1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ approval Lisa Lubomski, PhD November 11 and 13, 2013

DRAFT – final pending AHRQ approval Where are we now? Give your frontline staff the vision to see system-level defects, and the voice to create a local SSI prevention bundle they can own.

Learning Objectives 3 After this session, you will be able to: Apply Science of Safety into your work Educate your team and executive partners on the Science of Safety Identify defects within your OR by administering the Perioperative Safety Staff Assessment (PSSA) Distribute and share PSSA results with your SUSP team Locate SUSP resources on the project website to help complete the above tasks DRAFT – final pending AHRQ approval

Comprehensive Unit-based Safety Program (CUSP) 1 4 CUSP for Surgery 1.Educate staff on science of safety 2.Identify defects 3.Recruit executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools We are here Adaptive Work

DRAFT – final pending AHRQ approval Advances in Medicine: Lingering Contradictions 5 Advances in medicine have led to positive outcomes: Most childhood cancers are curable AIDS is now a chronic disease Life expectancy has increased 10 years since the 1950s However, sponges are still found inside patients’ bodies after operations. Postoperative X-Ray Reveals Unwanted Situations 2

DRAFT – final pending AHRQ approval Why is your SUSP work important? in 25 people will undergo surgery 7 million (25%) in-patient surgeries followed by complication 1 million (0.5 – 5%) deaths following surgery 50% of all hospital adverse events are linked to surgery AND are avoidable

DRAFT – final pending AHRQ approval How Can These Errors Happen? 7 People are fallible Medicine is still treated as an art, not a science Systems do not catch mistakes before they reach the patient

DRAFT – final pending AHRQ approval Educate staff on the Science of Safety 12, 13 8 Understand that the system determines performance and safety is the property of the system -Majority of errors don’t belong to individual doctors or nurses Use strategies to improve system performance -Standardize -Create independent checks for key processes -Learn from mistakes Recognize that teams make wise decisions with diverse and independent input

DRAFT – final pending AHRQ approval System Factors Impact Safety 14 9 Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional

DRAFT – final pending AHRQ approval Safety is a Property of the System 10

DRAFT – final pending AHRQ approval Educate staff on the Science of Safety 12, Understand that the system determines performance and safety is the property of the system -Majority of errors don’t belong to individual doctors or nurses Use strategies to improve system performance -Standardize -Create independent checks for key processes -Learn from mistakes Recognize that teams make wise decisions with diverse and independent input

DRAFT – final pending AHRQ approval Standardize When You Can 12

DRAFT – final pending AHRQ approval Create Independent Checks 13

DRAFT – final pending AHRQ approval Educate staff on the Science of Safety 12, Understand that the system determines performance and safety is the property of the system -Majority of errors don’t belong to individual doctors or nurses Use strategies to improve system performance -Standardize -Create independent checks for key processes -Learn from mistakes Recognize that teams make wise decisions with diverse and independent input

DRAFT – final pending AHRQ approval Communication Breakdowns 15

DRAFT – final pending AHRQ approval Basic Components and Process of Communication 21 16

DRAFT – final pending AHRQ approval Comprehensive Unit-based Safety Program (CUSP) 1 17 CUSP for Surgery 1.Educate staff on science of safety 2.Identify defects 3.Recruit executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools We are here Adaptive Work

DRAFT – final pending AHRQ approval What is a defect? 18 Anything that happens that you do not want to happen again.

DRAFT – final pending AHRQ approval 19 Examples of Defects That Affect Patient Safety

DRAFT – final pending AHRQ approval How can your team identify defects? 20 Event reporting systems, liability claims, sentinel events, M&M conference Perioperative Staff Safety Assessment (PSSA) – completed by all staff members (not just medical) in the clinical area

DRAFT – final pending AHRQ approval PSSA taps into the wisdom of frontline providers 21 Frontline providers: –Understand the patient safety risks in their clinical areas –Have insight into potential solutions to these problems We need to tap into this knowledge and use it to guide safety improvement efforts

DRAFT – final pending AHRQ approval What is the Perioperative Staff Safety Assessment (PSSA)? 22 Asks providers to complete 4 questions: Please describe how you think the next patient in your unit/clinical area will be harmed Please describe what you think can be done to prevent or minimize this harm Please describe how you think the next patient in the OR will get a Surgical Site Infection Please describe what you think can be done to prevent this Surgical Site Infection

DRAFT – final pending AHRQ approval When and Who administers the PSSA? 23 Who: SUSP project lead or a designee Recommendation: Administer PSSA following training on the Science of Safety – providers will have lenses to see system problems To encourage staff to report safety concerns, establish a collection box or envelope in an accessible location where completed forms can be dropped off Staff should complete the PSSA at least every 6 months

DRAFT – final pending AHRQ approval What do you do with the PSSA results? 24 Prioritize identified defects using the following criteria: Likelihood of the defect harming the patient Severity of harm the defect causes How commonly the defect occurs Likelihood that the defect can be prevented in daily work

DRAFT – final pending AHRQ approval How will the next patient be harmed? (SSI Specific) Percentage of Responses (%)

DRAFT – final pending AHRQ approval PSSA follow-up 26 It is crucial that physician and nurse leaders respond to staff patient concerns The SUSP team and other leaders must be ready to follow-up on the defects identified on the PSSA You will use PSSA data to create your local surgical care improvement bundle

DRAFT – final pending AHRQ approval Next steps 27 **Present the SOS video and administer PSSA during these ideal times: Medical staff Grand Rounds New staff orientation Regularly scheduled staff meetings (for nurses, surgeons, anesthesiologists, etc) Lunch and learn sessions Special educator sessions Make video available in break room Hang up SOS factsheet in break room, restroom, etc. Annual recertification requirements Hospital Intranet

DRAFT – final pending AHRQ approval Next Steps Engage staff who’ve watched the video 28 Discuss safety events in the clinical area What systems may have led to these events? How can the principles of safe design be applied to prevent future events? How can staff and others in the clinical area improve communication? How can these concepts be applied in the SUSP project?

DRAFT – final pending AHRQ approval Next steps Use these tools to educate staff on the Science of Safety 29 Next stepTools to useLocation of tool Educate SUSP team on Science of Safety (SOS)** Science of Safety video Science of Safety training attendance sheet A Live Walkthrough of the SUSP Website! Administer Perioperative Staff Safety Assessment (PSSA) to SUSP team** Perioperative Staff Safety Assessment Hang SOS factsheet in break room, rest room, etc. SOS factsheet Collate results of PSSA and share with SUSP team Reference this presentation for help with sharing results

DRAFT – final pending AHRQ approval References 30 1.Pronovost P, Cardo D, Goeschel C, et al. A Research Framework for Reducing Patient Harm. Oxford Journals. 2011; 52(4): Bates DW, Cullen DJ, Laird N, et al. Incidence of Adverse Drug Events and Potential Adverse Drug Events. ADE Prevention Study Group. JAMA. 1995; 274(1): 29–34. 4.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. 1995; 23(2): Andrews LB, Stocking C, Krizek T, et al. An Alternative Strategy for Studying Adverse Events in Medical Care. Lancet. 1997; 349(9048):

DRAFT – final pending AHRQ approval References 31 6.Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March Klevens M, Edwards J, Richards C, et al. Estimating Health Care- Associated Infections and Deaths in U.S. Hospitals, PHR. 2007;122:160– Ending health care-associated infections, AHRQ, Rockville, MD;

DRAFT – final pending AHRQ approval References World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. Accessed August 7, 2013./ 11.Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. Patient-Assessment- Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQuality MeasuresFINAL.PDF. Published March Accessed August 7, Baker DP, Day R, Salas E. (2006), Teamwork as an Essential Component of High-Reliability Organizations. Health Services Research. 41:1576– Pronovost P, Goeschel C, Marstellar J,et al. Framework for Patient Safety Research and Improvement. Circulation Journal of the American Heart Association. 2009; 119:

DRAFT – final pending AHRQ approval References Vincent C, Taylor-Adams S, Stanhope N. Framework for Analysing Risk and Safety in Clinical Medicine. BMJ. 1998;316: Healthcare-Associated Infection: A Preventable Epidemic. Committee on Oversight and Government Reform. ent&task=view&id=3649&Itemid=2. Accessed August14, Center for Disease Control. Appendix B: Summary of Recommended Frequency of Replacements for Catheters, Dressing, Administration Set and Fluids. MMWR. 2002;51:RR Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating Catheter- related Bloodstream Infections in the Intensive Care Unit. Crit Care Med. 2004; 32(10):

DRAFT – final pending AHRQ approval References Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med. 2006; 355: Pronovost P, Goeschel C, Needham D. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ 2010;340:c Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. Accessed August 7, Dayton E, Henrikson K. Teamwork and Communication: Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. Jt Comm J Qual Patient Saf. 2007; 31(1): Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215(2):