Aligning Surgical Pathology & Informatics to Promote Patient Safety
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1 Aligning Surgical Pathology & Informatics to Promote Patient Safety labinfotech infotechsummit April 11, 2008 Jeffrey L. Myers, M.D. A. James French Professor & Director, Anatomic Pathology University of Michigan, Ann Arbor, MI
2 labinfotech infotechsummit 2008 Aligning Surgical Pathology & Informatics to Promote Patient Safety Objectives The problem of safety in surgical pathology Solutions for which informatics is key Aligning surgical pathology with informatics resources the principle and the experience
3 labinfotech infotechsummit 2008 Aligning Surgical Pathology & Informatics to Promote Patient Safety Objectives The problem of safety in surgical pathology
4 The goal of this report is to break the cycle of inaction.... Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable barriers, it is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort. Report of the Institute of Medicine (IOM) Committee on Quality of Health Care in America November, 1999
5 Crossing the Quality Chasm: A New Health System for the 21st Century Six Specific Aims for Improvement Health care should be: Safe Effective (i.e. avoiding underuse and overuse) Patient-centered Timely Efficient (i.e. avoiding waste) Equitable
6 Crossing the Quality Chasm: A New Health System for the 21st Century Six Specific Aims for Improvement Health care should be: Safe (i.e. error free) Effective (i.e. avoiding underuse and overuse) Patient-centered Timely Efficient (i.e. avoiding waste) Equitable
7 Errors in Medicine Application to Surgical Pathology* Diagnostic Error or delay in diagnosis Failure to employ indicated tests Use of outmoded tests or therapy Failure to act on results of monitoring or testing Treatment Preventive Other Failure of communication * Modified from Leape et al. Qual Rev Bull 1993; 19: 144-9
8 Errors in Medicine Application to Surgical Pathology* 60-80% of accidents involve human error e.g. human error involved in 82% of preventable anesthesia incidents (Cooper et al. Anesthesiology 1978; 49: )
9 $3 million in damages... attorney s fees and interest.
10 Four months and a double mastectomy later, doctors told Eason that her tissue sample had been mislabeled, and that she never had cancer.
11 ... the sample her diagnosis was based on had been contaminated with cancerous cells from another patient s specimen
12 Error Rates in Anatomic Pathology Measuring Frequency of Diagnostic Discordance % % 10.0% % 8.0% 8.0% % % 6.0% 4.0% 4.0% 2.0% 2.0% 0 Incoming Pathologist generated Patient and/or clinician generated *Renshaw & Gould. Am J Clin Pathol % 16.00% 12.00% 12.00% 8.00% 8.00% 0.0% 0.0% Total errors Significant errors 14.10% 14.10% 4.00% 4.00% 0.00% 0.00% 2.20% 2.20% 1.20% 0.96% 1.20% 0.96% 0.26% 0.26% Safrin Safrin and and Bark Bark Whitehead Whitehead et et al al Lind Lind et et al. al.
13 Institute of Medicine (IOM) Quality of Health Care in America Committee Types of Error active errors occur at the level of the frontline operator modified from Woods et al. Behind Human Error: Cognitive Systems, Computers and Hindsight. Crew Systems Ergonomic Information and Analysis Center, WPAFB, Dayton, OH. the sharp end of complex health care system
14 Institute of Medicine (IOM) Institute of Medicine (IOM) Quality of Health Care in America Committee Types of Error active errors occur at the level of the frontline operator latent errors tend to be removed from the direct control of the operator (e.g. poor design, poorly structured organizations, etc.)
15 Institute of Medicine (IOM) Quality of Health Care in America Committee Types of Error active errors occur at the level of the frontline operator the blunt end of complex health care system latent errors tend to be removed from the direct control of the operator (e.g. poor design, poorly structured organizations, etc.) modified from Woods et al. Behind Human Error: Cognitive Systems, Computers and Hindsight. Crew Systems Ergonomic Information and Analysis Center, WPAFB, Dayton, OH.
16 Every system is perfectly designed to achieve exactly the results it gets. Don Berwick s Central Law of Improvement
17 labinfotechsummit 2007 SAFETY IN SURGICAL PATHOLOGY significant errors occur in anatomic pathology practice at a low but predictable frequency our complex processes set us up to fail we can do better! How?
18 labinfotech infotechsummit 2008 Aligning Surgical Pathology & Informatics to Promote Patient Safety Objectives The problem of safety in surgical pathology Solutions for which informatics is key
19 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Provide leadership Respect human limits in process design
20 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Respect Human Limits in Process Design avoid reliance on memory use constraints and forcing functions avoid reliance on vigilance provider order entry patient-specimen identification standardized workflow standardized results reporting case-appropriate content at signout
21 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Respect Human Limits in Process Design avoid reliance on memory use constraints and forcing functions avoid reliance on vigilance simplify key processes standardize work processes
22 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Provide leadership Respect human limits in process design Promote effective team functioning Anticipate the unexpected Create a learning environment
23 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Create a Learning Environment encourage reporting of errors and hazardous conditions ensure no reprisals for reporting of errors event identification report generation data analysis Thomas & Petersen. J Gen Intern Med 2003
24 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Create a Learning Environment encourage reporting of errors and hazardous conditions ensure no reprisals for reporting of errors develop a working culture in which communication flows freely regardless of authority gradient implement mechanisms of feedback and learning from error
25 Designing for Safety in Health Care IOM Committee on Quality of Health Care in America Create a Learning Environment encourage reporting of errors and hazardous conditions ensure no reprisals for reporting of errors develop a working culture in which communication flows freely regardless of authority gradient implement mechanisms of feedback and learning from error
26 Medical Errors Very Important Causes Blendon et al. N Engl J Med 2002; 347: 1933 MDs Public insufficient time spent with patients 37% 72% overwork, stress, fatigue 50% 70% failure to work together or communicate as team 39% 67% understaffing of nurses 53% 65% complexity of care 38% 62%
27 Challenge How to create meaningful organizational links between surgical pathology and informatics in a way that facilitates innovative solutions?
28 labinfotech infotechsummit 2008 Aligning Surgical Pathology & Informatics to Promote Patient Safety Objectives The problem of safety in surgical pathology Solutions for which informatics is key Aligning surgical pathology with informatics resources the principle
29 Aligning Surgical Pathology & Informatics organizational, administrative alignment common vision & mission common strategic goals understanding of operational imperatives prioritization of resources
30 Organizational & Administrative Alignment Department Chair Division of Finance & Administration Anatomic Pathology Informatics Clinical Research MLabs Programs Translational Research Clinical Pathology Educations & Training Programs Sponsored Programs
31 Informatics Needs in Pathology CP IT demand TIME
32 Organizational & Administrative Alignment Department Chair Division of Finance & Administration Anatomic Pathology Informatics Clinical Research MLabs Programs Translational Research Clinical Pathology Educations & Training Programs Sponsored Programs
33 #1 on Top 10 List of Things NOT to Say to Surgical or Anatomic Pathology Directors
34 #1 on Top 10 List of Things NOT to Say to Surgical or Anatomic Pathology Directors Our LIS was chosen by CP. It actually doesn t work well for us.
35 Informatics Needs in Pathology Why AP now? image digitization new testing & research technologies recognition of quality & safety gap CP IT demand AP TIME
36 Organizational & Administrative Alignment Department Chair Division of Finance & Administration Anatomic Pathology Informatics Clinical Research MLabs Programs Translational Research Clinical Pathology Educations & Training Programs Sponsored Programs
37 Aligning Surgical Pathology & Informatics organizational, administrative alignment alignment of tasks a deep common understanding of practice needs and the resolve to respond with innovative and timely solutions
38 Alignment of Tasks Division Director Operations Administrator AP Laboratory Operations Group Laboratory Medical Directors Chief Technologists autopsy & forensics electron microscopy immunohistochemistry histology cytology
39 Alignment of Tasks AP Laboratory Operations Group Charge administrative oversight of laboratory operations specimen receiving and accessioning cytopathology histology & immunohistochemistry electron microscopy autopsy AP-related laboratory information systems identify and prioritize opportunities for enhancing and improving laboratory performance using lean tools and principles
40 Alignment of Tasks AP Laboratory Operations Group Ul Balis Paulette Dozier Doug Fullen Martin Lawlor Steve Mandell Beth Minors Kalyani Naik John Perrin Barbara Rogers Theresa Russell Dan Visscher Members Kathy Davis Diana French Paul Killen Dave Lucas Claire Michael Jeff Myers Craig Newman Christine Rigney Charles Ross Denise Sulavik Jason Carvalho/ Bryan Coffing clinical informatics laboratory management lab directors/physician leadership administration residents
41 Aligning Surgical Pathology & Informatics organizational, administrative alignment alignment of tasks alignment of strategy commitment to common strategic vision and shared definition of excellence (i.e. shared success metrics)
42 Alignment of Strategy Top of mind when anyone anywhere imagines excellence in application of clinical informatics to solutions in anatomic pathology!
43 labinfotech infotechsummit 2008 Aligning Surgical Pathology & Informatics to Promote Patient Safety Objectives The problem of safety in surgical pathology Solutions for which informatics is key Aligning surgical pathology with informatics resources the principle and the experience
44 Aligning Surgical Pathology & Informatics Outcomes new tools with specific safety focus critical values alerts management report web application for facilitating case handoffs communication
45 New Tools With Safety Focus Communication
46 Aligning Surgical Pathology & Informatics Outcomes new tools with specific safety focus critical values alerts management report web application for facilitating case handoffs bar code driven electronic order entry for special stains bar code driven block labeling stalled case management report communication identification flow
47 Aligning Surgical Pathology & Informatics Outcomes new tools with specific safety focus surgical pathology rotation redesign implemented August 2007
48 SURG PATH ROTATION REDESIGN Pre-Launch Tool Development/Deployment training, competency documentation for histotechs incremental histotechnologist position realigned reporting relationships, new staffing model for PAs policy development (histotech supervision, specimen transportation, tissue procurement) new functionality in LIS (assigning faculty at COE, stalled case management report) web-based based calendars
49 SURG PATH ROTATION REDESIGN Pre-Launch Tool Development/Deployment web-based service team calendars develop a working culture in which communication flows freely regardless of authority gradient
50 Beth Valka create positive environment to minimize negative backlash IT types Kathy Davis
51 IT King Ul Balis create space to openly share ideas as problems emerged typical surg path types Matt Wasco Dave Lucas
52 Aligning Surgical Pathology & Informatics Outcomes new tools with specific safety focus surgical pathology rotation redesign implemented August 2007 IT participation in lean projects
53 Aligning Surgical Pathology & Informatics Outcomes new tools with specific safety focus surgical pathology rotation redesign implemented August 2007 IT participation in lean projects opportunities to co-develop innovative solutions
54 Richard Whisnant Tammy Densmore Bill Roth Suncoast Pathology Solutions
55 bar code driven specimen identification and workflow monitoring at grossing, embedding and cutting stations gross descriptions built from template driven pick-lists + free text suite of tools to improve diagnostic performance while minimizing preventable workflow errors bar code driven patient ID and workflow monitoring forced functions to acknowledge patient-specific historical data, prevent incomplete case review, and ensure compliance with QA plan at report verification template driven reporting customized by client real time tracking of diagnostic performance opportunities to pull relevant knowledge content linked to unique report elements (e.g. grade) at signout Suncoast Pathology Solutions
56 bar code driven specimen identification and workflow monitoring at grossing, embedding and cutting stations gross descriptions built from template driven pick-lists + free text suite of tools to improve diagnostic performance while minimizing preventable workflow errors bar code driven patient ID and workflow monitoring forced functions to acknowledge patient-specific historical data, prevent incomplete case review, and ensure compliance with QA plan at report verification template driven reporting customized by client real time tracking of diagnostic performance opportunities to pull relevant knowledge content linked to unique report elements (e.g. grade) at signout Suncoast Pathology Solutions
57 bar code driven specimen identification and workflow monitoring at grossing, embedding and cutting stations gross descriptions built from template driven pick-lists + free text suite of tools to improve diagnostic performance while minimizing preventable workflow errors bar code driven patient ID and workflow monitoring forced functions to acknowledge patient-specific historical data, prevent incomplete case review, and ensure compliance with QA plan at report verification template driven reporting customized by client real time tracking of diagnostic performance opportunities to pull relevant knowledge content linked to unique report elements (e.g. grade) at signout Suncoast Pathology Solutions
58 Opportunities to co-develop innovative solutions... in real nice places!
59 labinfotech infotechsummit 2008 Aligning Surgical Pathology & Informatics to Promote Patient Safety Objectives The problem of safety in surgical pathology Solutions for which informatics is key Aligning surgical pathology with informatics resources the principle and the experience
CAP Companion Society Meeting at USCAP 2009 Quality Assurance, Error Reduction, and Patient Safety in Anatomic Pathology
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