© 2010 college of medicine © 2010 college of medicine andreas a. theodorou, md chief, pediatric...

© 2010 College of Medicine© 2010 College of Medicine

Andreas A. Theodorou, MDChief, Pediatric Critical Care Medicine

Associate Head, Department of PediatricsProfessor, Clinical Pediatrics

The University of ArizonaChief Medical Officer, UMC

Evidence Based Approach Evidence Based Approach to Quality Improvementto Quality Improvement

University Medical CenterUniversity Medical CenterTucson, ArizonaTucson, Arizona


To Err Is Human: Building a Safer To Err Is Human: Building a Safer Health System (IOM, 2000)Health System (IOM, 2000)

• The first of 4 IOM reportsThe first of 4 IOM reports• ““The burden of harm conveyed by the The burden of harm conveyed by the

collective impact of all of our health collective impact of all of our health care quality problems is staggering.”care quality problems is staggering.”

• 44,000-98,000 people die each year 44,000-98,000 people die each year from mistakesfrom mistakes

• UMC Responded!UMC Responded!• ““Quality and Safety First”Quality and Safety First”


Crossing the Quality Chasm: A New Health Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001)System for the 21st Century (IOM, 2001)

Second of 4 IOM reportsSecond of 4 IOM reportsSafety problems because:Safety problems because:

Inability to translate knowledge into practice, Inability to translate knowledge into practice, apply new technology safely and apply new technology safely and appropriately and to make the best use of appropriately and to make the best use of resources (financial and human)resources (financial and human)

Blaming health providers is not the Blaming health providers is not the answer!answer!

We must address the system flawsWe must address the system flaws


Health Professions Education: A Bridge Health Professions Education: A Bridge to Quality (IOM, 2003)to Quality (IOM, 2003)

• Third of 4 IOM reportsThird of 4 IOM reports

• ““All health professionals should be All health professionals should be educated to deliver patient-centered educated to deliver patient-centered care care as members of an as members of an interdisciplinary teaminterdisciplinary team, emphasizing , emphasizing evidence-based practice, quality evidence-based practice, quality improvement approaches, and improvement approaches, and informatics.”informatics.”


J. Lyle Bootman (co-chair) Dean, U of A College of Pharmacy


Several Evidence Based Clinical Several Evidence Based Clinical Guidelines Including…Guidelines Including…

• StrokeStroke• Traumatic Brain InjuryTraumatic Brain Injury• SepsisSepsis• Core MeasuresCore Measures• Central Line BundleCentral Line Bundle• Ventilator Associated Pneumonia BundleVentilator Associated Pneumonia Bundle• ““Time-Out” check listTime-Out” check list


National Patient Safety GoalsNational Patient Safety Goals

• Established by The Joint CommissionEstablished by The Joint Commission• Statistically found to be problem areasStatistically found to be problem areas

• Improve the accuracy of patient identification. Improve the accuracy of patient identification.

• Improve the effectiveness of communication among Improve the effectiveness of communication among caregivers. caregivers.

• Improve the safety of using medications. Improve the safety of using medications. • Reduce the risk of health care-associated infections. Reduce the risk of health care-associated infections. • Accurately and completely reconcile medications across the Accurately and completely reconcile medications across the

continuum of care. continuum of care. • Reduce the risk of patient harm resulting from falls. Reduce the risk of patient harm resulting from falls.


National Patient Safety GoalsNational Patient Safety Goals

Continued…Continued…• Encourage Patients’ active involvement in their own care Encourage Patients’ active involvement in their own care

as a patient safety strategyas a patient safety strategy• Identify patients at risk for suicide.Identify patients at risk for suicide.• Fulfill expectations set forth in the Universal Protocol Fulfill expectations set forth in the Universal Protocol

(prevent wrong-site, wrong person, wrong procedure)(prevent wrong-site, wrong person, wrong procedure)• Reduce the likelihood of patient harm with the use of Reduce the likelihood of patient harm with the use of

anticoagulation therapyanticoagulation therapy• Recognize and Respond to Change in Patient’s Condition Recognize and Respond to Change in Patient’s Condition

(RRT/EMT)(RRT/EMT)


How Do We Measure Quality?How Do We Measure Quality?Who’s Doing the Measuring?Who’s Doing the Measuring?

InternallyInternally Incident reportsIncident reports Peer ReviewsPeer Reviews Physician ProfilesPhysician Profiles Sentinel EventsSentinel Events M & M’sM & M’s Patient SatisfactionPatient Satisfaction QI “projects”QI “projects” Root Cause AnalysisRoot Cause Analysis FMEA FMEA

ExternallyExternally (some allow (some allow public access)public access) Gov’t AgenciesGov’t Agencies

CMSCMS AHRQAHRQ Medical BoardsMedical Boards

Private AgenciesPrivate Agencies The Joint CommissionThe Joint Commission NQFNQF UHCUHC HealthGradesHealthGrades ““Best Hospitals”Best Hospitals” ““Best Docs”Best Docs”

Health Care PlansHealth Care Plans


Must have a reliable data sourceMust have a reliable data source

University HealthSystem ConsortiumUniversity HealthSystem Consortium The University HealthSystem Consortium (UHC), Oak The University HealthSystem Consortium (UHC), Oak

Brook, Illinois, formed in 1984, is an alliance of 103 Brook, Illinois, formed in 1984, is an alliance of 103 academic medical centers and 219 of their affiliated academic medical centers and 219 of their affiliated hospitals representing approximately 90% of the hospitals representing approximately 90% of the nation's non-profit academic medical centers. nation's non-profit academic medical centers.

UHC offers an array of performance improvement UHC offers an array of performance improvement products and services. Powerful databases provide products and services. Powerful databases provide comparative data in clinical, operational, faculty comparative data in clinical, operational, faculty practice management, financial, patient safety, and practice management, financial, patient safety, and supply chain areas.supply chain areas.


Core MeasuresCore Measures

• Acute Myocardial InfarctionAcute Myocardial Infarction• Heart failureHeart failure• PneumoniaPneumonia• Surgical Care Improvement ProjectSurgical Care Improvement Project• Children’s Asthma CareChildren’s Asthma Care

• http://www.hospitalcompare.hhs.gov/http://www.hospitalcompare.hhs.gov/


• Relationship Between Medicare’s Relationship Between Medicare’s Hospital Compare Performance Hospital Compare Performance Measures and Mortality RatesMeasures and Mortality Rates• Rachel M. Werner, MD, PhD; Eric T. Rachel M. Werner, MD, PhD; Eric T.

Bradlow, PhD Bradlow, PhD JAMA. 2006;296:2694-2702JAMA. 2006;296:2694-2702..


UMC MICU UMC MICU Quality Improvement ProjectsQuality Improvement Projects

• Multidisciplinary approachMultidisciplinary approach• Nursing, physician, pharmacy, RT, quality Nursing, physician, pharmacy, RT, quality

improvementimprovement

• Data collection by staff/QIData collection by staff/QI• Success related to investment of individuals Success related to investment of individuals

• Introduce innovationsIntroduce innovations• Improvements in daily practiceImprovements in daily practice

• Evidence basedEvidence based


UMC MICU UMC MICU Quality Improvement ProjectsQuality Improvement Projects

• Monthly meetings- forum for discussionMonthly meetings- forum for discussion

• Literature review of best practiceLiterature review of best practice

• Discover problems and look for causeDiscover problems and look for cause• Leaders in each project areaLeaders in each project area

• Discuss new ideas for change in practiceDiscuss new ideas for change in practice


5 East Blood Stream Infections per 1000 CVL Days

0

200

400

600

800

1000

1200

CV

L D

ays

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

rate

per

100

0 C

VL

day

s

BSI 3 7 4 3 6 5 3 4 6 3 3 3 4 5 3 1 1 0

CVL Days 624 966 801 971 745 752 502 566 499 889 778 893 811 765 887 853 889 825

Rate 4.81 7.25 4.99 3.09 8.05 6.65 5.98 7.06 12.02 3.37 3.86 3.36 4.93 6.54 3.38 1.17 1.12 0.00

2Q 04

3Q 04

4Q 04

1Q 05

2Q 05

3Q 05

4Q 05

1Q 06

2Q 06

3Q 06

4Q 06

1Q 07

2Q 07

3Q 07

4Q 07

1Q08 2Q083Q 08

CVL Insertion Packs 2Q04

IHI2Q05

CVL Checklist2Q06

Checklist Revised3Q06

Full -body Drape in Packs3Q07

Clave4Q07

Data Source: Infection PreventionGraph: G Priestley, RN

PICC Team1Q08

Infection Control Update 1Q08

Arrow kits w Anti microbial catheter 3Q08

Great Job, 5East! BSI's = 0!


5East Ventilator-associated Pneumonia Rate

0

2

4

6

8

10

12

14

16

18V

AP

Rat

e /

1,00

0 V

enti

lato

r D

ays

5East VAP Rate 15.66 15.6 9.33 4.33 4.4 2.9 7.33 7.82 4.4 6.22

1Q 07 2Q 07 3Q 07 4Q 07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09

Data: Infection PreventionGraph: G Priestley, RN

Infection Prevention Update 1Q08

Focus on Oral Care 2Q08

Sedation Update: Intermittent Bolus Option 1Q09

Prior Interventions: RASS, HOB, Oral Care, Daily Wake-up,


Medication Error Reduction StrategiesMedication Error Reduction Strategies

• What is the evidence of value of other What is the evidence of value of other technological innovations?technological innovations?

• What level of evidence is needed to What level of evidence is needed to justify expense of such innovations?justify expense of such innovations?• Automated dispensing devicesAutomated dispensing devices• Smart infusion pumpsSmart infusion pumps• Bar codingBar coding

Leape et al. JAMA 2002;288:501Leape et al. JAMA 2002;288:501


Patient Safety MeetsPatient Safety MeetsEvidence-Based MedicineEvidence-Based Medicine

• Shonjania et al. Making health Care Safer: Shonjania et al. Making health Care Safer:

A Critical Analysis of Patient Safety A Critical Analysis of Patient Safety

PracticesPractices;2001. AHRQ publication 01-E058;2001. AHRQ publication 01-E058

• UCSF-Stanford University Evidence-Based UCSF-Stanford University Evidence-Based

Practice CenterPractice Center

• 40 investigators around the country40 investigators around the country

• Over 80 “safety practices” reviewedOver 80 “safety practices” reviewed



Medium strength of evidenceMedium strength of evidence11

• Computerized physician order entry (CPOE)- Computerized physician order entry (CPOE)- fully implemented in few health systemsfully implemented in few health systems

• On-site pharmacist with participation on ICU On-site pharmacist with participation on ICU rounds- approximately 30% of health systems rounds- approximately 30% of health systems report having a pharmacist on attending rounds report having a pharmacist on attending rounds (survey not specific to ICU setting)(survey not specific to ICU setting)22

1. Shojania K et al. JAMA 2002;288:508-111. Shojania K et al. JAMA 2002;288:508-112. Pedersen et al. Am J Health-Syst Pharm 2001;58:22512. Pedersen et al. Am J Health-Syst Pharm 2001;58:2251



• Medication ReconciliationMedication ReconciliationPronovost et al. Journal of Critical Care, Vol 18, No 4 (December), Pronovost et al. Journal of Critical Care, Vol 18, No 4 (December), 2003: pp 201-2052003: pp 201-205

• 46% of medication errors occur on 46% of medication errors occur on

admission or dischargeadmission or discharge

• Marked decrease in errors after initiation of Marked decrease in errors after initiation of

discharge surveydischarge survey

• The Joint Commission (Patient Safety Goal)The Joint Commission (Patient Safety Goal)


The National Quality Forum/The National Quality Forum/Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

• 30 Safe Practices for Better Health Care30 Safe Practices for Better Health Care • AHRQ March 2005, Pub No. 05-P007AHRQ March 2005, Pub No. 05-P007

• Pharmacists should actively participate in the Pharmacists should actively participate in the medication-use processmedication-use process

• Implement CPOE systemImplement CPOE system• Standardize the methods for labeling, packaging, Standardize the methods for labeling, packaging,

and storing medicationand storing medication• Identify “high alert” drugsIdentify “high alert” drugs• Dispense medications in unit-dose or unit-of-use Dispense medications in unit-dose or unit-of-use

form, whenever possible form, whenever possible


Organization-wide UMC QI ProjectOrganization-wide UMC QI Project• Medication Delivery SystemMedication Delivery System• Implementations:Implementations:

• Computerized Physician Order Entry (SCM)Computerized Physician Order Entry (SCM)• Electronic Medication Administration RecordElectronic Medication Administration Record• Established Medication Use SubcommitteeEstablished Medication Use Subcommittee• Weekly audits of med bins and PyxisWeekly audits of med bins and Pyxis• Clinical pharmacists assigned to specific unitsClinical pharmacists assigned to specific units• Changed bin fill timesChanged bin fill times• Established 3rd Floor Pharmacy Satellite ClinicEstablished 3rd Floor Pharmacy Satellite Clinic• Separated look alike/sound alike drugs in pharmacySeparated look alike/sound alike drugs in pharmacy

• Evaluation showed Improvements:Evaluation showed Improvements:• Reported distribution errors decreased 16%Reported distribution errors decreased 16%• Rate of prescription errors reduced by 95%Rate of prescription errors reduced by 95%• Medications missing from patient bins Medications missing from patient bins decreased by 50%decreased by 50%


Medication Error Reduction StrategiesMedication Error Reduction Strategies Smart Infusion Pumps Smart Infusion Pumps

• Rothschild et al. A controlled trial of smart infusion Rothschild et al. A controlled trial of smart infusion

pumps to improve medication safety in critically ill pumps to improve medication safety in critically ill

patients. patients. Crit Care Med 2005;33(3):533-540Crit Care Med 2005;33(3):533-540

• I.V. med errors and ADEs can be detected by smart pumpsI.V. med errors and ADEs can be detected by smart pumps

• No measurable impact on serious error rate due to poor complianceNo measurable impact on serious error rate due to poor compliance

• ““Smart pumps have great promise…”Smart pumps have great promise…”

• Leape.Leape. Crit Care Med 2005;33(3): 679-80Crit Care Med 2005;33(3): 679-80

• ““Humans can always defeat technology if it is Humans can always defeat technology if it is

perceived as a barrier.”perceived as a barrier.”


Five Years After Five Years After To Err is HumanTo Err is HumanWhat Have we Learned?What Have we Learned?Leape and Berwick. JAMA 2005;293: 2384Leape and Berwick. JAMA 2005;293: 2384 InterventionIntervention ResultResult

CPOECPOE 81% reduction in med errors81% reduction in med errors

Pharmacist rounding with teamPharmacist rounding with team 66 - 78% reduction of 66 - 78% reduction of preventable ADEspreventable ADEs

Reconciliation Medication Reconciliation Medication PracticesPractices

90% Reduction in medication 90% Reduction in medication errorserrors

Reconciling and standardizing Reconciling and standardizing medication practicesmedication practices

60-64% Reduction in ADEs60-64% Reduction in ADEs

Standardizing insulin dosingStandardizing insulin dosing Hypoglycemic episodes Hypoglycemic episodes decrease 63%decrease 63%

Standardizing warfarin dosingStandardizing warfarin dosing Out-of-range INR decrease 60%Out-of-range INR decrease 60%

Trigger tool and automationTrigger tool and automation ADEs decrease by 62%ADEs decrease by 62%


The New Yorker: The ChecklistThe New Yorker: The ChecklistDecember 10, 2007 Atul GawandeDecember 10, 2007 Atul Gawande


A Surgical Safety Checklist to Reduce Morbidity and A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global PopulationMortality in a Global Population

Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir

Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D.,

Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group. NEJM January 2009Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group. NEJM January 2009

• Results :The rate of death was 1.5% before the Results :The rate of death was 1.5% before the checklist waschecklist was introduced and declined to 0.8% introduced and declined to 0.8% afterward (P=0.003). Inpatientafterward (P=0.003). Inpatient complications complications occurred in 11.0% of patients at baseline andoccurred in 11.0% of patients at baseline and in in 7.0% after introduction of the checklist (P<0.001).7.0% after introduction of the checklist (P<0.001).

• Conclusions: Implementation of the checklist was Conclusions: Implementation of the checklist was associated withassociated with concomitant reductions in the rates concomitant reductions in the rates of death and complicationsof death and complications among patients at least among patients at least 16 years of age who were undergoing16 years of age who were undergoing noncardiac noncardiac surgery in a diverse group of hospitals.surgery in a diverse group of hospitals.


UHC Data with BenchmarksUHC Data with Benchmarks

UMC

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