Mary Baum President & CEO BA&T September 18, 2015
Objective Why patient safety is so difficult to solve? The problem remains Advances in clinical workflow A collaborative approach Metrics matter Just start. 3/8/2016 2
Complex vs. Complicated A rocket to the moon and raising a child? Extracting a brain tumor and a judge deciding guilt or innocence? Complicated procedures (Rocket and Brain Surgery) require an expert, are based on a repeatable plan, step-by-step need to be well trained. It assumes a rational and top-down planning, smooth implementation, policy, work delegation. They fail occasionally 3 Mile Island and the Challenger 3/8/2016 3
Complex Systems like Healthcare Complex Systems - Filled with moving parts, varied expertise, interdependence constant adaptation. The environment is constantly changing and unpredictable. It is turbulent. Even with facades of command and control and policy manuals the outcome can be unpredictable. They are spider webs of interconnecting strands. The answer is complex 3/8/2016 4
Healthcare - Pressures 3/8/2016
Neonatal Care 2018 93,955 ICU Beds all types 10-20% of all hospital beds 20-30% of costs Average cost per year in US $81.7B Average costs for preterm births in US $26B Changing dynamics Regulations Reimbursement Outcome Penalties and metrics Patient and Family satisfaction 3/8/2016 6
Implication of an Error The Context Mortality rates for VLBW 240.4 per 1,000 live births 77.3% of infants with VLBW admitted to a NICU Preterm births have increased more than 35% 500,000 babies born before 37 weeks annually US Average bill of $280,000 (56X as much as a healthy baby) Not intentional or due to reckless behavior Adverse Events 74 per 100 patients Infiltrates Nosocomial infections Accidental extubation Intraventricular hemorrhage Skin breakdown Misidentification 9% of errors ( wrong diagnosis) Medication error 3/8/2016 7
Etiology of an Error Complex Interactions between - Human factors causal or latent: Low staffing Multiple caregivers ( Interns, residents, fellows weekends), insufficient staffing and high census influences LOS and outcome Inadequate staff training Staff fatigue Poor team coordination Equipment malfunction Poor communication 3/8/2016 8
Specific and Clear Measures for Safety? Not Really Several identified and consistent objectives that are clustered around aspects of care Central catheter infection rate Ventilator associated pneumonia Nurse patient ratio team performance LOS (30-35% 4 days or fewer, 55-70% 20 days) Patient/family satisfaction 3/8/2016 9
High Level Safety Metrics Survival rates Staffing and structure Benchmark case mix adjusted LOS and create meaningful goals Clinical guidelines Case management Integrated home health team Communication with family Readmission rate Satisfaction levels 3/8/2016 10
Solutions - Many Views Point of Care System level Care provider level Patient level Team level 3/8/2016 11
Parallel Play 3/8/2016
How Do We Start To Make Change? Process Culture 3/8/2016
Goals Understanding that workflow is the framework for how you get there. A set of processes Set of people and resources Set of interactions among the processes, people and resources 3/8/2016
Why Workflow? Clinical Workflow The interrelationship between humans, the tools and the environment 3/8/2016 15
Sausage Making Its Messy 3/8/2016
New building/unit - old process Latent Conditions: 1. Inevitable failures between the couch cushions 2. Location of equipment 3. New technology 4. Confusing procedures change with the new physical design 5. Training gaps new equipment/new work 6. Staff shortages 7. Staffing patterns 8. Poor design with team working patterns 9. Supply placement/inventory management 10. Cross team and interdisciplinary team work patterns L&D, transport etc. 11. Patient care path flow 3/8/2016
Patient Safety and Teamwork Equipment design Use of technology Reliable and predictable work process scheduling and staffing matching employees knowledge and expertise to job requirements Team training vulnerabilities Management practice Rewards and incentives 3/8/2016 18
Patient Safety and Teamwork Context - High level cognitive work and fast-paced team decision making in a rapidly changing technical environment overload and breakdown in communication and in team performance Physical setting re-design where most of the work has focused Missing - The people side of workflow the team collaboration determines how healthcare professionals behave interact and influence and relate to one another 3/8/2016 19
What gets lost? Information is omitted, lost or misinterpreted The latent consequences between the couch cushions Solution - honest (no-blame), transparent and open communication preventing, reporting, analyzing, tracking and monitoring ensures workers are thinking about safety and implementing safety measures successfully 3/8/2016 20
Bottlenecks = Poor Outcomes Nurse shortages Nurse patient ratios Long distance between rooms Multidisciplinary work- harder to collaborate New builds/units and towers Not all change is an improvement Managing extreme complexity Managing 178 actions per day per patient Errors in just 1% translates to 2 errors per day per patient NICU/ICU care succeeds only when the odds of doing harm are low enough for the odds of doing good to prevail (Atul Gawande Dec. 2007 The New Yorker) 50% of ICU patients experience serious complications Line infections 5M lines a year/10 days and 4% are infected/prolonged LOS VAP: 10 days on a vent, 6% develop bacterial pneumonia 40-55% mortality 3/8/2016 21
Current State Mini observation summary: Process variability Communication Documentation Utilization of space Transport conundrum/process Admit process Discharge process Mixed acuity Work done in silos Supplies Staff assignment 3/8/2016
Metrics - Working? Results Wasted time, increased risk, Press Ganey Scores, redundancy, silos of activity, dollars, inefficiency and outcomes suffer 3/8/2016
A beginning Compliance monitored for 1 month Doctors skipped at least one step in more than 1/3 of patients ( wash hands, clean skin, cover with sterile drape, mask, sterile dressing etc.) Empower nursing to ask if line is still needed/or stop a doctor if they missed a step Results amazing 0% line infections prevented 43 infections and 8 deaths, saved $2M in costs (Keystone initiative Dec. 2006) 3/8/2016 24
Fundamental problem? We don t view delivery of care as a science We see science as disease and biology Finding effective therapies But ensuring that we work in efficient ways and delivering therapies effectively is ignored most 3/8/2016 25
Workflow - Quality Improvement? Current State how is your staff spending their time Systematically define how in your hospital/your unit you can improve Analyze the data- What are your numbers /data current state analysis Best practice - Do you know what others have established as evidence based improvement strategies? Focus on key vulnerabilities - Develop strategies to overcome barriers /reluctance to invest time and resources in expertise to support quality improvement Culture change BIG topic Curiosity, creativity and transparency Identify opportunities to improve Develop and understand your data ( before and after change) 3/8/2016 26
Workflow - Quality Improvement? Blame free culture identify risk/mistakes and work together to prevent reoccurrence of the problem Leadership needs to be involved and foster interdisciplinary efforts Adopt methodologies that can assess outcomes for improvement efforts Routinely measure, analyze and study Benchmark for best and worst Take time to examine outcomes and process Create a vison for the future aspirational goals Create a plan test and revise 3/8/2016 27
Get involved performance improvement works Albert Einstein Insanity is doing the same thing over and over again and expecting different results 3/8/2016 28
Thank You!! 3/8/2016 29