 Million Lives Saved Campaign
Interventions targeted at harm:
Prevent Pressure Ulcers...
Reduce MDRO/MRSA Infections…
Prevent Harm from Medications...
Deliver Evidence-Based Care for CHF, AMI, Pneumonia…
Prevent ventilator pneumonia
Prevent central line infections
Detailed How-to Guides on each intervention are available at under the Materials tab. 15

17. “New” Reality of US Healthcare
Evidence Based Care – Core Measures
Medicare/insurance no longer pays for defined “never events” (10/08)
National versus Local Standards
Public reporting of quality data and safety events - transparency
AHRQ measures reported to the public
Patient Centered Care

18. What is Patient Centered Care?
Defined by the IOM:
“…care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.“
New 2011 TJC Standards

19. Opportunities for Improvement
Communication challenged
Fragmented health care system
Complex systems within hospitals
Lack of standardization
Hierarchies produce steep authority gradients
Need better teamwork and communication
Product of our success
Advanced technology, rapid changes
Necessary knowledge exceeds limits to human capacity
> 6000 meds, >4000 treatments to choose from
Professional craftsman model
No longer effective

20. Professional Craftsman Model “The Old Way”
With extensive training
Eminence based training – not always evidence based
Came “special privileges”
Full autonomy= full responsibility
Creates a steep authority gradient
Others have been there only to assist the MD in the past
No recognized group decision making
Results in the ‘Perfection Myth’

21. Safety Implications Related to the ‘Perfection Myth’
Safety depends on individuals - myth
Safety really depends on teamwork and communication
Error is due to carelessness – myth
More often a system or process error
We have responded in the past with peer review, “be safer next time”, more education, 5 rights
Punishment results in fewer errors - myth
System Improvements should be the focus

22. Dysfunctional Response to Error
Justification/rationalization
“Complications happen”
Blame the patients
Dishonesty with patients
Cover-up/Non-reporting
Fear loss of reputation
Healthcare workers look the other way when colleagues error

23. Who Is Watching Out For Patients?
46% of physicians failed to report at least one
serious medical error, even though 93% of them
said they should report ALL significant medical
errors they observe.
45% said they did not report impaired or
incompetent colleague physicians even though 96%
said they should
- ANNALS OF INTERNAL MEDICINE, DEC. 4, 2007
67% of physicians have not been involved in
collaborative efforts to improve quality
– COMMONWEALTH FUND NATIONAL SURVEY OF PHYSICIANS, 2007

24. A Different (Planetree) Approach
Caring for the Caregivers
Leadership support for safety
Non-punitive reporting systems
Set up systems and processes for safety
Redundancy and double checks
Medication administration vs. blood transfusion
Standardization of processes
Checklists, pre-printed orders
Find out about work-arounds
Multidisciplinary quality committees

25. Caring for the Caregivers
Teamwork and communication support
Enhanced communication models
Robust reporting systems with feedback
Errors recognized as system failures
Mutual Support – I have your back
Nurse Residency Programs
Plan for and educate about limitations of human performance

26. Plan for the ‘Human Factor’
Humans make mistakes
Fatigue, interruptions, distractions, etc
Overestimate abilities, underestimate limitations
Goal is to keep inevitable mistakes from becoming consequential
Reliable systems combined with effective communication is best practice

27. Human Limitations
Limited memory capacity–5 to 7 pieces of information in short term memory
Negative effects of stress –increased error rates, tunnel vision
Negative influence of fatigue
Limited ability to multitask
Variable judgments and perceptions

28. Human Error is Inevitable Because:
Inherent human limitations
Complex, unsafe systems
Safety is often assumed, not assured
We count on the expert individual
“It won’t happen to me” or “it doesn’t happen here” attitude

29. Build on human factor skills
Standardized (SBAR) communication
Telephone order read-backs
Starbucks figured it out
Create redundancies, double checks
Situational awareness
Time-outs, include the patient (patient centered)
Decrease interruptions
Debriefings after emergencies
Patient Centered focus
Bedside report including the patient/family
Hourly rounding
Heparin for patient, MD told patient, RN did not know patient going back to surgery….

30. A Different (Planetree) Approach
Patient centered approach
Knowledge about condition and choices
Access to medical records
Access to information – library/literature searches
Health literacy
Care partners
Another “ear to hear”
Patient and Family Advisory Council
Learn from their experiences

31. Planetree Patient Centered Care and Safety
“The patient is one of the most important allies in reducing medical errors.”
ISMP Medication Safety Alert Oct.2004
“Research indicates that when patients actively participate in their overall healthcare management, medical errors are reduced.”
ISMP Medication Safety Alert Nov. 2004
Patients who have a clear understanding of their instructions, including how to take their medicines and when to make follow-up appointments, are 30 percent less likely to be readmitted or visit the emergency department
February 3, 2009, Annals of Internal Medicine

32. Planetree Criteria Promote Quality and Safety
Planetree promotes a healing partnership between patients and caregivers.
It’s a model of care that is committed to enhancing healthcare from the patient perspective.
Empowers caregivers to do what is right for the patient.
360° data shows us that it is working!

33. Surgical Care Improvement Process Measures

34. Teamwork works! D-T-B times improved!

35. VVH Culture of Safety Survey
Survey done July 2010
Statistical improvements from 2008
Standardized AHRQ survey
Designed to measure 4 major areas
Overall perceptions of safety
Overall patient safety grade
Frequency of event reporting
Number of events reported

37. Valley View Healthgrades™ Award
Valley View Hospital is rated among the top 5% in patient satisfaction scores
The Planetree patient centered philosophy actively supports programs to meet patient and family needs

38. “What Is the Likelihood of Recommending This Hospital?”

39. VVH and Planetree Comparison39

42. Turnover Rate: All Nurses On Payroll

43. Growth in Equity

44. Lessons learned
Safety and quality is not created by counting and control measures
We have learned that stories, complex dialogue, and teamwork create safety
We thought competent, careful clinicians were sufficient to create safety
We have learned safety requires leadership, a supportive environment, a system focus, and solid teamwork
Quality and patient safety are supported in a Planetree patient centered environment and the Planetree philosophy promotes a ‘generative’ culture

45. How Different Organizational Cultures Handle Safety Information
Pathological
Culture
Bureaucratic
Generative
·       Don’t want to know
·       May not find out
·       Actively seek it
·       Messengers
(Whistle blowers) are shot
·       Messengers are listened to if they arrive
·       Messengers are trained and rewarded
·       Failure is punished or concealed
·       Failure leads to local repairs
·       Failures lead to far-reaching reforms
·       New ideas are actively discouraged
·       New ideas often present problems
·       New ideas are welcomed

46. Planetree Creates A Culture of Quality and Safety
An accountable culture
A culture of learning
A culture of partnership
A just culture
Mutual Trust
The system trusts that you will call out
You must trust that the system will listen