Lisa Lubomski, PhD Cohort 5 presentation May 19 th and May 21 st

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DRAFT – final pending AHRQ approval 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

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The Science of Improving Patient Safety and Identifying Defects. Lisa Lubomski, PhD Cohort 5 presentation May 19 th and May 21 st. 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 . - PowerPoint PPT Presentation

Transcript of Lisa Lubomski, PhD Cohort 5 presentation May 19 th and May 21 st

Page 1: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

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The Science of Improving Patient Safety and Identifying Defects

DRAFT – final pending AHRQ approval

Lisa Lubomski, PhD

Cohort 5 presentationMay 19th and May 21st

Page 2: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

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 measures Environmental 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, MDUniversity of Virginia

Melanie Morris, MDUniversity of Alabama

Skandan Shanmugan, MDUniversity of Pennsylvania

Miriana PeharJohns 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 23rd!

Page 3: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

Learning Objectives

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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

Page 4: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Comprehensive Unit-based Safety Program (CUSP)1

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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

Page 5: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Advances in Medicine: Lingering Contradictions

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Postoperative X-Ray Reveals Unwanted Situations2

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.

Page 6: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Why is your SUSP work important?10

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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

Page 7: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

How Can These Errors Happen?

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People are fallibleMedicine is still treated as an art, not a scienceSystems do not catch mistakes before they reach the patient

Page 8: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Educate staff on the Science of Safety12, 13

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• 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

Page 9: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

System Factors Impact Safety14

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HospitalDepartmental Factors

Work EnvironmentTeam Factors

Individual ProviderTask Factors

Patient Characteristics

Institutional

Page 10: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Safety is a Property of the System

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Page 11: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Educate staff on the Science of Safety12, 13

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• 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

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Standardize When You Can

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Page 13: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Create Independent Checks

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Page 14: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Educate staff on the Science of Safety12, 13

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• 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

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DRAFT – final pending AHRQ approval

Communication Breakdowns

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Page 16: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Basic Process of Communication21

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Page 17: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Comprehensive Unit-based Safety Program (CUSP)1

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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

Page 18: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

What is a defect?

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Anything that happens that you do not want to happen again.

Page 19: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

D E F E C T I N T E RV E N T I O NUnstable oxygen tanks on beds

Oxygen tank holders repaired or new holders installed institution wide

Medication look-alikeEducation conducted, medications physically separated, and letter sent to manufacturer

Missing equipment on cart Checklist developed for stocking cartInconsistent use of Daily Goals rounding tool

Consensus reached on required elements of Daily Goals rounding tool

Inaccurate information by residents during rounds Electronic progress note developed

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Defect Examples That Affect Patient Safety

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DRAFT – final pending AHRQ approval

How can your team identify defects?

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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

Page 21: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

PSSA Taps Wisdom of Frontline Providers

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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

Page 22: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

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What is the PSSA?

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Perioperative Staff Safety Assessment (PSSA) asks providers to complete 4 questions:

1How will the next

patient in your unit or clinical area be

harmed?

2What can be done to prevent or minimize

this harm?

3How will the next

patient in the OR get a Surgical Site

Infection?

4What can be done to prevent this Surgical

Site Infection?

Page 23: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

When and Who administers the PSSA?

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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

Page 24: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

What’s Next? Interpreting PSSA results

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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

Page 25: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

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SSI Specific PSSA Sample Results 22

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Percentage of Responses (%)

How will the next patient be harmed?

Page 26: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

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PSSA follow-up

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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

Page 27: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

DRAFT – final pending AHRQ approval

Present the Science of Safety (SOS) video and administer PSSA during these ideal times:

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Medical staff Grand RoundsNew staff orientationRegularly scheduled staff meetings (for nurses, anesthesiologists, surgeons, etc.)Lunch & Learn sessionsSpecial educator sessions

Make video available in break roomHang up SOS factsheet in break room, restroom, etc. Annual recertification requirementsHospital IntranetOthers?

Next Steps

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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

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Next step Tools to use Location of toolEducate SUSP team on Science of Safety (SOS)**

Science of Safety videoScience 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

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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

Page 31: Lisa Lubomski, PhD Cohort  5 presentation May 19 th  and May 21 st

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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

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Questions?

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References

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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.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.

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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

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.

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.

References

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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/NationalImpactAssessmentofQualityMeasuresFINAL.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.

References

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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.

References

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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.

References