1. 1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ approval Lisa Lubomski, PhD Cohort 5 presentation May 19 th and May 21 st

2. DRAFT – final pending AHRQ approval Join SUSP Affinity Groups! Learn from experts and other SUSP hospital teams who are working on what you’re working on Early recovery protocol (ERP) Preop care coordination SCIP measuresEnvironmental management Pain management, fluid management, postop mobility Glucose control, bowel prep, oral antibiotics Antibiotic prophylaxis, normothermia, skin prep OR traffic, sterile technique, surface contamination Traci Hedrick, MD University of Virginia Melanie Morris, MD University of Alabama Skandan Shanmugan, MD University of Pennsylvania Miriana Pehar Johns Hopkins Hospital Coaching calls every other month Quarterly Coaching Calls Click this link SUSP Affinity Group Registration Link to register for an affinity group by Friday, May 23 rd !SUSP Affinity Group Registration Link Click this link SUSP Affinity Group Registration Link to register for an affinity group by Friday, May 23 rd !SUSP Affinity Group Registration Link

3. Learning Objectives 3 After this session, you will be able to: 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 Apply Science of Safety into your work DRAFT – final pending AHRQ approval

4. 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

5. DRAFT – final pending AHRQ approval Advances in Medicine: Lingering Contradictions 5 Postoperative X-Ray Reveals Unwanted Situations 2 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.

6. DRAFT – final pending AHRQ approval Why is your SUSP work important? 10 6 1 in 25 people will undergo surgery 7 million (25%) complications result from in-patient surgeries 1 million (0.5 – 5%) deaths follow surgery Surgery is linked to 50% of all hospital adverse events Most hospital adverse events are AVOIDABLE

7. 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

8. 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 Recognize that teams make wise decisions with diverse and independent input

9. 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

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

11. DRAFT – final pending AHRQ approval Educate staff on the Science of Safety 12, 13 11 Understand that the system determines performance and safety is the property of the system 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

12. DRAFT – final pending AHRQ approval StandardizeWhenYou Can Standardize When You Can 12

13. DRAFT – final pending AHRQ approval Create Independent Checks 13

14. DRAFT – final pending AHRQ approval Educate staff on the Science of Safety 12, 13 14 Understand that the system determines performance and safety is the property of the system Use strategies to improve system performance Recognize that teams make wise decisions with diverse and independent input

15. DRAFT – final pending AHRQ approval Communication Breakdowns 15

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

17. 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

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

19. DRAFT – final pending AHRQ approval 19 Defect Examples That Affect Patient Safety

20. 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 in the clinical area, not just medical staff

21. DRAFT – final pending AHRQ approval PSSA Taps 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

22. DRAFT – final pending AHRQ approval What is the PSSA? 22 Perioperative Staff Safety Assessment (PSSA) asks providers to complete 4 questions: 1 How will the next patient in your unit or clinical area be harmed? 2 What can be done to prevent or minimize this harm? 3 How will the next patient in the OR get a Surgical Site Infection? 4 What can be done to prevent this Surgical Site Infection?

23. 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

24. DRAFT – final pending AHRQ approval What’s Next? Interpreting PSSA results 24 Prioritize identified defects using the following criteria: Likelihood of the defect harming the patient Severity of harm the defect causes Frequency of the defect occurrence Likelihood of preventing defect in daily work

25. DRAFT – final pending AHRQ approval SSI Specific PSSA Sample Results 22 25 Percentage of Responses (%) How will the next patient be harmed?

26. 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

27. DRAFT – final pending AHRQ approval Present the Science of Safety (SOS) video and administer PSSA during these ideal times: 27 Medical staff Grand Rounds New staff orientation Regularly scheduled staff meetings (for nurses, anesthesiologists, surgeons, etc.) Lunch & 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 Others? Next Steps

28. DRAFT – final pending AHRQ approval 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? Engage Viewers of Science of Safety

29. DRAFT – final pending AHRQ approval 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 Tools: Science of Safety

30. DRAFT – final pending AHRQ approval 30 Apply Science of Safety principles in 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). 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 Recap of Learning Objectives

31. DRAFT – final pending AHRQ approval 31 Every system is designed to achieve the results it gets. The principles of safe design are standardize when you can, create independent checks, and learn from defects. Teams make wise decisions when there is diverse input. The Perioperative Staff Safety Assessment helps teams identify defects that the team can address and design interventions that prevent them from occurring in the future. Lessons Learned

32. DRAFT – final pending AHRQ approval 32 Questions?

33. DRAFT – final pending AHRQ approval 33 1.Pronovost P, Cardo D, Goeschel C, et al. A Research Framework for Reducing Patient Harm. Oxford Journals. 2011; 52(4): 507-513. 2.http://home.earthlink.net/~radiologist/tf/050800.htmhttp://home.earthlink.net/~radiologist/tf/050800.htm 3.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):294-300. 5.Andrews LB, Stocking C, Krizek T, et al. An Alternative Strategy for Studying Adverse Events in Medical Care. Lancet. 1997; 349(9048): 309-313. 6.Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

34. DRAFT – final pending AHRQ approval 34 7.Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March 2009. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf 8.Klevens M, Edwards J, Richards C, et al. Estimating Health Care- Associated Infections and Deaths in U.S. Hospitals, 2002. PHR. 2007;122:160–166. 9.8. Ending health care-associated infections, AHRQ, Rockville, MD; 2009. http://www.ahrq.gov/qual/haicusp.htm. http://www.ahrq.gov/qual/haicusp.htm 10.World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. http://www.who.int/patientsafety/challenge/safe.surgery/en/. Accessed August 7, 2013./

35. DRAFT – final pending AHRQ approval 35 11.Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQuali tyMeasuresFINAL.PDF. Published March 2012. Accessed August 7, 2013. 12.Baker DP, Day R, Salas E. (2006), Teamwork as an Essential Component of High-Reliability Organizations. Health Services Research. 41:1576–1598. 13.Pronovost P, Goeschel C, Marstellar J,et al. Framework for Patient Safety Research and Improvement. Circulation Journal of the American Heart Association. 2009; 119:330-337. 14.Vincent C, Taylor-Adams S, Stanhope N. Framework for Analysing Risk and Safety in Clinical Medicine. BMJ. 1998;316:1154. 15.Healthcare-Associated Infection: A Preventable Epidemic. Committee on Oversight and Government Reform. http://democrats.oversight.house.gov/index.php?option=com_content&task =view&id=3649&Itemid=2. Accessed August14, 2013.

36. DRAFT – final pending AHRQ approval 36 16.Center for Disease Control. Appendix B: Summary of Recommended Frequency of Replacements for Catheters, Dressing, Administration Set and Fluids. MMWR. 2002;51:RR-10. 17.Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating Catheter-related Bloodstream Infections in the Intensive Care Unit. Crit Care Med. 2004; 32(10):2014-2020. 18.Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med. 2006; 355:2725-2732. 19.Pronovost P, Goeschel C, Needham D. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ 2010;340:c309 20.Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. http://www.onthecuspstophai.org/. Accessed August 7, 2013.

37. DRAFT – final pending AHRQ approval 37 21.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):34-47. 22.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):193-200.