1. Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@comcast.net People, Priorities, & Learning Together Module1

2.  44,000 to 98,000 preventable death in hospitals related to medical errors annually (IOM report, 1999)  238,337 deaths due to potentially avoidable patient safety incidents between 2004-2006 (HealthGrades)  $50 billion in total costs  5 th leading cause of death in US-more than AIDS, breast cancer, MVAs 2

3. The History of CUSP – Michigan Project  Keystone project – Michigan initiative-75 Hospitals, 127 ICUs  In Collaboration with Johns Hopkins 'Quality and Research Institute  Reduce errors and improve patient outcomes in ICUs  Combination of evidence based medicine and quality improvement  5 interventions implemented over a 2 year Grant funded period  Still going strong after 5 years!!!! 3

4. ◦ CUSP:Science of Safety ◦ CLABSI ◦ VAP ◦ Daily Goals ◦ Sepsis ◦ Oral Care ◦ Delirium Partnership between Johns Hopkins University and MHA Initiated with AHRQ Matching Grant Sustained with participant fees in 2005 and 2006 4

5. 1. Form a unit CUSP team with executive sponsorship 2. Measure unit culture 3. Educate staff on Science of Safety 4. Identify defects using the Staff Safety Assessment; prioritize defects 5. Learn from one defect per quarter 6. Implement team/communication tools 5

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7.  Must be unit based ◦ If you want to understand and impact unit culture and safety the team members should include front line staff  Who should be on the team? ◦ Those involved in delivering patient care on unit – will vary by unit type  Team Leader  Nurses—representatives from all shifts  Physician—unit medical director, residents  Pharmacist  Infection control practitioner  Nurse manager/unit leader 7

8.  Executive should become a member of the team  Executive should review defects, ensure teams have resources to reduce risk, hold teams accountable for decreasing/improving risks  Round at least quarterly with goal of talking with at least 60% of the staff  Key Messages for Executive sponsors 8

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10. That’s not the way we do it here!!! What is a Culture? Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179 10

11.  How to will be discussed on October’s call  HSOPS tool 11

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13. Lucien L. Leape, MD Harvard School of Public Health

14.  People are fallible  Medicine is still treated as an art, not science  Need to view the delivery of healthcare as a science  Need systems that catch mistakes before they reach the patient 14

15. Process FactorsPeople Factors  Variable input (diff pts)  Inconsistency/variation  Complexity  Too many/complicated steps  Human intervention  Tight time constraints  Hierarchical culture  Fatigue  Inattention/distraction  Unfamiliar situations/new problem  Using past solutions  Equipment design flaws  Communications errors  Mislabeling/inadequate instructions 15

16. Catheter pulled with Patient sitting Communication between resident and nurse Lack of protocol For catheter removal Inadequate training and supervision Patient suffers Venous air embolism 8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004. 9. Reason J, Hobbs A., 2000. 16

17. Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional Adapted from Vincent BMJ 17

18.  Every system is perfectly designed to achieve the results it gets  Understand principles of safe design ◦ standardize, create checklists, learn when things go wrong  Recognize these principles apply to technical and team work  Teams make wise decisions when there is diverse and independent input Caregivers are not to blame 18

19.  Standardize ◦ Eliminate steps if possible  Create independent checks  Learn when things go wrong ◦ What happened? ◦ Why? ◦ What did you do to reduce risk? ◦ How do you know it worked? 19

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21.  Two questions for bedside staff: ◦ 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 21

22.  List all defects  Discuss with staff what are the largest safety risks? 22

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24.  What happened?  Why did it happen (system lenses)?  What could I do to reduce the risk?  How do you know the risk was reduced? ◦ Create policy/process/procedure ◦ Ensure staff know policy/process or procedure ◦ Evaluate if change has occurred Will spend sessions 3 and 4 on Learning from Defects 24

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26.  Daily rounds/goals  Pre-procedure briefing  Morning briefing  Huddles  Learn from a defect 26

27. (culture and teamwork)

28. % of respondents within an ICU reporting good teamwork climate Teamwork Climate Across Michigan ICUs

29. % of respondents within an ICU reporting good safety climate Safety Climate Across Michigan ICUs

30. % of respondents within an ICU reporting good teamwork climate Teamwork Climate Across Michigan ICUs No BSI 21% No BSI 21% No BSI 44% No BSI 44% No BSI 31% No BSI 31% No BSI = 5 months or more w/ zero The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

31. Time periodMedian Central Line Associated Bloodstream Infection Rate Baseline2.7 Intervention1.6 0-3 months0 4-6 months0 7-9 months0 10-12 months0 13-15 months0 16-18 months0 31

32. Lives Saved – 1,729* Patient Days Saved – in excess of 127,000* Dollars Saved – 0ver $246 Million* Culture of Safety improved 28% Teamwork improved 15% * Based on the Johns Hopkins Opportunity Calculator 32

33. "Needs Improvement“ Statewide Michigan CUSP ICU Results Less than 60% of respondents reporting good safety or teamwork climate =“needs improvement” Statewide in 2004 84% needed improvement, in 2006 41% Non-teaching and Faith-based ICUs improved the most Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

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36.  Session 1:Forming a CUSP team and Science of Safety Education  Session 2:Staff Safety Assessment and Measuring Culture  Session 3:Learning from a Defect-part 1  Session 4:Learning from a Defect-part 2  Session 5:Safety Culture Results and Action Planning  Session 6:Evidence-based Practice, Just Culture and CUSP team tools 36

37.  Set up your CUSP team  Calendar out 6 months of team meetings  Recruit an executive  Listen to physician engagement call  If team set up, educate team on the Science of Safety, establish plan on how to roll out to unit staff 37

38. We all are responsible for the safety of our patients----Own the issues  “If not this, then what??”  “If not now, then when?”  “If not us, then who??” 38

39. “ It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” Florence Nightingale Advocacy = Safety 39

40. “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.” Atul Gawande in his book, Better: A Surgeon’s Notes on Performance 40

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