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Measuring Progress in Patient Safety

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Presentation on theme: "Measuring Progress in Patient Safety"— Presentation transcript:

1 Measuring Progress in Patient Safety
Peter Pronovost, MD, PhD, FCCM Johns Hopkins University BNVBBVB


3 Exercise Please answer each question with a score of 1 to 5
Exercise Please answer each question with a score of 1 to is below average, 3 is average and 5 is above average How smart am I How hard do I work How kind am I How tall am I How good is the quality of care we provide

4 Improving Sepsis Care (n= 19 ICUs)
36% Reduction (NS) 69% Reduction (p < 0.001)

5 Improving Sepsis Care (n= 19 ICUs)
36% Reduction (NS) 69% Reduction (p < 0.001)

6 x Central Mandate Scientifically Sound Feasible Local Wisdom
Safety efforts are where the x is. We need to migrate to be more scientifically sound and tap into local wisdom

7 Context Have we created a culture of safety?
Conceptual model for measuring safety Process Outcome Structure How often do we harm? Have we reduced the likelihood of harm? How often do we do what we are supposed to? IT Context Have we created a culture of safety? Adapted from Donebedian

8 Keystone ICU Safety Dashboard
2004 2006 How often did we harm (BSI) 2.8/1000 How often do we do what we should 66% 95% How often did we learn from mistakes 100s % Needs improvement in Safety climate Teamwork climate 84% 82% 43% 42% Pronovost JAMA 2007

9 Pronovost BMJ 2008

10 Comprehensive Unit-based Safety Program (CUSP)
Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter and implement teamwork tools The intervention we used to improve culture and learn from mistakes is the comprehensive unit based safety program. Your role in the csicu was as the executive who adopted that unit. You can tell some of the defects you surfaced. Pronovost J, Patient Safety, 2005

11 What can be measured as a valid rate?
Rate requires Numerator- event Denominator- those at risk for event Surveillance for events and those at risk Minimal and Known Error Random error Systematic error

12 Sources Variation in Safety measures
True variation in Safety V data quality/definition/methods of collection V case mix V historical rates Chance


14 Measuring Preventable Harm
Measure rate or counts directly High sensitivity low specificity Estimate observed/expected (O/E) Low sensitivity and specificity Link process and outcome High specificity and moderate sensitivity

15 Process Measures Validity of the construct
Validity of how we measure construct

16 It is Ok to have non-rate measures
Self reported measures are generally not valid as rates A common mistake is interpreting a non-rate measure as a valid rate



19 Learning from Mistakes
What happened? Why did it happen (system lenses) What could you do to reduce risk How to you know risk was reduced Create policy/process/procedure Ensure staff know policy Evaluate if policy is used correctly Pronovost 2005 JCJQI

20 Pronovost Health affairs in press
Identify Hazards ( 3. Mitigate Risks 2. Analyze & Prioritize Hazards 4. Evaluate Effectiveness of Risk Reduction Patient Safety Learning Communities Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control. Pronovost Health affairs in press

21 GYN/OB JHOC Medicine Neurosciences Oncology Ophthalmology
FAC: Fetal Assessment Center/OB Ultrasound  GSS - Shared Specialty Suite  Asthma & Allergy - Allergy & Clinical Immunology  BRU  GSS - Medical Oncology  GSS - Wilmer 110  GSS - GYN/OB 420  JHOPC - Express Testing  Asthma & Allergy - Pulmonary  EMU  IPOP Clinic - HIPOP Location  GSS - Wilmer Laser Center  GSS - GYN/REI  JHOPC - OR  Asthma & Allergy - Rheumatology  JHOPC Neurosciences  IPOP Clinic - IPOP Location  WECP & ER  HAL-2  JHOPC - PACU  Blalock 4 - Endoscopy  MEY 8 (12) Weinberg OPD - 1st Floor  Wilmer OR  JHOPC GYN/OB  WM - Shared Specialty Suite  Blalock 5 Echo Lab (2) MEY 9 (5) Weinberg OPD - 2nd Floor  Wilmer PACU  MCE  Cardiac CT  NCCU7  WGA 5 (5) Wilmer White Marsh  NEL-2 Nursery  CCP-5 (5) WGB 5  Wilmer: Other - E Balt Divisions  NEL-2 Obstetric OR  CCU-5 (7) WGC-5 (3) Wilmer: Other - Satellites  NEL-2 PACU  CVC  WGD 5  Nelson Harvey 2  CVIL- CardioVascular Interventional Lab  OSL-2  Dialysis Unit  OSL-3 Nursery  GSS - Internal Medicine  OSL-3  HAL-5 (5) WGB-4  HAL-8 (7) Hospitalist Unit (5) JHOPC - Exec Health & Travel Clinic  JHOPC - Medicine Clinics 


23 CAST Each contributing factor rate Each Intervention rate
importance of the problem and contributing factors in causing the accident importance of the problem and contributing factors in future accidents Each Intervention rate How well the intervention solves the problem or mitigates the contributing factors for the accident Rates the team belief that the intervention will be implemented and executed as intended

24 “The way we do things around here”
What is Culture*?: “The way we do things around here” here 1 attitude = opinion…everyone’s attitude = culture *aka Climate



27 Executive Perceptions vs. Frontline Perceptions:
Executives overestimate: Teamwork Climate 4X Safety Climate 2.5X Executive Confidence vs. Executive Accuracy: -Often wrong but rarely in doubt… -Currently no incoming data-streams -Halo Effects -Frontline data fills the gap

28 * Statistically Significant
6 of 7 domains have shown statistically significant improvements since 2006. * Statistically Significant 28

29 71 Teamwork Climate 2008 67 Teamwork Climate 2007 64 Teamwork Climate 2006 62 Teamwork Climate 2005 This illustrates the teamwork domain scores (safety on the next slide) for each of the 150+ units across the organizaiton. It is important to notice the variability…even with an organizational domain score of 71. It also shows how many units are below the danger zone threshhold (60%). 29

30 60 Safety Climate 2006 65 Safety Climate 2007 70 Safety Climate 2008 59 Safety Climate 2005 30

31 #4. “I Would Feel Safe Being Treated Here As A Patient.”
% of respondents within an ICU that agree

32 #3. “Nurse Input Is Well Received In This ICU.”
% of respondents within an ICU that agree

33 #26. “In This ICU, It Is Difficult To Speak Up If I Perceive A Problem With Patient Care.”
% of respondents within an ICU that agree

34 #32. “Disagreements In This ICU Are Resolved Appropriately (i. e
#32. “Disagreements In This ICU Are Resolved Appropriately (i.e. not who is right, but what is best for the patient).” % of respondents within an ICU that agree

35 Questions for Reflection
How do you know you are safer? How will you become more efficient in your measurement efforts? How will you better tap into local wisdom?

36 Focus and Execute


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