Embracing Patient Safety Organization-wide

Embracing Patient Safety Organization-wide Evan M. Benjamin, MD, FACP Senior VP, Healthcare Quality Baystate Health Associate Professor of Medicine Tufts University School of Medicine

Objectives Define strategies for making large scale change: Patient safety as the paradigm Understand behaviors that can make change and sustain gains in patient safety Be able to implement leadership tactics to improve patient safety in a health system or practice

Baystate Health, Inc. 3 hospital health system in Massachusetts Flagship 700 bed Tertiary Care Referral Center Western Campus of Tufts University School of Medicine Member CoTH, 10 residency programs, 300 residents 1200 member medical staff, 206 faculty physicians 50,000 admissions/year and 30,000 surgeries/year Members of UHC, Premier, IHI IMPACT and a Stand-up for Patient Safety NPSF Organization

Why is Change so Hard? Culture No shared vision No Urgency Poorly aligned expectations Ineffective leadership

Embracing Safety Means Successful Change

Kotter s Eight Steps for Successful Change 1. Create Urgency 2. Build the Guiding Team 3. Get the Vision right 4. Communicate for buy-in 5. Empower others to Act 6. Create short term wins 7. Don t let up 8. Make it Stick: create a new culture

To Err is Human: Medical Errors IOM: 44,000-98,000 deaths in US hospitals annually as a result of error Over 1 million serious preventable medication errors annually 3.7% of hospital admissions result in adverse events, 58% of these are from preventable errors Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384.

Crossing the Quality Chasm: Quality Chasm exists IOM defined quality care as care that is safe, timely effective, efficient, equitable and patient centered Translating scientific advances into clinical benefit We continue to face large variations in quality, safety and inequities of care

Misuse Wrong patient or wrong procedure Medication Errors wrong drug, wrong dose Procedural Errors technical error Care Management Errors delay in treatment or mismanagement of condition

Never Events National Quality Forum formulated 28 Serious Reportable Events Events which are reasonably preventable NQF, serious reportable events in healthcare, October 2006 Criteria: Clearly identifiable, reportable Indicative of a problem in safety systems Now part of non-payment for care

The National Quality Forum s List of 28 Serious Adverse Events

Harm in US Healthcare Post operative complications Infections/Sepsis DVT/PE Pressure Ulcers Hospital Acquired Infections VAP/central line/uti Iatrogenic pneumothorax Perforation

3 Hospital System 2002-03: 17 Never Events 2 Wrong site/side surgery: Medial vs. lateral elbow debridement Renal vascular ablation 1 Wrong patient procedure: Diagnostic lumbar puncture (LP) in 2 bed room 2 PEs from DVT prophylaxis underuse 2 Post op retained foreign objects: Required 2 additional operations 2 Medication errors with serious harm: Wrong medication administration: Insulin overdose instead of antibiotic Wrong medication order: amitriptyline 2 Care management errors: death Managing hyperglycemia Communication error of a critical lab result (culture) 6 Falls: Falls with injury

Kotter s Eight Steps for Successful Change 1. Increase Urgency 2. Build the Guiding Team 3. Get the Vision right 4. Communicate for buy-in 5. Empower others to Act 6. Create short term wins 7. Don t let up 8. Make it Stick: create a new culture

Organizational Infrastructure for Patient Safety Dedicated full time professional for Patient Safety (the patient safety officer ) Embedded within a department of Quality with expertise in improvement science Dedicated partner in a QI leader Patient Safety Committee Senior Leaders (CEO, CMO, CNO) supportive of PSO Integration of risk management, QI, Infection Control, Credentialing with a strategic aim of Patient Safety.

Baystate Medical Center Quality Organizational Chart Baystate Health Board Quality and Safety Committee Division of Healthcare Quality Quality Management Patient Safety BMC Hospital Quality Council Patient Safety Committee Medical Staff Executive Committee Case Management / Risk Management Clinical Decision Support Infection Control Performance Improvement Quality/Safety Research Performance Improvement Service Line Teams - Adult Medical/Surgical ICU PI Team - Oncology Services PI Team - Ambulatory Services PI Team - Pathology Services PI Team - Behavioral Health Services PI Team - Pulmonary Services PI Team - Cardiac Services PI Team - Radiology Services PI Team - Children s Hospital PI Team - Surgery/Anesthesia Services PI Team - Emergency Medicine PI Team - Trauma Services PI Team - Medical Services PI Team - Women s Services PI Team

Address Strategy and Culture of Safety Safety as a Strategic Priority Goal setting Role of Leadership Senior Leader Walk Rounds Assess Patient Safety Culture AHRQ Survey Just culture

Board Strategy Agenda: Devote sufficient time on agenda Lead the agenda with Quality, Safety Alignment: Set bold aims in safety Monitor performance Link strategy to plan Quality Literacy: Ongoing education on safety Expertise in patient safety in governance Patient-Centeredness: Share stories Involve patients

Medical Error Algorithm Adapted from: James Reason, Managing the Risks of Organizational Accidents, 1997 Were the actions as intended? YES Were the consequences as intended? YES Sabotage, malevolent damage, suicide, etc. NO NO Unauthorized substance? Medical condition? NO Substance abuse w/o mitigation YES YES Substance abuse w/ mitigation NO Knowingly violating safe operating procedures? Were procedures available, workable intelligible and correct? YES Possible reckless violation YES NO Systeminduced violation NO Possible negligent error Pass substitution test? NO Diminishing culpability NO Deficiencies in training & selection or inexperience? YES Systeminduced error YES History of unsafe acts? YES Blameless Error. Corrective training or counselling indicated COUNSEL CONSOLE COACH COACH DISCIPLINE PUNISH NO Blameless Error

Communicate Transparency Open and Honest conversations about Quality and Safety: event reporting Telling the Truth Safety Briefings and Stand-downs

Safety Reporting System Reporting by Category 3200 3173 3134 Care Coordination/Records Error related to Proc/Trtment/Test 2800 Medication error Equipment/Supplies Complication of Proc/Trtment/Test 2400 Other/Miscellaneous Fall 2000 Med safety - Auto disp machine problem Transfusion Med Safety - Other Adverse Drug Reaction 1600 Skin Integrity Other 1200 1182 Behavioral Inappropriate behavior by staff Environmental hazard 800 620 534 507 497 Equip safety situation/preventive maint Medication safety - Narcotics discrepancy Unauthorized presence 400 305 225 177 174 91 73 51 40 27 23 13 3 3 2 1 1 Med safety - Drug diversion/theft Damage to property Lost/stolen property 0 Pow er failure

Empowerment through Engagement Engage Physicians Physician led initiatives that fit the domain Hospital Acquired infections in the ICU Cardiac care guidelines Surgical Time out Checklists

Engagement Engage Physicians and Staff Crew Resource Management Team STEPPS by AHRQ

Tenerife Accident, KLM airlines, 1977

Teamwork: Crew Resource Management Focus on teamwork, communication, flattening hierarchy, situational awareness, collective decision making Non-punitive reporting of near misses, errors Challenges are accepted Briefings, debriefings, goals, simulation, common mental model

Lower is Better Hospital Acquired Infections Rate Leapfrog Hospitals Target 0.4 0.35 % Patients 0.3 0.25 0.2 0.15 0.1 0.05 0 FY07Q1 (8) FY07Q2 (14) FY07Q3 (18) FY07Q4 (17) FY08Q1 (1) FY08Q2 (8) FY08Q3 (5) FY08Q4 (4) FY09Q1 (5) FY09Q2 (1) FY09Q3 (1) Hospital Acquired Infections Prevention Bundles: Ventilator Acquired Pneumonia (VAP) Elevated bed, weaning assessment, mouth care etc Blood Stream Infection (BSI) from CVC Full sterile barrier etc

Track and Measure Over Time Measure Harm as a system level performance Harm score (ie NQF-8) Global Trigger Tool (IHI) Improve analysis techniques RCA FMEA Better Incident Reporting

Dashboards BAYSTATE MEDICAL CENTER FY 2006-2009 STRATEGIC PLAN METRICS FY 2009 - FY 2013 CLINICAL QUALITY % Patients 100.0 95.0 90.0 85.0 80.0 FY08 Q2 Higher is Better FY08 Q3 FY08 Q4 EFFECTIVENESS Clinical Composite Care Score Actual Performance against Top Decile Includes:AMI,HF,PN,SCIP,CAC,Stroke FY09 Q1 BMC FY09 Q2 FY09 Q3 FY09 Q4 Top Decile HQI FY10 Q1 FY10 Q2 Index 1.2 0.9 0.6 0.3 0.0 Lower is Better FY08 Q2 FY08 Q3 FY08 Q4 MORTALITY Index = actual mort/exp mort FY09 Q1 BMC FY09 Q2 FY09 Q3 Target FY09 Q4 FY10 Q1 FY10 Q2 Rate 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 FY08 Q2 Lower is Better FY08 Q3 FY08 Q4 FY09 Q1 SAFETY** FY09 Q2 FY09 Q3 FY09 Q4 BMC Leapfrog "Top 50" FY10 Q1 FY10 Q2 **Safety Score - Rates of BSI, DVT, PO Sepsis, HAPU, Fall/Injury 80% Higher is Better PATIENT CENTERED CARE (Outpatient % Excellent Overall Quality of Care) 80% Higher is Better PATIENT CENTERED CARE (Inpatient % Excellent Overall Quality of Care) % Excellent 70% 60% 50% % Excellent 70% 60% 50% 40% FY 06 FY 07 FY 08 FY 09 FY 09 Q2 FY 10 Q2 40% FY 06 FY 07 FY 08 FY 09 FY 09 Q2 FY 10 Q2 BMC PRC 75th %'ile PRC 90th %'ile BMC PRC 75th %'ile PRC 90th %'ile

Make it Stick Align System Measures and Projects ( drivers ) Align Incentives Use of Reliability Science: make the right thing easy to do Standardize Teamwork Simulation

Mortality Driver: Measure to Drivers Primary Drivers Secondary Drivers Reduce Patient Harm Reduce Hospital Acquired Infection Reduce Adverse Drug Events Reduce Post-op DVT Reduce Unnecessary Death Improve Communication & Teamwork Improve Hand-offs Team STEPPS Training SBAR Training Improve Evidence-based Care Sepsis Bundle Care Glucose Management Stroke Bundle Care Improve End of Life Care Advance Care Planning Palliative Care Team Hospice

Reliability Rates Reliability Defect Approx Sigma 90% 10-1 0.25 99% 10-2 2.7 99.9% 10-3 3.8 99.99% 10-4 4.6 99.999% 10-5 5.3 99.9999% 10-6 5.9

Getting to 10-2 Performance with Better Systems Can t be asked to work harder Need to focus on Systems that allow us to improve Focus on 10-2 Reliability concepts: Standardization of process Make the action desired the default Opt out so the desired action = flow of work Create redundancies and time lapses Build design aids into the system Hardwire system thinking

Surgery: Antibiotic Prophylaxis 100 SIP: Prophylactic AB Discontinued within 24 Hours of Surgery End Time Baystate Medical Center Springfield MA USA SIP: Prophylactic AB Discontinued within 24 Hours of Surgery National Top Decile Top Decile BMCRate BMC Rate % % Patients 80 60 40 Educa- SIP tion 20 starts; to all education staff to all staff 0 Apr 02 CT surg orders CPOE changed Personal sets used Discussion Education with MDs/PAs with MDs/PAs Ongoing Take discussion, advantage education, of habits: sharing scheduling, of evidence, external benchmarking, benchmarking Commit Time to change outs external Opt benchmarking out orders Reviewed with TJRsurgeons, Standardization order sets changed of order sets Internal Internal benchmarking, benchmarking MD specific MDspecific scorecards scorecards Ongoing 1:1 review 1:1 review Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug 02 02 02 02 02 03 03 03 03 03 03 04 04 04 04 04 04 05 05 05 05 05 05 06 06 06 06

Simulation Cultural change Medical Education Teamwork/TeamSTEPPS Central line simulation certification Checklist Sterile technique Tied to credentials/privileges

Conclusions Large Scale Change is challenging but possible A Culture of Safety is large scale change Leadership tactics can facilitate change and result in Patient Safety Organization-wide