7-8 September 2016 Sheraton Hotel & Towers Ho Chi Minh City, Vietnam

Transcription

1 7-8 September 2016 Sheraton Hotel & Towers Ho Chi Minh City, Vietnam

2 Patient Safety at What Cost? Prof Anupam Sibal MD, FIAP, FIMSA, FRCP (Lon), FRCP (Glas), FRCPCH, FAAP Group Medical Director, Apollo Hospitals Group Clinical Professor Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia Senior Consultant Pediatric Gastroenterologist and Hepatologist Apollo Centre for Advanced Pediatrics Delhi, India

3 Virgin Galactic Overview Effect $250,000

4 Cost of most expensive dress? $30 million Nightingale of Kuala Lumpur

5 Cost of most expensive diamond? $57.5 million The Oppenheimer Blue

6 Cost of most expensive wedding? $110 million* Princess Diana and Prince Charles Inflation adjusted

7 Cost of human life?

8 Cost for a fall related injury $13,000 Source: Joint Commission

9 Cost per adverse drug event $5,000 Source: AHRQ, Interim Update on 2013 Annual Hospital Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013

10 Cost per pressure ulcer $17,000 Source: AHRQ, Interim Update on 2013 Annual Hospital Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013

11 Cost per urinary tract infection $1,000 Source: AHRQ, Interim Update on 2013 Annual Hospital Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013

12 Cost per central line blood stream infections $17,000 Source: AHRQ, Interim Update on 2013 Annual Hospital Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013

13 Cost per ventilator associated pneumonia $21,000 Source: AHRQ, Interim Update on 2013 Annual Hospital Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013

14 Cost per surgical site infection $21,000 Source: AHRQ, Interim Update on 2013 Annual Hospital Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013

15 Healthcare Associated Infections Burden Source: Estimating the Cost of Health Care Associated Infections: Mind Your p s and q s Healthcare Epidemiology

16 Cost of surgical mistakes Type of never event Cases Retained foreign body Average pay out 4,857 $86,247 Wrong patient 27 $109,648 National Practitioner Data Bank between 1990 and 2010 financial consequences of surgical never events. Source: Surgical never events in the United States, Surgery, Dec. 17, 2012, American Medical News

17 Cost of surgical mistakes Type of never event Cases Average pay out Wrong site 2,413 $127,159 Wrong procedure 2,447 $232,035 National Practitioner Data Bank between 1990 and 2010 financial consequences of surgical never events. Source: Surgical never events in the United States, Surgery, Dec. 17, 2012, American Medical News

18 Global occurrence of adverse events Approximately 42.7 million adverse events occur in the world annually Approximately 116,986 adverse events occur everyday Approximately 4874 adverse events occur every hour Approximately 81 adverse events occur every minute Source for estimation: The global burden of unsafe medical care: analytic modelling of observational studies; BMJ Qual Saf : originally published online September 18, 2013;

19 Healthcare Associated Infections ALOS of patients Without HAI With BSI With UTI With VAP 6.2 days 17.1 days 18.5 days 18.0 days Source: International Nosocomial Infection Control Consortium report, 2012, Data summary of 36 countries for covering 422 ICUs, The American Journal of Infection Control in 2012

20 Healthcare Associated Infections Crude mortality of patients Without HAI 10% Patients with UTI 17.3% Patients with BSI 24.7% Patients with VAP 25.2% Source: International Nosocomial Infection Control Consortium report, 2012, Data summary of 36 countries for covering 422 ICUs, The American Journal of Infection Control in 2012

21 Cost of global preventable harm costs Estimated per day cost of preventable medical harm $2.7 billion Estimated per hour cost of preventable medical harm $114 million Source for estimation: If applied to the most recent estimate in Health Affairs that says preventable medical harm is ten times what the IOM report says, then that cost could be $735 billion to $980 billion almost $1 trillion annually. Journal of Healthcare Finance; The Economics of Health Care Quality and Medical Errors, 2012

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23 Safety in other industries Aviation Safety Program, NASA Source: National Aeronautics and Space Administration FY 2015 PRESIDENT S BUDGET REQUEST SUMMARY

24 Safety in other industries Sustained Value Data (Centre for Chemical Process Safety)

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31 Safe care is less expensive care Litigation costs for a medication error: as per NHS Litigation Authority September 2013 Monica Sprague Jorge has agreed to a $9.5 million settlement in a hospital infection lawsuit filed against Emerson Hospital in Concord, Massachusetts Legal claims related to in hospital falls resulted in payment of costs or damages, with mean payment of CAN$28,721 Malpractice lawsuits $279,000/monetary settlement for a stage IV pressure ulcer Sources/ estimation: Costing statement: medicines optimization (March 2015), NICE The Schmidt Firm, PLLC Canadian Patient Safety Institute, Economics of Patient Safety High Cost of Stage IV Pressure Ulcers, PMC, US National Library of Medicine

32 Brandeis Study Impact of Accreditation Return to ICU within 24 hours or discharge Accredited = 0.1% vs. 0.9% Savings = US$34,400 per hospital/year Staff turnover rate Accredited = 3.0% vs. 13.0% Savings = US$53,210 per hospital/year Shepard DS, et al. Value and Impact of International Hospital Accreditation: A Case Study from Jordan. Eastern Mediterranean Health Journal; in press, 2015.

33 More than 80 hospitals collaborate Implementation of the Network s best practices, children are being protected from harm Estimated savings of more than $109 million Saved 5,897 children from serious harm

34 Stories Retold

35 Mrs. Mary L. McClinton Treated for a brain aneurysm at Virginia Mason Medical Centre in 2004 Died because mistakenly injected with chlorhexidine, an antiseptic, instead of intravenous contrast dye

36 Her death galvanized us Our board said that if we cannot ensure safety of our patients we shouldn t be in business Cathie Furman, RN, Senior Vice President of Quality and Compliance Virginia Mason

37 Virginia Mason Set aside its dozen or so organizational goals Declared a single goal To ensure the safety of our patients through the elimination of avoidable death and injury Safety remained the single annual organizational goal for three years

38 Systematically implemented new safety protocols Virginia Mason Production System Tripled the time that nurses spent at the bedside Instituted checklists Patient Safety Alert Systems

39 Culture of Secrecy in Health Care Same error had occurred previously at another hospital two years ago No mechanism to share information across organizations

40 Josie King Admitted to Johns Hopkins Hospital with second degree burns from a bathtub accident 15 years ago

41 At the Johns Hopkins Hospital, she received skin grafts and healed Within weeks, she was acting like her old self

42 Then her condition deteriorated Josie grew pale and unresponsive She died of what was ultimately identified as septic shock Just days before she was scheduled to return home

43 Root cause analysis Dehydration and an unnecessary dose of methadone A second root cause analysis Septic shock from a hospital acquired infection and that the narcotic was not to blame The larger picture Systems had failed Communications had broken down And a parent s repeated pleas that her daughter was thirsty were not heeded

44 Moral moment for Johns Hopkins Significant culture change in its history 3 bold steps Made safety the No. 1 priority of Johns Hopkins Medicine Started board of trustees meeting with a safety report instead of a financial review Created a safety focused Centre for Innovation in Quality Patient Care (funded with $500,000)

45 In the 15 years since Johns Hopkins Medicine Pioneered a culture of accountability and patient safety advances All six Johns Hopkins hospitals recognized by the Joint Commission as Top Performers on Key Quality Measures program by 2015 But before that could happen, safety became the top priority

46 Armstrong Institute for Patient Safety and Quality "The Armstrong Institute has a single purpose: To eliminate harm." C. Michael Armstrong, former CEO and chairman of AT&T and Hughes Electronics, former board chairman of Johns Hopkins Medicine $10 Million Donation

47 Comprehensive Unit Based Safety Program (CUSP) Frontline staff Knowledge and support to tackle safety hazards More than 170 CUSP teams CUSP teams and checklists in 1,100 ICUs in 44 US states Bloodstream infections down by 40 percent saving 500 lives and $34 million

48 Caring for the Second Victims Psychological first aid to Second Victims

49 Designing Safe Systems Project Emerge Leaders collaborate with John Hopkins Engineers Tablet based application to help clinicians reduce preventable harms Microsoft working with Armstrong Institute

50 The JCI Journey of the Apollo Group... Apollo Kolkata Apollo Mauritius Apollo Ahmedabad The first JCI accredited hospital in Bangladesh Apollo Dhaka The first JCI accredited Stroke program in the world Apollo Bangalore Apollo Hyderabad The first JCI accredited hospital in India Indraprastha Apollo Delhi Apollo Ludhiana Apollo Chennai

51 The NABH Journey of the Apollo Group... ASH, Vanagram Chennai Apollo Hospitals Bhilai Apollo Hospital Trichy Apollo BGS Hospitals Mysore Apollo Hospitals Bhubaneswar Apollo Hospital Hyderguda Apollo Hospital, Kakinada Apollo Hospitals Secunderabad Jehangir Hospital Pune Apollo Hospitals Ahmedabad Apollo Hospitals Bilaspur Apollo Hospitals Noida Apollo Speciality Hospitals Madurai ASH Nandanam, Chennai

52 Apollo Quality Program Monitoring Parameter Clinical Handovers Scoring 1 Percentage compliance to completion of In house transfer form before patient transfer >90% 80-90% <80% 2 Percentage compliance to use of nursing handover form for patient handover >90% 80-90% <80% 3 Percentage compliance to use of physician handover form for patient handover >90% 80-90% <80% 4 No. of instances (per month) where Clinical Handovers were one of the proximate causes for the adverse clinical events and outcomes 0 1 >1 IPSGs 5 IPSG 1 Tracker score 100% % <90% 6 IPSG 2 Tracker score 100% % <90% 7 IPSG 3 Tracker score 100% % <90% 8 IPSG 4 Tracker score 100% % <90% 9 IPSG 5 Tracker score 100% % <90% 10 IPSG 6 Tracker score 100% % <90% Surgical Care Improvement 11 Percentage of patients receiving antimicrobial prophylaxis one hour before surgery >95% 90-95% <90% 12 Percentage of patients excluded from SSI calculation due to lack of follow up for the requisite time frame <20% 20-30% >30% 13 SSI <2.2% % >2.86% 14 Number of instances of wrong patient, wrong side, wrong procedure surgery None Any 15 Compliance to communicating sponge and instrument count to surgeon before skin closure >95% 90-95% <90% 16 Incidents of retained foreign body during surgery None Any Medication Safety 17 Medication errors per 100 discharges <2.2% % >2.86% 18 Medication errors due to sound alike look alike drugs as a percentage of total errors <2% 2-4% >4% Standardization of medical records Percentage compliance to minimum content 19 of medical records on closed audits >90% 80-90% <80% Clinical handovers International Patient Safety Goals (IPSGs) Surgical care improvement Minimizing medication errors Completion of medical records 20 Accuracy of ICD - 10 coding >95% 90-95% <90%

53 Apollo Quality Program Monitoring Parameter Clinical Handovers Scoring Percentage compliance to completion of In house transfer form before patient transfer Percentage compliance to use of nursing handover form for patient handover Percentage compliance to use of physician handover form for patient handover No. of instances (per month) where Clinical Handovers were one of the proximate causes for the adverse clinical events and outcomes >90% 80 90% <80% >90% 80 90% <80% >90% 80 90% <80% 0 1 >1

54 Apollo Quality Program Monitoring Parameter IPSG 1 Tracker score IPSG 2 Tracker score IPSG 3 Tracker score IPSG 4 Tracker score IPSG 5 Tracker score IPSG 6 Tracker score Scoring IPSGs 100% % <90% 100% % <90% 100% % <90% 100% % <90% 100% % <90% 100% % <90%

55 Apollo Quality Program Monitoring Parameter Surgical Care Improvement Scoring Percentage of patients receiving antimicrobial prophylaxis one hour before surgery >95% 90 95% <90% Percentage of patients excluded from SSI calculation due to lack of follow up for the requisite time frame <20% 20 30% >30% SSI <2.2% % >2.86% Number of instances of wrong patient, wrong side, wrong procedure surgery None Any Compliance to communicating sponge and instrument count to surgeon before skin closure >95% 90 95% <90% Incidents of retained foreign body during surgery None Any

56 Apollo Quality Program Monitoring Parameter Medication Safety Scoring Medication errors per 100 discharges <2.2% % >2.86% Medication errors due to sound alike look alike drugs as a percentage of total errors <2% 2 4% >4%

57 Apollo Quality Program Monitoring Parameter Scoring Standardization of medical records Percentage compliance to minimum content of medical records on closed audits >90% 80 90% <80% Accuracy of ICD 10 coding >95% 90 95% <90%

58 APOLLO QUALITY PROGRAM Cumulative Scores: Apollo Hospitals Apollo

59 Group annual average percentage compliance to use of patient handover forms Medication Errors Nursing handover In house Apollo

60 Group annual average number of incidents of retained foreign body Medication Apollo

61 Apollo ICU Checklist

62 Apollo Safe Surgery Checklist

63 Location: Month: S.no Parameters Value 1 Patient falls 2 Patient falls as per 1000 adjusted patient days 3 Needle stick injuries 4 Patient pressure ulcers 5 Patient Pressure ulcers per 1000 adjusted patient days 6 Missing patient records 7 Missing patients records per 100 discharges 8 Legal cases against the hospital 9 Legal cases against the hospital per 100 discharges 10 Legal action against the hospital 11 Any Sentinel Apollo

64 Incident Apollo

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66 Non punitive culture Acknowledging reporting of incidents

67 Multidisciplinary huddles Encouraging open communication

68 Leadership Rounds Understanding grass root problems

69 Employee Connect Employees are encouraged to speak up

70 Empowering Staff Valuing frontline staff

71 Empowering Staff Monitoring local quality and safety data

72 Culture of Safety Encouraging staff feedback

73 What is the cost of creating a culture of safety?

74 Cost Benefits of Safety Source: Indraprastha Apollo Hospitals, New Delhi, India

75 Solving the Infection and Profitability Web (From Fewer Infections to More Profit) Reduced Infections Reduced ALOS Less HAI Cases More Admits with lesser ALOS Increased Bed Turnover More Increased profits Controlled Costs

76 Implementing safety financial impact LET THE NUMBERS TALK!! Areas affected Impact Average Length of Stay days ALOS reduced Average bill amount/patient (Rs) 2,260,000 1,664,871 Rs. 595,128 per bill benefit to the patient Number of Bed Days bed days saved Savings (Because of reduced ALOS and Infection rates) Rs. 61,520,550 ($0.9 million) Source: Indraprastha Apollo Hospitals, New Delhi, India

77 Adverse Drug Events The Cost Cost of Adverse Drug Events per hospital per year: $5,600,000 * (700 bedded teaching hospital) PUBLISHED COSTS OF MEDICATION ERRORS LEADING TO PREVENTABLE ADVERSE DRUG EVENTS IN US HOSPITALS, ISPOR 20th Annual Meeting, Philadelphia, May 18 20, 2015, Abstract # PHP73 The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group Bates DW 1, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, Sweitzer BJ, Leape LL

78 Preventing Medication Errors The operating cost per year Commercial Bar Code Medication Administration (Annual Operating Cost): $600,000* CPOE (Annual Operating Cost): $500,000** Clinical Pharmacist (18) (Annual Cost): $1,620,000*** $600,000 $500,000 $1,620,000 safety applications barcode and rfid technologies Computerized Physician Order Entry (CPOE) Systems, AcademyHealth, barker pharmd/2016/04/2016 pharmacist salary guide/***

79 Preventing Medication Errors The operating cost per year Commercial Bar Code Medication Administration (Annual Operating Cost): $600,000 CPOE (Annual Operating Cost): $500,000 Clinical Pharmacist (18) (Annual Cost): $1,620,000 $600,000 $500,000 $1,620,000 $2,720,000

80 Savings through Prevention $5,600,000 $2,720,000 = (Cost of medication error) (Cost of prevention) (Savings through prevention)

81 Savings through Prevention $5,600,000 $2,720,000 = $2,880,000 (Cost of medication error) (Cost of prevention) (Savings through prevention)

82 Slow down and take your eyes off the computer Look at the patient in the bed and listen Listen to that mother who is saying something is wrong Sorrel King s advice to everyone involved in patient care, 15 years after her daughter, Josie King s death in John Hopkins

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84 Brain has100 billion neurons, gives off the equivalent power of a 20 watt light bulb The brain stores 100 trillion bits of information over the course of 70 years Breathing one pint of air 17 times a minute, we take in 78 million gallons in an average life span 45 miles of nerves that send impulses as rapidly as 325 miles per hour Heart pumps enough blood in an average lifetime to fill the fuel tanks of 56 moon rockets 2100 gallons of blood are pumped through 62,000 miles of blood vessels in a day. 8,000,000 new red blood cells are produced in the bone marrow every second

85 Six Thousand Trillion Dollars

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