© 2008 The Board of Trustees of the University of Illinois

Creating and sustaining a culture of improvement:importance of patient and family engagement

Timothy McDonaldVice President for Quality and Safety

University of Illinois Hospital and Health Sciences System

How ? has always felt about lawyers

The Problem

Institute of Medicine: 1999 report that shook the medical world 

Making Matters Worse

Safety Culture and the response to a hospital associated condition

• LH 46 y.o. patient undergoes C‐section– Begins routinely– Complications with bleeding ensue– Case lasts 2 hours– Discharged home – Returns to ED 6 months later with abdominal pain– Taken to OR for exploratory laparotomy– Sponge found upon exploration– Surgeon suggests to team that it would be inappropriate to tell patient of finding of sponge

What next?

What about open, honest and effective communication?

• Barriers • Benefits

Taking a “Principled Approach”

• Benefits– Maintain trust– Learn from mistakes– Improve patient safety– Employee morale– Psychological well‐being– Accountability– Money– Less litigation

• Barriers– Culture– No institutional support– Loss of job– Reputation– “Shame and blame”– Loss of control– Loss of license– Fear of lawyers, litigation– Non‐standard process– Money

2005 UIC Board approves“communication‐ resolution” program

• Comprehensive• Integration of safety, risk, quality and credentials

• Linkage to claims and legal – deal with the fears• Longitudinal patient safety education plan

– UGME– GME– CME

Need a process for execution

• Reporting• Investigation• Initial communication with patient/family• Identification of preventive measures• Resolution• Follow‐up and ongoing data collection• Education of event/improvements

A Comprehensive Response to Patient Incidents: The Seven Pillars. McDonald et al Quality and Safety in Health Care, Jan 2010

• Reporting• Investigation• Communication• Apology with remediation• Process and performance improvement• Data tracking and analysis• Education – of the entire process

Driven by the Power of:Patient and Family Engagement

The Seven Pillars:A Patient and Family‐Centered Comprehensive Approach to the 

Prevention and Response to Patient Safety EventsLD.04.04.05

Unexpected Event reported toSafety/Risk Management

Patient Harm?

Consider “Second Patient”Error Investigation

Hold bills

InappropriateCare?

Full Disclosure with Rapid Apology and Remedy

RI.01.02.01

Process and Performance Improvement

Data Base

PatientCommunicationConsult Service

24/7Immediately

AvailableRI.01.02.01

Yes

Yes

No

No

“Near misses”

Activation of Crisis Management Team

October  7, 2011

Another communicating openly and resolving early

October  7, 2011

Process improvement: Significant change in national guidelines

• July 1, 2012 ASA• Specifically, in section 3.2.4 of the Standards for Basic Anesthetic Monitoring, the ASA states, "...During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.

Back to the case investigation

• What do you want to know?

Designing process improvement strategies

• Must understand the problem in order to design solutions

Choosing your AIM:“No Thing Left Behind”

Designing process improvement strategies

• Must understand the problem in order to design solutions– Changes– Measurement– Feedback – Rapid cycle

Patient presents with a retained instruments: a ‘never’ event

Scope of the Problem

• 1 in 1000 vs 1 in 5000 surgical cases• Potentially catastrophic• Res Ipsa Loquitur: “the thing speaks for itself”• Media Nightmare• JC sentinel, NQF and CMS “never event”

A standard process for intraop instrument/sponge management

Surgery

Count beforefinal closure

CorrectCount?

IntraopX-ray

CountBeforeIncision

NO! ToPACU

Yes

Back to RCAs: common causes associated with the “standard process” for managing intraop

instruments/sponges

• Relies entirely on human counting processes– The human factor – normalized deviance in counting process

• Lack of consistency in count vs. no need to count• Inability to count: emergencies• Count was correct or not done in most claims related to

retained foreign objects• Some procedural objects not routinely counted (OR towels etc)• Relies on human factor for detection on x-ray• Relies on effective communication

A standard process for intraop instrument/sponge management

Surgery

Count beforefinal closure

CorrectCount?

IntraopX-ray

CountBeforeIncision

NO!To

PACU

Yes

Potential PointsOf Failure

“Evidenced-based” medicine and retained objects

January 16, 2003

Risk factors for retained objects

• Emergency open cavity surgery• Unexpected change in surgical procedure• BMI > 35• No count of sponges or instruments• “Case-controlled analysis of medical

malpractice claims may identify and quantify risk factors…”

UIC data for additional risks or common causes from UIC RCAs

• Extending beyond change of shift• Greater than 6 hours in duration• Multiple (>1) surgical services involved• When indication for x-ray was unclear

Radiologist must know about “other indications” via order for x-ray

• Must communicate results to team• Team must take action if positive for potential

retained object.

Identifying areas for improvement

Implementing a modified process

Surgery

Count beforefinal closure

CorrectCount?

IntraopX-ray

CountBeforeIncision

No!

Yes

OtherIndication?

NoYes!To

PACU or ICUCommunication

Steps needed to create a highly reliable process

• Standardized process for “counting” before during and after procedures

• Assessment of “high risk status”• Ordering x‐ray for incorrect count or other• Listing x‐ray indication as “potential retained object”• Obtaining x‐ray in a timely fashion• Communicating result as a “critical result”• Appropriate following up

Areas of “culture” pushback

Steps needed to create a highly reliable process

• Standardized process for “counting” before during and after procedures

• Assessment of “high risk status”• Ordering x‐ray for incorrect count or other• Listing x‐ray indication as “potential retained object”• Obtaining x‐ray in a timely fashion• Communicating result as a “critical result”• Appropriate following up

Steps needed to create a highly reliable process

• Standardized process for “counting” before during and after procedures: nursing, surgeons

• Assessment of “high risk status”: surgeons• Ordering x‐ray for incorrect count or other: surgeons, nursing• Listing x‐ray indication as “potential retained object”: nursing, 

surgeons• Obtaining x‐ray in a timely fashion: radiology, nursing, surgeons• Communicating result as a “critical result”: radiology, nursing 

surgeons• Appropriate following up

How to overcome barriers

• Engage all stakeholders• Brainstorm ideas• Create the will to change• Plan small steps of execution• Celebrate wins• Engage patients and families in the process

• There is a way to get our bearings. When you're in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?‐Don Berwick, MD May, 2012

Resources for Patient and Family Engagement

Identify key metrics for measurement

• Options?

Identify key metrics for measurement

• Options?• Audit high risk patients• X‐ray compliance• PDSA with feedback• Continuous engagement of stakeholders

Data

Benefits of the project?

Lessons learned in past 50 months

• 14 objects identified in “correct count” cases• 2 neck case• 1 OB case• 1 ortho case• 1 chest• 9 abdominal cavity• No claims since implementation• One health system – 0 retained objects in last 530

days

A “near-miss” in OB: the reason we do this!

• 28 year old primigravid• Worrisome FHR; scalp electrode placed• 2 hours later emergent c-section• Emergency abdominal surgery indication for x-ray• Intraop x-ray taken after closure of abdomen• Patient taken to PACU

OB x-ray after surgery

OB x-ray after surgery

Scalp electrode remnant

Gratified Patient: Improved Process

Questions

• Timothy B McDonald– tmcd@uic.edu