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ASA Building Safer Systems. ASA Without data, you are just another person with an opinion.

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Presentation on theme: "ASA Building Safer Systems. ASA Without data, you are just another person with an opinion."— Presentation transcript:

1 ASA Building Safer Systems

2 ASA Without data, you are just another person with an opinion.

3 ASA Safety Safety is not a specific thing. In complex organizations, safety is created by people as they do their work. There are strategies and designs that favor safe performance.

4 Safety is Produced by SocioTechnical Systems ….preventing errors and improving safety require a systems approach…. The problem is not bad people; the problem is that the system needs to be made safer. Safety is a characteristic of systems and not of their components. Safety is an emergent property of systems. ….healthcare organizations must develop a systems orientation to patient safety…. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. ….this higher level of quality cannot be achieved by further stressing current systems of care… Trying harder will not work. IOM 2001

5 ASA HROs: High Reliability Organizations: Characteristics Process auditing and other active searches (eg, equip testing) for possible failures. High quality standards Risk perception: examining even small but unexpected events. Command and control: –Fluid decision-making (flex hierarchy) –Formal rules and procedures (but flexible) –Constant training Karlene Roberts, 2005

6 ASA Safety in Medicine: Needed Changes Specify limits to maximum performance. [How many cases should we do?] Decrease individual autonomy: –Regulations – the minimum necessary –Teamwork –specialization Fatigue, overtime, excessive work schedules, staff shortages, stress. Amalberti R, 2005

7 ASA Accident Models

8 ASA hazards Some holes due to active failures Other holes due to latent conditions (resident pathogens) losses Successive layers of defenses, barriers, and safeguards This model is being increasingly criticized as an example of how to understand accidents. It is too static; the defects are often transient; and the whole system is more dynamic than the model suggests.

9 ASA Sequential accident models inevitably lead to a root cause, which is the basis of the root cause analysis. The search for a root cause (often a human), tends to perpetuate the blame-the-person outcome. It also suggests that eliminating a root cause will solve the problem.

10 ASA A detailed inquiry finds multiple parallel factors that led to the event considered to be the root cause. Systemic (not sequential) accident model

11 ASA Systemic Accident Model Before the accident.

12 ASA Systemic Accident Model Retrospective analysis might suggest that the outcome of the actions taken was predictable. We have not completely escaped blame-&-train.

13 ASA System Features

14 ASA Aviation has achieved a rate of injurious accidents. Surgery is said to have a rate.

15 ASA In the medical arena, the most common system failure is in education. The person at the sharp end (eg, the surgeon) did not know enough or was not experienced enough to make the correct judgment or action. TrainingExperience High/low volume VA Hernia Trial: 85% of participating surgeons were still climbing the learning curve. System Features Who is responsible?

16 ASA Year Hull loss accidents per year Hull loss accident rate Airplanes in service Millions of departures 25, Business as usual 19, Accident Rate / Million Departure Our Goal Departures Million The Evolution of Aviation Safety Boeing 2004 Statistical Data – May 2005

17 ASA Teams in Aviation & Medicine Improved safety in commercial aviation, stemmed from better aircraft, better system designs, automation, and rule-making. Work in aviation and medicine is done by teams. Aviation: CRM reduced cockpit hierarchy, and communication improved. Moved on the LOSA & TEM. Medicine is practiced by teams, and team development is now a major issue. That leads to CRM; better communication; and observational studies of surgical work (LOSA). System Features

18 ASA System Features Importance of Teams in Surgical Performance Importance of Teams in Surgical Performance Error Management in Pediatric Cardiac Surgery: Carthey, J et al (unpublished) Multicenter study of neonatal arterial switch operation in GB. 173 ASOs observed by experts in error management. Errors defined as major or minor, and compensated or uncompensated. The total number of minor errors in a case, whether compensated or not, was directly related to the chances that a major error would not be corrected, and a serious complication or death would result. Minor errors and uncompensated major errors and deaths were less common with stable teams.

19 ASA O.R. Vicious Cycle High nurse turnover Nurse Dissatisfaction Nurse less able Random case assignments SPD dysfunctional Equipment missing Surgeon angry Flow interrupted Case more difficult O.R. tension mounts Performance drop Dysfunctional team.

20 ASA Hypothetical staffing pattern during a four-hour case. Nurses, surgeon, and anesthesiologists can be a different mix several times per hour. No stable teams; communication affected; information lost. System Features

21 ASA System Features O.R. Communication – A Team Activity O.R. Communication – A Team Activity Lingard L et al. Communication failures in the O.R. Qual Saf Health Care 2004;13:330. Lingard L et al. Getting teams to talk. Qual Saf Health Care 2004;14:340 Lingard L et al. Team Communications in the O.R.: Patterns and sites of tension. Acad Med 2002;77:232. Seek harmony to preserve teams and avoid unsafe behaviors. How the surgeon acts is key. Bottom Line:

22 ASA Loose coupling Tight coupling Tight coupling connects parts of the system so rigidly that actions at one place are immediately transmitted throughout. Prediction and control become harder, and accidents increase. An Important Failure Mode: Tight Coupling In systems-talk, this is going solid. System Features

23 ASA System Features Everyday Examples of Tight Coupling No hospital beds No ICU beds Overbooked IR schedule Shortage of surgical instruments: cases delayed Inadequate resources to staff O.R. cases Lengthy queues for operations. Elective surgery in off hours. Long queues for routine outpatient appointments. Examples of failing to set production limits that match production capacity.

24 ASA The Useful Concept of Gaps SBAR (or SCAP) Read-backFace-to-face Hand-off IT (van Eaton) Checklists Standardized orders Complexity creates gaps in care, where information can be lost. Every transition in care constitutes a gap. The increasing fragmentation of medical care is producing more gaps. Information loss at gaps can be decreased by handoff routines and checklists. HANDOFFSCHECKLISTS & ETC. System Features

25 ASA Checklists & Standardized Orders Pre-op planning O.R. scheduling Admission scheduling Night before checklist Pre-op checklist (briefing) Post-op care checklist Admission and pre- op orders Postop orders Transition orders Discharge orders Discharge instructions As many as 11 checklists between evaluation in the clinic and discharge from the hospital. Checklists Orders System Features

26 ASA Anesthesia1 Patient Surgeon Prepare Surgical Ward Clinic R.R. Operation O.R. Nurses O.R. Nurses Anesthesia2 O.R. Suite PreOp Home Nurses ReferringMD Surgical Patient Flowchart System Features

27 ASA Anesthesia1 Patient Surgeon Prepare Surgical Ward Clinic R.R. Operation O.R. Nurses O.R. Nurses Anesthesia2 O.R. Suite PreOp Home Nurses ReferringMD & ·Eleven handoffs ·Eight procedural subsystems System Features

28 ASA Christian CK, Zinner MJ, Dierks MM: A prospective study of patient safety in the operating room. Surgery 2006;139:159. Communication deficits during the operation -- lost information. Poorly synchronized multitasking that delayed case progress. Observational study of O.R. systems during general surgery cases. Hand-offs during inappropriate times -- information loss. Counting protocol delayed case and of questionable quality. Circulating nurses performed retrieval errands too often. Good work: LW System Features

29 ASA Demonstrates how investigations done in the O.R. by surgeons can detect system faults. And eliminate unsafe practices. And presumably, improve efficiency. The findings of this study could probably be replicated in most large hospitals. As surgeons troubleshoot O.R. systems, surgeons require a share of administrative authority to implement the changes. Christian CK, Zinner MJ, Dierks MM: A prospective study of patient safety in the operating room. Surgery 2006;139:159. System Features

30 ASA Conclusions Progress in understanding –The systems nature of safety –The nature of surgical systems –System faults that affect safety –And how to fix them Surgeons must be directly involved in 1) O.R. administration and 2) observational studies of the surgical system to bring about the required changes.

31 ASA

32 To Err is Human... Or Is It? ACS Efforts – Error Prevention and Patient Safety Thomas R. Russell, MD, FACS April 20, 2006

33 ASA Omnibus per artem fidemque prodesse

34 ASA The American College of Surgeons Dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

35 ASA

36 Institutes of Medicine Three reports, starting with To Err Is Human: Building a Safer Health System, published in Demonstrate that our current health care system neither controls spending nor ensures access to quality care Clarion call for all to reevaluate their role –Quality –Cost

37 ASA Shift from saving lives by preventing errors to implementing evidence-based practices to improve quality Domain of effectiveness of service, test or therapy to create better outcomes – i.e. statistical lives To Err Is Human

38 ASA

39 Quality Surgical Care Correct Diagnosis Proper Staging Proper Risk Assessment –Disease –Treatment Proper Treatment –Best evidence –Best technology –Best technique Proper Outcome –Survival –No complications –Disease cured –Symptoms relieved –Function restored –Death with dignity ACS is working in all these areas

40 ASA Quality Surgical Care Structure Process Outcomes

41 ASA Education

42 ASA ACGME/ABMS Core Competencies Medical Knowledge Medical Knowledge Patient Care Patient Care Interpersonal and Communication Skills Interpersonal and Communication Skills Professionalism Professionalism Practice-based Learning and Improvement Practice-based Learning and Improvement Systems-based Practice Systems-based Practice

43 ASA


45 American College of Surgeons Case Logging System Practice-Based Learning & Improvement

46 ASA Closed Claims Project A standardized collection of reviews of claims involving surgical mishaps from records kept by liability insurance companies 461 claims reviewed to date Purpose – to identify common problems and develop best practices and protective systems to improve patient safety

47 ASA


49 Education Program for Accreditation of Educational Institutes Will serve as regional sites where surgeons may learn new procedures, emerging technologies, and rarely performed procedures

50 ASA ACS Efforts to Enhance Education in Surgical Skills

51 ASA Education Content in clinical areas and broad-based subjects of interest Supports e-learning, case logs, and sharing information about their practices Maintain and submit documentation regarding MOC-related activities

52 ASA

53 ACS Efforts to Define Curriculum Content for Entering Surgery Residents

54 ASA Research and Optimal Patient Care

55 ASA Current ACS Quality Improvement Programs Facility Certification Programs –Trauma centers –Cancer centers –Bariatric centers Continuous Quality Improvement –ACS National Surgical Quality Improvement Program (NSQIP) –American College of Surgeons Oncology Group National Outcomes Data Bases –National Trauma DataBank –National Cancer Data Base –NSQIP

56 ASA

57 Development of ACOSOG May 1998: Initial NCI Award March 1999:1st trial opens September 1999:NCI Site visit in Chicago May 2000:5 Year NCI Award

58 ASA Future Directions Expand clinical trials to include studies in trauma, burns / critical care, vascular and cardiovascular diseases Expand Centers programs in Continuing Medical Education to educate surgeons in the performance of new operations and use of new technology

59 ASA American College of Surgeons Data Bases National Cancer Data Base- NCDB National Trauma Data Base- NTDB American College of Surgeons National Surgical Quality Improvement Program- ACS NSQIP ACS Bariatric Surgery Data Base ACS Individual Fellow Self-Reporting Data Base Collaborations in Progress –SAGES –STS –AAOS –SVS

60 ASA Collaborative Efforts CMS Surgical Care Improvement Project (steering committee) (SCIP) Physicians Consortium for Quality Improvement (AMA) –Perioperative Care Work Group (co-chair) National Quality Forum (NQF) Ambulatory Care Quality Alliance (steering committee) (AQA) –Subgroup on Surgery and Procedures (chair) Surgical Quality Alliance (chair) (SQA) –Developing quality measure priorities and consensus across surgical specialties

61 ASA National Quality Forum Cancer Care Quality Indicators –Colon Cancer Colonoscopy preoperative or within 6 months At least 12 nodes resected for non-metastatic disease Adjuvant chemotherapy for node positive disease

62 ASA Membership

63 ASA Membership Expanded membership base RAS-ACS Affiliate Member category

64 ASA

65 Membership Innovative methods of communicating with membership Journal of the American College of Surgeons now distributed to all ACS Fellows free of charge Surgery News, new monthly newspaper Electronic methods: ACS NewsScope, e- mail alerts, Colleges Web site, and Web portal

66 ASA


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