2Objectives of Presentation Provide concepts of how the Planetree philosophy can support system changes to enhance a culture of quality and safetyUnderstand safety implications related to human performanceDiscuss how a patient centered approach can enhance patient and family involvement and patient safetyPresent 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
3What Started Safety Awareness? To Err is Human – IOMStudy showed adverse events happen in 2.9 to 3.7 percent of hospitalizationsExtrapolated over 33.6 million admissions per year = 44,000-98,000 deaths due to medical error per yearPoor communication and a lack of teamwork was identified as a root cause of most safety problems
411 Years After the IOM “To Err is Human…” Report: What Has Changed? 4
5Safety Hazard Probabilities (events per million opportunities) Acquiring HIV from 1 unit of transfused blood 0.7All heads on 20 coin tossesDeath of commercial airline passengerDeath: general anesthesiaDeath: motor vehiclePreventable hospital deathsOrlikoff,J. Orlikoff and Associates, Inc. Chicago, IL. Jan. 2010
6Cost 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 2006Shannon et al, “Economics of Central-Line Associated Bloodstream Infections” American Journal of Medical Quality Supplement to Vol.21, No.6 Nov/Dec 2006Run thru these next few slides to emphasize what’s happening… do they know their numbers for these events?
7National Health Expenditures per Capita, 1980– 2007 Data: OECD Health Data 2009 (June 2009).
8What are the “Other” Cost of Errors? Errors may be career ending eventsCaregivers don’t intend to harmTrust issues and safety concerns on part of the consumers and payersFrustrated consumersSilence often surrounds issues which may result in malpractice claimsSensational negative media coverage
9News HeadlinesSEPT. 2006: “HOSPITAL CHANGES PROCEDURES AFTER PREEMIE DEATHS”:Three preemies die after they receive adult doses of heparin at a hospital in IndianapolisNOV. 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.
10State of ColoradoLocal TV news coverage on prevention of central line infectionsDiscussed use of central line bundleShortly thereafter, legislators in the State received a “slew” of s from constituents demanding use of the central line bundle be made into law!
11Put it in Perspective25% of US patients state they have experienced a medical error - 50% of those resulting in serious harm42% of health care workers (HCW) state they have been personally involved in a medical errorHCW’s state they fear becoming a patientSeek the best MD – not the MD on callSeek out high volume places for complicated surgeriesSeek 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)
12What is Patient Safety Freedom from accidental injury through: Systems and processes that decrease the likelihood of mistakesandSystems and processes that increase the likelihood of prompt identification and correction of errors and mistakes before they cause harm to a patient
13What 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)
14Evidence Based Care Bundles Hospital Infections are Preventable! FACT - 80,000 CLABIs per year, cause about 28,000 deathsIn 103 ICUs in Michigan median CLABI rate per 1,000 catheter days declined from 2.7 to ZEROHOW? - It’s simpleHand 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.
15IHI- 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 pneumoniaPrevent central line infectionsDetailed How-to Guides on each intervention are available at under the Materials tab.15
17“New” Reality of US Healthcare Evidence Based Care – Core MeasuresMedicare/insurance no longer pays for defined “never events” (10/08)National versus Local StandardsPublic reporting of quality data and safety events - transparencyAHRQ measures reported to the publicPatient Centered Care
18What 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
19Opportunities for Improvement Communication challengedFragmented health care systemComplex systems within hospitalsLack of standardizationHierarchies produce steep authority gradientsNeed better teamwork and communicationProduct of our successAdvanced technology, rapid changesNecessary knowledge exceeds limits to human capacity> 6000 meds, >4000 treatments to choose fromProfessional craftsman modelNo longer effective
20Professional Craftsman Model “The Old Way” With extensive trainingEminence based training – not always evidence basedCame “special privileges”Full autonomy= full responsibilityCreates a steep authority gradientOthers have been there only to assist the MD in the pastNo recognized group decision makingResults in the ‘Perfection Myth’
21Safety Implications Related to the ‘Perfection Myth’ Safety depends on individuals - mythSafety really depends on teamwork and communicationError is due to carelessness – mythMore often a system or process errorWe have responded in the past with peer review, “be safer next time”, more education, 5 rightsPunishment results in fewer errors - mythSystem Improvements should be the focus
22Dysfunctional Response to Error Justification/rationalization“Complications happen”Blame the patientsDishonesty with patientsCover-up/Non-reportingFear loss of reputationHealthcare workers look the other way when colleagues error
23Who Is Watching Out For Patients? 46% of physicians failed to report at least oneserious medical error, even though 93% of themsaid they should report ALL significant medicalerrors they observe.45% said they did not report impaired orincompetent colleague physicians even though 96%said they should- ANNALS OF INTERNAL MEDICINE, DEC. 4, 200767% of physicians have not been involved incollaborative efforts to improve quality– COMMONWEALTH FUND NATIONAL SURVEY OF PHYSICIANS, 2007
24A Different (Planetree) Approach Caring for the CaregiversLeadership support for safetyNon-punitive reporting systemsSet up systems and processes for safetyRedundancy and double checksMedication administration vs. blood transfusionStandardization of processesChecklists, pre-printed ordersFind out about work-aroundsMultidisciplinary quality committees
25Caring for the Caregivers Teamwork and communication supportEnhanced communication modelsRobust reporting systems with feedbackErrors recognized as system failuresMutual Support – I have your backNurse Residency ProgramsPlan for and educate about limitations of human performance
26Plan for the ‘Human Factor’ Humans make mistakesFatigue, interruptions, distractions, etcOverestimate abilities, underestimate limitationsGoal is to keep inevitable mistakes from becoming consequentialReliable systems combined with effective communication is best practice
27Human LimitationsLimited memory capacity–5 to 7 pieces of information in short term memoryNegative effects of stress –increased error rates, tunnel visionNegative influence of fatigueLimited ability to multitaskVariable judgments and perceptions
28Human Error is Inevitable Because: Inherent human limitationsComplex, unsafe systemsSafety is often assumed, not assuredWe count on the expert individual“It won’t happen to me” or “it doesn’t happen here” attitude
29Build on human factor skills Standardized (SBAR) communicationTelephone order read-backsStarbucks figured it outCreate redundancies, double checksSituational awarenessTime-outs, include the patient (patient centered)Decrease interruptionsDebriefings after emergenciesPatient Centered focusBedside report including the patient/familyHourly roundingHeparin for patient, MD told patient, RN did not know patient going back to surgery….
30A Different (Planetree) Approach Patient centered approachKnowledge about condition and choicesAccess to medical recordsAccess to information – library/literature searchesHealth literacyCare partnersAnother “ear to hear”Patient and Family Advisory CouncilLearn from their experiences
31Planetree 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. 2004Patients 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 departmentFebruary 3, 2009, Annals of Internal Medicine
32Planetree 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!
35VVH Culture of Safety Survey Survey done July 2010Statistical improvements from 2008Standardized AHRQ surveyDesigned to measure 4 major areasOverall perceptions of safetyOverall patient safety gradeFrequency of event reportingNumber of events reported
37Valley View Healthgrades™ Award Valley View Hospital is rated among the top 5% in patient satisfaction scoresThe Planetree patient centered philosophy actively supports programs to meet patient and family needs
38“What Is the Likelihood of Recommending This Hospital?”
44Lessons learnedSafety and quality is not created by counting and control measuresWe have learned that stories, complex dialogue, and teamwork create safetyWe thought competent, careful clinicians were sufficient to create safetyWe have learned safety requires leadership, a supportive environment, a system focus, and solid teamworkQuality and patient safety are supported in a Planetree patient centered environment and the Planetree philosophy promotes a ‘generative’ culture
45How Different Organizational Cultures Handle Safety Information PathologicalCultureBureaucraticGenerative· 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
46Planetree Creates A Culture of Quality and Safety An accountable cultureA culture of learningA culture of partnershipA just cultureMutual TrustThe system trusts that you will call outYou must trust that the system will listen