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Measuring Progress in Patient Safety Peter Pronovost, MD, PhD, FCCM Johns Hopkins University.

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Presentation on theme: "Measuring Progress in Patient Safety Peter Pronovost, MD, PhD, FCCM Johns Hopkins University."— Presentation transcript:

1 Measuring Progress in Patient Safety Peter Pronovost, MD, PhD, FCCM Johns Hopkins University

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3 Exercise Please answer each question with a score of 1 to 5. 1 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

4 Improving Sepsis Care (n= 19 ICUs) 69% Reduction (p < 0.001) 36% Reduction (NS)

5 Improving Sepsis Care (n= 19 ICUs) 69% Reduction (p < 0.001) 36% Reduction (NS)

6 Central Mandate Local Wisdom Scientifically Sound Feasible x

7 Structure Context Have we created a culture of safety? ProcessOutcome Have we reduced the likelihood of harm? How often do we do what we are supposed to? How often do we harm? Conceptual model for measuring safety IT Adapted from Donebedian

8 Keystone ICU Safety Dashboard How often did we harm (BSI)2.8/10000 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

9 Pronovost BMJ 2008

10 Comprehensive Unit-based Safety Program (CUSP) 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter and implement teamwork tools Pronovost J, Patient Safety, 2005

11 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

12 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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14 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

15 Process Measures Validity of the construct Validity of how we measure construct

16 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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19 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

20 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

21 GYN/OBJHOCMedicineNeurosciencesOncologyOphthalmology 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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23 CAST Each contributing factor 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

24 What is Culture*?: The way we do things around here *aka Climate 1 attitude = opinion …everyones attitude = culture

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27 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

28 ****** * Statistically Significant

29 64 Teamwork Climate Teamwork Climate Teamwork Climate Teamwork Climate 2005

30 60 Safety Climate Safety Climate Safety Climate Safety Climate 2005

31 % of respondents within an ICU that agree #4. I Would Feel Safe Being Treated Here As A Patient.

32 % of respondents within an ICU that agree #3. Nurse Input Is Well Received In This ICU.

33 % of respondents within an ICU that agree #26. In This ICU, It Is Difficult To Speak Up If I Perceive A Problem With Patient Care.

34 % of respondents within an ICU that agree #32. Disagreements In This ICU Are Resolved Appropriately (i.e. not who is right, but what is best for the patient).

35 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?

36 Focus and Execute

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