Presentation on theme: "Hospital Performance and Best Practice Management: Altering systems of care in the hospital to improve patient safety J. Christopher Farmer."— Presentation transcript:
1Hospital Performance and Best Practice Management: Altering systems of care in the hospital to improve patient safetyJ. Christopher Farmer
2Discussion pointsOvercoming the culture: “change does not apply to me”Knowing what changes make a positive differenceOvercoming the impact of human factorsMaking positive changes durable
3The “Mom” Test If your mom becomes an ICU patient.. Does experience level matter? (intubation, central line placement, advanced medical decision-making)Are your expectations different at 2PM from 2AM?What level of communications do you expect? Assigned nurse vs. resident vs. attending physician? Every day?What are your expectations regarding supervision of “learners” caring for your mom?
4Universal laws that we often forget... Today’s problems come from yesterday’s solutionsDividing an elephant in half does not produce two small elephantsCause and effect are not closely related in time and spaceBehavior grows better before it grows worseThe harder you push, the harder the system pushes backSmall changes can produce big results, but the areas of highest leverage are often the least obviousFrom The Fifth Discipline by Peter Senge 1990
5Quality lapses in the hospital... where are the brakes? Systems of care versus individualsCommunicationsEducationFailure to recognizeFailure to rescueNon-integration
6DEATH DAY 7 DAY 12 DAY 2 DAY 4 DAY 6 DAY 8 DAY 9 DAY 10 DAY 14 DAY 16 72 year old man admitted for elective neurosurgeryExtubated, no gag reflex, npo, tube feediings orderedDAY 2DAY 4Dobhoff inserted, ongoing dysarthria, transferred to wardDAY 6T 38 C, increased rsspiratory secretions, chest Xray + urine analysis ordered, no antibioticsT 39.2 C, HR 120, RR 30, chest Xray - pneumonia, all cultures (+), antibiotics orderedDAY 7DAY 8T 39.7 C, HR 140, RR 40, returned to MICU, broad spectrum antibiotics administeredDAY 9Antibiotics adjusted, reintubated, ARDS developsDAY 10Persistent ARDS, sepsis, family conference convenedDAY 12ARDS and sepsis not improving, now in renal failureDAY 14Decision: no dialysis, no tracheostomy, no PEGDAY 16DAY 18Decision not to pursue further ICU careDEATH
7What is patient safety? The absence of harm The presence of quality The perception of value
8Quality versus patient safety... Clinical acts versus care processes aimed at preventionPrevention of adverse eventsCompliance with “the rules”
9Yes, the details are important... Protocolized (standardized) management improves clinical outcomes (published data)SepsisAcute myocardial infarctionCentral line insertion and catheter site maintenanceVentilator use strategies in ARDSVentilator bundleGlucose controlSedation and delirium managementSurgical site wound careDaily goals sheet (communications tool)Communications tools for assessment and transfer to lower levels of careRapid response teamsMultidisciplinary, team-based roundsUse of remote ICU virtual presence monitoring by intensivists and critical care nursesOn-site intensivist programOn-site hospitalist programAdverse drug event prevention program
11Sepsis: putting it all together Revised and implemented a Severe Sepsis and Septic Shock order set that includes all components of the Sepsis Resuscitation and Sepsis Management BundlesTargeted early sepsis recognitionInstituted sepsis screening in the ICU, using the IHI screening tool, on all new admissions and patients with greater than three-day length of stay (LOS)Incorporated screening into multidisciplinary rounds and the Patient Daily Goals/Plan of Care Implemented a “Sepsis Alert” screening tool in the Emergency Department (ED): Posted Sepsis Alert Screen in ED rooms and on ED chart backs as prompters to staffAdded sepsis screening to the ED standardized T-System documentation for all ED patientsImplemented screening on Medical Response Team (MRT) callsInstituted ED chart review of patients admitted with a sepsis diagnosis to monitor compliance with appropriate screening and initiation of the Sepsis Resuscitation Bundle; gave feedback to ED staff and physiciansPrioritized ED/ICU collaboration for timely transfer of septic patients to ICU; ED nurse notified the ICU float charge nurse of positive sepsis screens Initiated sepsis resuscitation (lactates, blood cultures, antibiotics, fluid resuscitation) in the ED as indicatedED staff and physicians were educated to the Sepsis Resuscitation BundleIntensivists assisted the ED as neededFocus was on prompt transfer of patients to ICU for insertion of central venous oximetry catheters Placed prompters in the ED to collect blood cultures prior to first dose antibiotic administration Implemented components of the Sepsis Resuscitation and Sepsis Management Bundles in ICU using a systematic, incremental approachBegan by obtaining orders for lactates for all positive sepsis screensTracked the volume of lactates collected in ED and ICU Added absolute neutrophils to CBC and CBCI reports Added prompters for the Resuscitation Bundle to the sepsis screening tools in ED and ICUPromoted utilization of central venous oximetry catheters by setting out the catheter for intensivists to use instead of a triple lumen catheterEducated physicians to the purpose and benefits of using the central venous oximetry catheter Established a sepsis resuscitation box (lab tubes, type and cross-match supplies, catheters, fluids, etc.)Revised the Pre-extubation Worksheet for lower tidal volumes and inspiratory plateau pressures — Respiratory Care monitored and followed up on compliancePosted criteria for steroids in ICU and added steroid order to the sepsis pre-printed order setImplemented Clinical Pharmacy review of cases for drotrecogin alfa based on established criteria Implemented a standing order process for nurse to automatically initiate the Insulin Drip Protocol for ICU patients with two blood glucose (BG) levels >150 mg/dL Addressed glycemic control in all rounds Consulted Clinical Pharmacy for insulin protocol patients with BG >150 mg/dL — also, the Pathology Department ed a daily list of uncontrolled patients to Nursing and Clinical Pharmacy. Implemented Clinical Pharmacy screening of all new total parenteral nutrition (TPN) orders for appropriateness and ongoing screening for early switching to enteral feedings Implemented a process for Infection Control Practitioner to call a huddle meeting with Nursing and the ICU Medical Director for initial positive blood isolates of ICU patients — the purpose was to determine the source of infection, discontinue lines as indicated, initiate antibiotics, etc. Installed the Surviving Sepsis database to concurrently enter and track data from ICU patient charts on sepsis bundle compliance and mortality — feedback to staff and physicians
15The Six Sigma model has three aspects Process Improvement focuses on improving broken processes.Process Design is aimed at developing “something from nothing.” The new products and services will encompass Six Sigma principles.Process Management translates Six Sigma in every day management decisions through the use of measurement systems.
16Living with 99.9%... 84 unsafe airline landings/day 1 major plane crash every three days16,000 items of lost mail/hour37,000 ATM errors/hour
17Hand washing...are we passing the test? Average compliance in a U.S. Hospital = 50%60% of CRBSI are S. aureus + Coagulase negative staphAlmost half of S. aureus-related CBRSI are MRSAIncreasing incidence of C. difficile + VRESince we can’t reliably “force” compliance with our current processes, then maybe we should consider redesigning the processes themselves?
18The ancient approach to human factors: The Code of Hammurabi “If the surgeon has made a deep incision in the body of a free man and has caused the man’s death or has opened the carbuncle in the eye and so destroys the man’s eye, they shall cut off his forehand.”Circa 2000 B.C.
19Re-design systems for...PreventionDetectionMitigation
20The impact of human factors Human Factors Engineering (HFE) are activities such as:function & task analysisworkload analysishuman error modelingsystem ergonomicshuman machine interface designusability testingworkspace layout contribute to an efficient, effective, usable and safe product, system or environmentThese contribute to an efficient, effective, usable and safe product, system, or environment
21The impact of human factors Human Factors Integration (HFI) is:a philosophy and set of management processes and tools that ensure human issues are identified, collated, shared and impact minimizedActively managing human factors and planning how human issues will be shared and acted upon by other teams or disciplines (e.g. system engineering, logistics, software)“We must accept that human error as inevitable – and design around that fact.” Donald Berwick
22And how does inpatient medicine score? Performance measureHealthcare averageIndustry standardDPMO244,6503.4Sigma level2.26Afessa et al, Crit Care Med, 2008
23Changing processes AND changing the culture! This is a leadership challenge!Must accomplish systems level changes that facilitate successMust study the processes with analytical discipline in order to make the correct changesManagement by walking aroundWhat is the hospital leadership change management plan?
24An incremental approach Develop a strategic plan for necessary changes in the hospitalTimeline, deliverables, accountable individuals, metrics of successBegin with a project that will establish a record of successPick the correct team membersConsider the use of an outside consultant to help articulate the “current state,” define priorities, techniques, leaders, methods, “outliers” (who will cause problems)A credible consultant can say and do things without alienating staff, and they will listen!
25“By far the most dangerous foe we have to fight is apathy - indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction.” Sir William Osler, 1932