dallas, tx november 2–4, 2012 improving outcomes through patient safety initiatives patricia a....

Dallas, TX • November 2–4, 2012

Improving Outcomes through

Patient Safety Initiatives

Patricia A. Patrician, PhD, RN, FAANAssociate Professor and Donna Brown Banton

Endowed Professor

University of Alabama at Birmingham

Birmingham, AL

Acknowledgement: Many slides came from American Association of Colleges of Nursing and Quality and Safety Education for Nurses Project, funded by the Robert Wood Johnson Foundation, PI: Linda Cronenwett, PhD, RN


Improving Outcomes through PatientSafety Initiatives

Session Code: 105 Contact Hours: 0.8 CRNI Units: 2Please use session code shown above when completing

your speaker evaluation and CE form.

Return the evaluation to the registration desk or receptacles located outside meeting rooms at the end of the day.

Handouts for this session are available online at www.ins1.org. Session recordings will also be available post-meeting courtesy of

B.Braun Medical/Aesculap Academy.

As a courtesy to both presenters and attendees, please turn off all cell phones and refrain from talking during the session.

Tonight’s Event:Industrial Exhibition and Networking Reception

3:30-5:30pm


Outline

• Overview: Patient safety and quality improvement

• National initiatives

• Infusion safety

• Additional resources


“First Do No Harm”

http://bcove.me/stbtnf90 (1:37 min.)

(CATHLEEN F. CROWLEY and ERIC NALDER,

HEARST NEWSPAPERS)


Betsy Lehman (1995)

• Received 4X Cytoxan dose for four days

• “If this can happen at a place like Dana-Farber, a nationally respected institute, what is happening in other places?” –Dr. Michael Colvin, Duke U. Comprehensive Cancer Center


Lewis Blackman (2000)

• http://www.qsen.org/video/blackman/video.php?qsen_a_Lewis_Blackman_Story.f4v (6.44 minutes)


Josie King (2001)

• http://www.qsen.org/video/josieking/ (13.33 minutes)


To Err is Human

Beginning in 2000, the Institute of Medicine released a series of reports that brought

attention to the issues of quality. The first, To Err is Human brought startling statistics to light about the number of needless deaths and injuries caused by medical errors.

Annual deaths•AIDS---------------------------- 16,516•Breast cancer----------------- 42,297•Motor vehicle accidents---- 43,458•Medical Errors--------------- 98,000


Crossing the Quality Chasm

• The second report, Crossing the Quality Chasm, provided a definition and aimed to improve quality of care. In this report, the Institute of Medicine defined quality as:

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.


Crossing the Quality Chasm

Crossing the Quality Chasm established six aims that have formed

a framework for moving forward with improving quality. The aims

are that care should be:

Safe Care should be as safe for patients in healthcare facilities as in their homes.

Timely Patients should experience no waits or delays in receiving care and service.

Effective The sciences and evidence behind healthcare should be applied and serve as the standard in the delivery of care.

Efficient Care and service should be cost-effective, and waste should be removed from the system.

Equitable Unequal treatment should be a fact of the past; disparities in care should be eradicated

Patient centered

The system of care should revolve around the patient, respect patient preferences, and put the patient in control.


Subsequent IOM Reports

http://www.iom.edu/Reports.aspxReports are free electronically – at least read the executive summaries!


• Minimize risk of harm to patients and providers through both system effectiveness and individual performance.

• Requires understanding of the complexity of care delivery, the limits of human factors, safety design principles, characteristics of high reliability organizations, and patient safety resources.

- QSEN/American Association of Colleges of Nursing, 2009

Patient Safety


•Science of the interrelationship between humans, their tools and the environment in which they live and work•So that systems and products can be built to enhance performance. •Can be used to reduce adverse events and errors by identifying how and why systems break down and how and why human beings mis-communicate. •Goal is to provide better designed systems and processes by:

–Simplifying processes

–Standardizing procedures

–Providing backup when humans fail

–Improving communication

–Redesigning equipment

–Understanding behavioral, organizational and technological limitations that lead to error. (WHO, 2009).

Human Factors Engineering


• Health care services are provided within a complex and technological setting that is prone to accidents.

• When systems fail, it is due to multiple faults that occur together.

• Human error is one of the greatest contributors to accidents (active error); however…

• Latent errors or system failures pose the greatest threat to safety in a complex system.

• Need to shift from emphasis on active errors to one on latent errors and fix the system, not the person.

Why Human Factors


• Organizational factors– Poorly designed equipment– Lack of appropriate communication– Fearful environment

• Work setting factors– Unworkable procedures– Inadequate or inaccessible

equipment– Storage of supplies

• Unsafe acts– Not following procedural guidelines– Hurried, stressed staff– Work-arounds for work setting and

organizational factors

Latent Condition Pathways

Hazards Accident

Defenses


Anatomy of a Near Miss

Intact defenses

Faileddefenses


Anatomy of an Error

Latent failures - conditions that lead to failures – hidden; not readily apparent; an accident waiting to happen.

Active failures – the “last straw”; the apparent error.

Latent failure

Latent failure

Latent failure

Active failure

Failed or absent defenses

Organizational influences

Unsafe supervision

Preconditions for unsafe acts

Unsafe acts

Mishap


While delivery of healthcare is extremely complex and there are tremendous systems challenges, nurses often have been held accountable for harm to patients . . .

. . . even while they have not had input into system designs and have little understanding of how complex systems leave them vulnerable to making errors.

-QSEN/American Association of Colleges of Nursing, 2009

Nurses and Patient Safety


•Within a culture of safety, when an adverse event occurs, the focus is on what went wrong, not who is the problem.

•A culture of blame has been pervasive in healthcare. The focus has often been to try to determine who has been at fault and, all too often, to mete out discipline.

– This approach leads to hiding rather than reporting errors and is the antithesis of a culture of safety.

Culture of Safety vs. Culture of Blame


•Elements of a culture of safety in an organization are establishment of safety as an organizational priority, teamwork, patient involvement, openness/transparency and accountability (Lamb, 2003).

•There are shared core values and goals, non-punitive responses to adverse events and errors, and promotion of safety through education and training.

Culture of Safety


• A safety culture requires strong, committed leadership, and engagement and empowerment of all employees. It entails periodic assessment of the culture and relationship between the organization culture and the quality and safety within the organization.

Culture of Safety


The IOM described 9 categories that provide opportunities to improve patient safety.

IOM Recommendations


• Approaches include making things visible so the user is able to see actions possible at any time.

• Use constraints and forcing-functions (makes it hard to do the wrong thing and easier to do the right thing).

1. User-centered design


• Standardizing and simplifying procedures and tasks decreases the demand on memory, planning, and problem-solving.

• The use of protocols and checklists reduces reliance on memory and serves as a reminder for the steps to be followed.

• Simplifying processes minimizes problem-solving.

• Having the usual dose of a medication as the default in an electronic order entry.

• Purchasing equipment that is easy to use and maintain are examples of simplification of processes.

2. Avoid reliance on memory


Work hours, work-loads, staffing ratios, distractions, and counterclockwise shift changes all affect patient safety.

3. Attend to work safety


• Checklists, well-designed alarms, rotating staff and breaks decrease the need for remaining vigilant for long periods.

• Look-alike medications should be stored far apart.

4. Avoid reliance on vigilance


• Training programs for effective interprofessional communication and collaboration include transitions in care and hand-offs.

• Introduction of new processes and technologies depends on a chain of involvement of frontline users and the need for pilot testing before widespread implementation.

5. Train for teamwork


• Patients and families should be in the center of the care process.

6. Involve patients in their care


Reorganization and organization-wide changes result in new patterns and processes of care.

7. Anticipate the unexpected


• Errors will occur despite the best of planning.

• Designing and planning for recovery will allow reversal or make it hard to carry out irreversible critical functions.

8. Plan for service recovery


•Information for decision making needs to be available at the point of care.

•This includes easy access to drug formularies, evidence-based practice protocols, patient records, laboratory reports, and medication administration records.

9. Improve access to timely, accurate

information


Quality Improvement

Quality and Safety Education for Nurses (QSEN) defines quality improvement as:

Use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems (Cronenwett et al., 2007).


Quality Improvement: Another Definition

". . .the combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, educators – to make changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning)."

– Batalden, P. & Davidoff, F. (2007). What is "quality improvement" and how can it inform health care? Quality and Safety in Health Care, 16(1), 2-3.


Improving Care

•Requires problem identification:–systematic process of defining problems–to identify potential causes of those problems –and develop strategies to improve care.

•Requires measurement


Institute for Healthcare Improvement (IHI)

AIM

MEASUREMENT

CHANGES


Problem Identification

• Routine monitoring

• Sentinel event or observation

• To better understand the problem:– Cause and effect diagrams (“fishbone” or

“Ishikawa”)– Process flow maps– Root cause analysis– Failure Mode and Effect Analysis


Root Cause Analysis (RCA)

From thinkreliability.com


• Identify the underlying causes of why an incident occurred

• So that the most effective solutions can be identified and implemented.

• It's typically used when something goes wrong (sentinel events)

• What's the problem? Why did it happen? Series of WHY’s

• What will be done to prevent it? • Uses process maps, fishbones, and others• See TapRoot®: http://www.taproot.com/index.php

RCA


• Documents current knowledge and actions about the risks of failures, for use in continuous improvement.

• Used during design to prevent failures. • Later it’s used for control, before and

during ongoing operation of the process. • Ideally, FMEA begins during the earliest

conceptual stages of design and continues throughout the life of the product or service.

Failure Mode and Effect Analysis (FMEA)


Selecting Measures• Measure things that matter to patients, providers

• Measure things you can change (actionable): what do you (or your team) “own”?

• Measure close to what you are after

– Temporally (time-wise): close to patient encounter

– Operationally (content-wise): close to your theoretical definition. If nursing sensitive outcome is your concept, and patient adverse events are your theoretical terms, is mortality a good measure?

• Measure at the correct level – hospital, unit, day, shift

• Measure as objectively as possible – self-reports versus pill counts


Selecting Measures• Measure things for which you have (or can get) comparisons

• Select a balanced set of measures (structure-process-outcomes)

• Measure things for which you already collect data • Select standardized and tested measures if possible (e.g.,

National Quality Forum (NQF); National Database of Nursing Quality Indicators (NDNQI); Collaborative Alliance for Nursing Outcomes; CALNOC); Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators: http://www.qualitymeasures.ahrq.gov/browse/by-topic.aspx

• Consider ease of data collection, especially if you are not actually collecting the data.


Instituting Change1. Establish sense of urgency2. Create guiding coalition3. Develop vision and strategy4. Communicate change vision5. Empower broad based action6. Generate short term wins7. Consolidating gains and producing more change 8. Anchoring new approaches in the culture

Kotter, J. (1996). Leading Change.


National Initiatives

• Agency for Healthcare Research & Quality (AHRQ)

• National Quality Forum (NQF)• Centers for Medicare and Medicaid Services

(CMS)• Institute for Healthcare Improvement (IHI)• Quality and Safety Education for Nurses

(QSEN)


Agency for Health care Quality &

Research (AHRQ)• Lead Federal agency charged with improving the

quality, safety, efficiency, and effectiveness of health care for all Americans

• As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services

• Research funding opportunities, data collection and reporting, data sources for research, clinical practice guidelines, consumer healthcare information


• Safety and quality: Reduce the risk of harm by promoting delivery of the best possible health care.

• Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed health care decisions.

• Efficiency: Transform research into practice to facilitate wider access to effective health care services and reduce unnecessary costs.

• Great collection of useful tools and other resources on web site

AHRQ Focus


National Quality Forum (NQF)

Promotes change through development and implementation of a national strategy for health care quality measurement and reporting.


Nursing Sensitive Measures – NQF

Definition• Nursing-sensitive performance measures are processes and outcomes - and structural proxies for these processes and outcomes (e.g., skill mix, nurse staffing hours) - that are affected, provided, and/or influenced by nursing personnel, but for which nursing is not exclusively responsible. Nursing-sensitive measures must be quantifiably influenced by nursing personnel, but the relationship is not necessarily causal.

• The NQF Report details 12 voluntary, NQF-endorsed consensus standards for nursing-sensitive care, including evidence-based nursing-sensitive performance measures, a framework for measuring nursing-sensitive care, and related research recommendations.

• This is the first-ever set of national standardized performance measures to assess the extent to which nurses in acute care hospitals contribute to patient safety, healthcare quality, and a professional work environment (NQF, 2012).


NQF - 12

• NSC-1 Death Among Surgical Inpatients with Treatable Serious Complications

• NSC-2 Pressure Ulcer Prevalence (Hospital-Acquired) • NSC-3 Restraint Prevalence • NSC-4 Patient Falls• NSC-5 Falls with Injury • NSC-6 Catheter-Associated Urinary Tract Infections (UTI) for Intensive

Care Unit (ICU) Patients • NSC-7 Central Line Catheter-Associated Blood Stream Infections for ICU

and Neonatal Intensive Care Unit (NICU) Patients • NSC-8 Ventilator-Associated Pneumonia for ICU and NICU Patients • NSC-9 Skill Mix • NSC-10 Nursing Care Hours per Patient Day • NSC-11 Voluntary Turnover • NSC-12 Practice Environment Scale-Nursing Work Index (PES-NWI)

Appendices


Centers for Medicare and Medicaid

Services (CMS)• In order to receive Medicare and

Medicaid reimbursement, hospitals and other health care organizations must meet certain standards or “conditions of participation”

• Health Care Financing Administration (HCFA)

• Increasing requirements for reimbursement in hospitals


Creating a Sense of Urgency:

“Never Events”Recent rules established by CMS have identified “never events,” which are serious and costly events that should never occur in a hospital if appropriate care is provided.

All nurses should be aware of information available from regularly collected data. For instance, all hospitals collect data related to infections, 30-day readmissions, pressure ulcers, and others.


“Never Events” and Hospital

ReimbursementHospitals no longer getpaid for the costs of certain Never Events, because they are preventable and should never happen to patients.


Institute for Healthcare

Improvement (IHI)• Motivating and building the will for change;

• Identifying and testing new models of care in partnership with both patients and health care professionals; and

• Ensuring the broadest possible adoption of best practices and effective innovations

• Great educational resource: IHI Open School


IHI Open School for Health Professionals

• Interprofessional educational community that gives students the skills to become change agents in health care improvement.

• Skills like quality improvement, patient safety, teamwork, leadership, and patient-centered care. Employers are looking for these skills, and patients expect providers to have them. But most schools barely touch on these topics.

• Health professionals and students in nursing, health administration, medicine, pharmacy, dentistry, policy, and other health professions can join.

• There are no applications, no admissions requirements, and no due dates.


Quality and Safety Education for Nurses

(QSEN)• Program to increase knowledge, skills, and attitudes of

nurses about quality and safety.

• The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work.

• Provide tools for faculty (staff development personnel) to teach these competencies.


QSEN Competencies

1. Patient-centered care

2. Teamwork and collaboration

3. Evidence-based practice

4. Quality improvement

5. Safety

6. Informatics


• Wachter: – Modest improvement– Grade: B -

• Bielaszka-DuVernay:– Cites McGlynn et al (2003): US adults receive 55% of

recommended care– Key issues – measuring improvement, incentives for

better quality, disparities in care, patient involvement, health care complexity

• Nembhard et al.,: – Significant barriers to improvement: Many are

organizational/cultural– Innovation implementation failures

Has Health Care Improved?


Infusion Safety: What can YOU do?

• Learn about patient safety and quality improvement (QI)

• Report potential and actual problems, concerns, errors

• Monitor your practice – processes and outcomes

• You job is not only to do your work, but to continuously improve your work (P. Batalden)


Infusion Safety

• Med errors: account for 20% of medical injuries

• IV medications associated with 54% of potential adverse drug events – 40% of deaths from adverse drug events

due to wrong dose– 16% deaths from adverse drug events due

to wrong drug


IV Infusion Safety Initiative

• Standardized medication delivery mechanism – identical IV smart pumps

• Decision-support drug library

– Dose-error Reduction Software

– Customized for different unit types

– Provides alerts

• Capnography monitors for all patients on PCA

• Expanded role for RTs: rounds; first responders

• Wireless networking system – connectivity to pharmacy for monitoring, trending data

• Ongoing monitoring and analysis . . . and improvementMaddox, R. R., Danello, S., Williams, C. K., & Fields, M. (2008). Intravenous infusion safety initiative: Collaboration,

evidence-based practices, and “smart” technology help avert high-risk adverse drug events and improve patient ouitcomes. In Advances in Patient Safety: New Directionsand Alternative Approaches. Vol 1-4, available at http://www.ahrq.gov/downloads/pub/advances2/vol4/Advances-Maddox_38.pdf


IV Infusion Safety Initiative Results

• Med errors averted: January-June 2006, 967 errors prevented, including 328 overdoses

• Decreased programming errors during PCA administration: 52 in first 4 months

• Cost savings: $2 million between Jan-Jun 2006• Improved nurse satisfaction with IV system• Nurses felt more comfortable with aggressive

pain management– St. Joseph’s/Candler Health System

– Read more at AHRQ Innovations Exchange: http://www.innovations.ahrq.gov/content.aspx?id=2375


Conclusion• It is not enough for a nurse to be well-

educated in the technical aspects of nursing and be well-intentioned in providing good care.

• Unless there are consistent efforts to measure and improve care, our health system will continue to provide great care in some places and situations, and mediocre or poor care in others.

• Nurses can make the difference.


Questions?

[email protected]

205-996-5211


• Agency for Healthcare Research & Quality, www.ahrq.gov• AHRQ Patient Safety Indicators (PSIs) – helpful in

defining/standardizing measures:http://www.qualityindicators.ahrq.gov/Default.aspx• Centers for Medicare & Medicaid Services, www.cms.gov• Hospital Compare, www.hospitalcompare.hhs.gov• Institute for Healthcare Improvement, www.ihi.org• Institute of Medicine, www.iom.edu• Institute for Safe Medical Practices, www.ismp.org• National Quality Forum, www.qualityforum.org• Quality and Safety Education for Nurses, www.qsen.org• The Joint Commission, www.jointcommission.org• US Pharmacopeia, www.usp.org

Quality and Safety Resources


Other Resources

Bielaszka-DuVernay, C. (2011). Health policy brief. Improving quality and safety. Health Affairs. www.healthaffairs.org

Institute of Medicine. (2001). Crossing the quality chasm. Report brief. Available at http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

Institute of Medicine. (1999). To err is human: Report brief. Available at http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

Nembhard, I. M., Alexander, J. A., Hoff, T. J., & Ramanujam, R. (2009). Why does quality of health care continue to lag? Insights from management research. Academy of Management Perspectives, 23(1), 24-42.

Wachter, R. (2010). Patient safety at ten: Unmistakable progress, troubling gaps. Health Affairs, 29(1),165-173.


• American Society for Quality www.asq.org

Global community of people passionate about quality who use the tools and their ideas to make our world work better. The global voice of quality.

• AcademyHealth http://academyhealth.org/Seeks to improve health and health care by generating new knowledge and moving knowledge into action.

Professional Organizations


• The Dartmouth Institute www.tdi.dartmouth.edu/Dedicated to improving health care through education, research, policy reform, leadership improvement, and communication with patients and the public.

• Microsystem Academy http://clinicalmicrosystem.org/The Place That Works: patients, families, and care teams.



• Healthcare.gov: http://www.healthcare.gov/law/resources/reports/quality03212011a.html#na“Take health care into your own hands.” Consumer- focused web site.

• Institute For Safe Medication Practices www.ismp.org/Devoted entirely to medication error prevention and safe medication use.



• Institute for Healthcare Improvement: http://www.ihi.org/Focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.

• Academy for Healthcare Improvement: http://www.a4hi.org/

Aim is to foster an interprofessional community that advances quality improvement in health care through scholarly and educational activities.



• National Quality Forum: www.qualityforum.org/

Promotes change through development and implementation of a national strategy for health care quality measurement and reporting.

• National Priorities Partnership http://www.nationalprioritiespartnership.org/Convened by the National Quality Forum, The National Priorities Partnership (NPP) offers consultative support to the Department of Health and Human Services on setting national priorities and goals for the HHS National Quality Strategy. The 48 member organizations also play a key role in identifying strategies for achieving the aims of better care, affordable care, and healthy people and communities; and facilitating coordinated, multi-stakeholder action.



• http://www.sgim.org/userfiles/file/SGIM%20August%202011%20Web(1).pdf

List of QI/Safety Journals


• The Joint Commission has a nice framework for conducting a Root Cause Analysis: http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/

• Great example of RCA: Smetzer, J., Baker, C., Byrne, F. D., & Cohen, M. R. (2010). Shaping systems for better behavioral choices: Lessons learned from a fatal medication error. The Joint Commission Journal of Quality and Safety, 36(4), 152-163.

RCA


• For more information on FMEAs, go to http://asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html

• Click on flowcharts or go to: http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html

FMEA

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