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© 2009 On the CUSP: STOP BSI The Science of Improving Patient Safety
© 2009 Immersion Call Overview Week 1: Project overview Week 2: Science of Improving Patient Safety Week 3: Eliminating CLABSI Week 4: The Comprehensive Unit-Based Safety Program (CUSP) Week 5: Building a Team Week 6: Physician Engagement
© 2009 Learning Objectives To recognize that every system is designed to achieve the results it gets To identify the basic principles of safe design that apply to both technical and team work To discuss how teams make wise decisions
© 2009 The Marvel of Modern Medicine
© 2009 Condition% of Recommended Care Received Low back pain68.5 Coronary artery disease68.0 Hypertension64.7 Depression57.7 Orthopedic conditions57.2 Colorectal cancer53.9 Asthma53.5 Benign prostatic hyperplasia53.0 Hyperlipidemia48.6 Diabetes mellitus45.4 Headaches45.2 Urinary tract infection40.7 Hip fracture22.8 Alcohol dependence10.5 RAND Study Confirms Continued Quality Gap 1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.
© 2009 The Problem is Large In U.S. Healthcare system – 7% of patients suffer a medication error 2 – On average, every patient admitted to an ICU suffers an adverse event 3,4 – 44,000- 98,000 people die in hospitals each year as the result of medical errors 5 – Nearly 100,000 deaths from HAIs 6 – Estimated 30,000 to 62,000 deaths from CLABSIs 7 – Cost of HAIs is $28-33 billion 7 8 countries report similar findings to the U.S. 2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995 3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995. 4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997. 5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999. 6. Klevens M, Edwards J, Richards C, et al., PHR, 2007 7. Ending Health Care-Associated Infections, AHRQ, 2009.
© 2009 How Can These Errors Happen? People are fallible Medicine is still treated as an art, not science Need to view the delivery of healthcare as a science Need systems that catch mistakes before they reach the patient
© 2009 Understanding the Science of Safety
© 2009 How Can We Improve? Understand the Science of Safety Every system is perfectly designed to achieve the results it gets Understand principles of safe design – standardize, create checklists, learn when things go wrong Recognize these principles apply to technical and team work Teams make wise decisions when there is diverse and independent input Caregivers are not to blame
© 2009 System Failure Leading to This Error Catheter pulled with Patient sitting Communication between resident and nurse Lack of protocol For catheter removal Inadequate training and supervision Patient suffers Venous air embolism 8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004. 9. Reason J, Hobbs A., 2000.
© 2009 System Factors Impact Safety Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional 10. Adapted from Vincent C, Taylor- Adams S, Stanhope N., BMJ, 1998.
© 2009 Evidence Regarding the Impact of ICU Organization on Performance Physicians 11 Nurses 12 Pharmacists 13 11. Pronovost P, Angus D, Dorman T, et al., JAMA, 2002. 12. Pronovost P, Dang D, Dorman T, et al., ECP, 2001. 13. Pronovost P, Jenckes M, Dorman T, et al., JAMA, 1999.
© 2009 Fatal Aviation Accidents per Million Departures 14. Statistical Summary of Commercial Jet Airplane Accidents, Aviation Safety Boeing Commercial Airplanes, July 2009.
© 2009 Principles of Safe Design Standardize – Eliminate steps if possible Create independent checks Learn when things go wrong – What happened – Why – What did you do to reduce risk – How do you know it worked
Line Cart Contents – 4 Drawers
© 2009 Eliminate Steps
© 2009 Create Independent Checks
© 2009 2 Year Results from 103 ICUs Time period Median CRBSI rate Incidence rate ratio Baseline2.71 Peri-intervention1.60.76 0-3 months 00.62 4-6 months 00.56 7-9 months 00.47 10-12 months 00.42 13-15 months 00.37 16-18 months 00.34 15. Pronovost P, Needham D, Berenholtz S et al., N Engl J Med, 2006.
© 2009 Principles of Safe Design Apply to Technical and Team Work
Basic Components and Process of Communication 16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
© 2009 % of respondents reporting above adequate teamwork ICU Physicians and ICU RN Collaboration 17. ICUSRS Data from Needham D, Thompson D, Holzmueller C, et al., Crit Care Med, 2004.
© 2009 Teamwork Tools Staff Safety Assessment Daily goals AM briefing Shadowing Barrier Identification and Mitigation Learning from Defects
© 2009Systems Every system is designed to achieve the results it gets To improve performance we need to change systems Start with pilot test one patient, one day, one physician, one room
© 2009 Teams Make Wise Decisions When There is Diverse and Independent Input Wisdom of Crowds Alternate between convergent and divergent thinking Get from the dance floor to the balcony level 18. Heifetz R, Leadership Without Easy Answers,1994.
© 2009 Don’t Play Man Down When you feel something say something
© 2009 Recap Develop lenses to see systems Work to standardize one process Infuse these principles of standardization and independent checks in other processes Don’t play man down
© 2009 Action Items Have all members of the CUSP/CLABSI Team view the Science of Improving Patient Safety videoScience of Improving Patient Safety Put together a roster of who on your unit needs to view the Science of Safety video Develop a plan to have all staff on your unit view the Science of Improving Patient Safety video – Assess what technologies you have available for staff to view – Identify times for viewing it (e.g., staff meetings, individual admin hours)
© 2009 Works Consulted 1. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348 (26): 2635-45. 2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29-34. 3. Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 23:294-300,1995. 4. Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse events in medical care. Lancet. 349:309-313,1997. 5. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Acad Pr; 1999. 6. Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR.122:160-166,2007. 7. Ending Health Care-Associated Infections, AHRQ, Rockville,MD, 2009. http://www.ahrq.gov/qual/haicusp.htm. http://www.ahrq.gov/qual/haicusp.htm 8. Pronovost P, Wu A, Sexton J, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med. 2004;140(12):1025-1033. 9. Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000. 10. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998; 316: 1154–7. 11. Pronovost P, Angus D, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. 12. Pronovost P, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective clinical practice: ECP. 2001;4(5):199- 206.
© 2009 Works Consulted 13. Pronovost P, Jenckes M, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7. 14. Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-2008. Boeing News Releases/Statements. July 2009. Aviation Safety Boeing Commercial Airplanes, Web. 21 Jan 2010.. 15. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32. 16. Dayton E, Henriksen K. Communication Failure: Basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007; 33(1): 34-47. 17. Needham D, Thompson D, Holzmueller C, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32:2227-33. 18. Heifetz R, Leadership Without Easy Answers, President and Fellows of Harvard College,1994.
© 2009 On the CUSP: STOP BSI The Science of Improving Patient Safety.
2 Describe the historical and contemporary context of the Science of Safety Explain how system design affects system results List the principles of safe.
The Science of Improving Patient Safety On the CUSP: Stop CAUTI 1 Sean Berenholtz, MD MHS Johns Hopkins University Quality and Safety Research Group.
© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Armstrong Institute for Patient Safety and Quality CUSP for Safe Surgery:
Assess and Adapt: Understanding the Science of Safety and Reliability Lisa H. Lubomski, PhD Assistant Professor, Johns Hopkins Medicine Armstrong Institute.
Unit 2 Principles of Quality and Safety for HIT Improving Patient Safety Component 12/Unit21Health IT Workforce Curriculum.
Vicki S. Good, MSN RN CENP CPPS Past President AACN System Adm Director Quality/Safety CoxHealth Courageously Building a Culture of Safety.
St. Mary’s and St. Joseph’s Stop BSI Project The Science of Improving Patient Safety A Johns Hopkins collaborative Document 7 Coaching Call 2, 10/19/2010.
Assess and Adapt: Understanding the Science of Safety and Reliability Presented by: Chris Goeschel, ScD MPA MPS RN FAAN Assistant Professor, Johns Hopkins.
© 2009 On the CUSP: STOP BSI The Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn form Mistakes and Improve Safety Culture.
© 2009 On the CUSP: STOP BSI Overview of STOP-BSI Program.
© 2009 On the CUSP: STOP BSI Implementing Daily Goals.
1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ approval Lisa Lubomski, PhD November 11 and 13, 2013.
Small Rural/CAH Learning Community Meeting May 23, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement.
Quality Improvement Principles of Quality and Safety for HIT Lecture a This material (Comp12_Unit2a) was developed by Johns Hopkins University, funded.
HAI Collaborative Meeting September 12, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement.
Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI People, Priorities, & Learning.
1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ approval Lisa Lubomski, PhD Cohort 5 presentation May 19 th.
Toward Eliminating Central Line Associated Blood Stream Infections.
© 2011 Melinda Sawyer, RN, MSN, CNS-BC Armstrong Institute for Patient Safety and Quality The Comprehensive Unit-based Safety Program (CUSP)
Staff Safety Assessment 1. Learning Objectives To understand Step 2 of CUSP:Identify Defects To understand how to Implement the Staff Safety Assessment.
Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group.
Improving ICU Care Through Teamwork Chris Goeschel RN MPA MPS
Learning From Defects. What is a Defect? Anything you do not want to have happen again.
Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital.
Sean Berenholtz, MD MHS FCCM September 20, 2011 at 2ET/1 CT/12 MT/11 PT Ventilator Associated Pneumonia Prevention CLABSI Supplemental Call Series.
Partnering for Quality Creating Reliability for Healthcare Peter Pronovost, MD, PhD Johns Hopkins University.
Small and Rural Critical Access Hospitals July 19, 2011.
Comparative Effectiveness Grant Toward Eliminating Central Line Associated Blood Stream Infections.
The Johns Hopkins Comprehensive Unit-based Patient Safety Program (CUSP) Peter Pronovost, MD, PhD, Johns Hopkins Univeristy.
Total Clinical Outcomes Management: Theory and Method Richard A. Epstein, Ph.D., M.P.H. Michael J. Cull, Ph.D., M.S.N. Department of Psychiatry.
Who We Are ~Where We are Going. Slide 2 Workshop Objectives Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety.
© 2009 On the CUSP: STOP BSI ICU Physician Staffing.
Peter Pronovost, MD, PhD Johns Hopkins University
© Copyright, The Joint Commission 2014 National Patient Safety Goals.
Institute For Healthcare Improvements 100k lives Campaign Clint MacKinney, MD, MS Duluth, Minnesota July 19, 2005.
1 Bridging Terminology and Classification Gaps among Patient Safety Information Systems Andrew Chang, JD, MPH, Laurie Griesinger, MPH, Peter Pronovost,
Michigan’s Keystone ICU Project:
1 Surgical Unit-Based Safety Program Proposed Resources for Partnership for Patients Terri Conner, Ph.D. Nybeck Analytics Partnership for Patients.
Ruben D Restrepo MD RRT FAARC Professor of Respiratory Care The University of Texas Health Science Center at San Antonio.
Translating Evidence into Practice Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University 1.
Comprehensive Unit Based Safety Program A webinar series for QI Managers, Nurse Leaders and others supporting healthcare improvement in Wisconsin’s.
Comprehensive Unit-based Safety Program (CUSP) On the CUSP: Stop CAUTI 1 Sean Berenholtz, MD MHS Johns Hopkins University Quality and Safety Research Group.
© 2009 On the CUSP: STOP BSI Physician Engagement.
Learning From Defects.
Patient Safety Marc J. Shapiro M.D. Brown Medical SchoolRhode Island Hospital Medical Simulation Center.
© 2009 On the CUSP: STOP BSI Senior Leadership of Quality and Safety Initiatives in Health Care.
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