1. Sean Berenholtz, MD MHS Learning From Defects and Implementing Daily Goals

2. Slide 2 Comprehensive Unit-based Safety Program (CUSP) 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools

3. Learning From Defects

4. Slide 4 Objectives To understand the difference between first order and second order problem solving To understand how to address each of the 4 questions in learning from defects – What happened, why, what will you do to reduce risk, and how do you know it worked

5. Slide 5 Case Example 65 yo M s/p lung resection for cancer Admit to ICU; discharged to floor POD 1 POD 3 develops hypoxia Admitted to ICU, intubated CXR shows extensive left lung collapse Decision to perform broncoscopy

6. Slide 6 System Failure Leading to Error Patient Illness Bronch cart not stocked Communication between resident and nurse Fatigue Patient suffers Hypoxic arrest

7. Slide 7 Problem Solving* First Order −Recovers for that patient yet does not reduce risks for future patients −Example: You go get the supply or you make do Second Order −Reduces risks for future patients by improving work processes −Example: You create a process to make sure supplies are stocked *Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72.

8. Slide 8 Learning From Defects Tool Frontline caregivers are eyes and ears of patient safety Practical investigative tool Can be used to investigate events or near misses Can also be used in Morbidity & Mortality Rounds, investigations resulting from sentinel events or liability claims Involves a 4 step structured process Guides the user through evaluation of system factors that may have contributed to an event

9. Slide 9 4 Questions (steps) to Learn from Defects What happened? – From the view of the person involved Why did it happen? – Evaluates the defect What will you do to reduce the chance it will recur? – Specific actions needed to reduce the likelihood of recurrence. How do you know that you reduced the risk that it will happen again?

10. Slide 10 Step 1. What Happened? Construct a brief, concise statement of the “story” surrounding the incident Reconstruct the timeline of the incident or near miss. Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking when the event occurred Try to view the world as they did when the event occurred Why did they make the decisions they made and take the actions they took? Source: Reason, 1990;

11. Slide 11 Step 2. Evaluate the Defect Evaluate the defect by: – Reviewing and checking all the factors that caused or negatively contributed to patient harm – Reviewing and checking all positive factors that might have reduced or eliminated harm

12. Slide 12 Probes to Contributing Factors: Examples PatientWas the patient acutely ill? Agitated? Anxious? Aged? Language barrier? Personal or social issues? TaskWas a stated policy/protocol or guidelines followed? Were labs available for decision making? CaregiverFatigue? Lack of experience by care givers? Any physical or mental health issues with provider? TeamWere handoffs (verbal or written) clear? Was there a clearly identified team leader? Were team members hearing one another’s concerns? Training and EducationWas established protocol followed? Were caregivers knowledgeable and competent?

13. Slide 13 Step 3. What will you do to reduce the risk of it happening again Prioritize most important contributing factors and most beneficial interventions Safe design principles – Standardize what we do −Eliminate defect – Create independent check – Make it visible Safe design applies to technical and team work

14. Slide 14 What will you do to reduce risk Develop list of interventions For 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 Select top interventions (2 to 5) and develop intervention plan – Assign person, task follow up date

15. Slide 15 Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant

16. Slide 16 Step 4. How do you know risks were reduced? Did you create a policy or procedure (weak) Do staff know about policy or procedure Are staff using the procedure as intended – Behavior observations, audits Do staff believe risks were reduced

17. Slide 17 Summarize and Share Findings Summarize finds – 1 page summary of 4 questions – Learning from defect figure Share within your organizations Share de-identified with others in collaborative (pending institutional approval)

18. Slide 18 Examples of where this was applied CUSP program Critical Care Fellowship Program Morbidity and Mortality Conferences Anesthesiology residency program

19. DefectInterventions Fellow 1Unstable oxygen tanks on bedsOxygen tank holders repaired or new holders installed institution-wide Fellow 2Nasoduodenal tube (NDT) placed in lungProtocol developed for NDT placement Fellow 3Medication look-alikeEducation, physical separation of medications, letter to manufacturer Fellow 4Bronchoscopy cart missing equipmentChecklist developed for stocking cart Fellow 5Communication with surgical services about night coverage White-board installed to enhance communication Fellow 6Inconsistent use of Daily Goals rounding toolGained consensus on required elements of Daily Goals rounding tool use Fellow 7Variation in palliative care/withdrawal of therapy orders Orderset developed for palliative care/withdrawal of therapy Fellow 8Inaccurate information by residents during roundsDeveloping electronic progress note Fellow 9No appropriate diet for pancreatectomy patientsDeveloping appropriate standardized diet option Fellow 10Wrong-sided thoracentesis performedEducation, revised consent procedures, collaboration with institutional root-cause analysis committee Fellow 11Inadvertent loss of enteral feeding tubePilot testing a ‘bridle’ device to secure tube Fellow 12Inconsistent delivery of physical therapy (PT)Gaining consensus on indications, contraindications and definitions, developing an interdisciplinary nursing and PT protocol Fellow 13Inconsistent bronchoscopy specimen laboratory ordering Education, developing an orderset for specimen laboratory testing Am J Med Qual 2009;24(3):192-5. Learning From Defects to Enhance Morbidity and Mortality Conferences

20. Slide 20 Evaluations Evaluations “one of the most valuable parts of [their] fellowship”...their project “improved [their] understanding of safe systems” “it was great to work with colleagues from other disciplines to improve patient care” “changing a system can be difficult, but [they] are better prepared to address patient safety defects after fellowship”

21. Slide 21 Learning from Defects in M&M Conference Select 1 or 2 meaningful cases Invite everyone who touches the process including administrators Summarize event Identify hazardous systems Close the Loop (issue, person, F/U) Share what you learn

22. Slide 22 Sources of Defects Adverse event reporting systems Sentinel events Claims data Infection rates Complications How is the next patient going to be harmed

23. Slide 23 Staff Identify Defects Survey staff; establish a collection box or envelope Identify and group common defects (such as communication, medications, patient falls, supplies, etc.) Summarize as frequencies (i.e., what percent of responses were for communication) QI team reviews data, set the agenda for discussion with executive partner

24. Slide 24 Key Lessons Focus on systems not people Prioritize Use Safe design principles Go mile deep and inch wide rather than mile wide and inch deep Pilot test Learn form one defect a month/quarter Answer the 4 questions

25. Slide 25 References Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32. Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108. Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000. Vincent C. Understanding and responding to adverse events New Eng J Med 2003;348:1051-6. Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87. Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):192-5.

26. Implementing Daily Goals

27. Slide 27 Learning Objectives To understand the importance of having daily goals To understand basics of communication To learn how to implement daily goals in your ICU To understand that daily goals is a tool to improve teamwork and communication AND supports interventions to reduce CLABSI and VAP

28. Slide 28 Importance of Daily Goals People and organizations who create explicit goals and provide feedback toward goals achieve more than those who do not Rounds generally provider rather than patient centered Discussion on rounds is divergent (brainstorming) rather than convergent (explicit plan)

29. Slide 29 % of respondents reporting above adequate teamwork ICU Physicians and ICU RN Collaboration ICUSRS Data

30. Slide 30 Communication Errors Communication errors most common contributing factor for all types of sentinel events reported to The Joint Commission Over 80% of staff responding to the question, “how will the next patient be harmed” list communication failure

31. Slide 31 Basic Components and Process of Communication Elizabeth Dayton, Joint Commission Journal, Jan. 2007

32. Slide 32 Daily Goals Standardizes communication and creates independent checks Helps ensure diverse input Adds convergent thinking to often divergent rounds Reduces encoding and decoding errors

33. Slide 33 Sample Daily Goals J Crit Care 2003;18(2):71-75

34. Slide 34 How to Use Goals? Be explicit Important questions – What needs to be done for discharge – What will we do today – What is patients greatest safety risk Completed on rounds and nurse reads back Stays with bedside nurse Modify to fit your hospital

35. Slide 35 Percent Understanding Patient Care Goals Pronovost daily goals Implemented patient goals sheet

36. Slide 36 Impact on ICU Length of Stay 654 New Admissions: 7 Million Additional Revenue Daily Goals

37. Slide 37 N Engl J Med 2006;355:2725-32; BMJ 2010;340:c309. Michigan Keystone ICU

38. Slide 38 Infect Control Hosp Epidemiol. 2011;32(4): 305-314 Michigan Keystone ICU (n=

39. Slide 39 Action Plan Present the idea to your local team Draft a daily goals form Obtain support from one or more physicians Monitor number of time physicians are paged (WIFM) – Daily goals reduced pages by 80% Pilot test on one patient Expand

40. Slide 40 References Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003;18(2):71-5. Dayton E, Henriksen K. Teamwork and Communication: Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. Jt Comm J Qual Patient Saf 2007;33(1):34-47. Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. The daily goals communication sheet: A simple and novel tool for improved communication and care. Jt Comm J Qual Patient Saf 2008;34(10):608-13. Timmel J, Kent PS, Holzmueller CG, Paine L,et.al. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36:252-60.