lisa lubomski, phd cohort 5 presentation may 19 th and may 21 st
DESCRIPTION
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 PresentationTRANSCRIPT
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The Science of Improving Patient Safety and Identifying Defects
DRAFT – final pending AHRQ approval
Lisa Lubomski, PhD
Cohort 5 presentation
May 19th and May 21st
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!
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
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
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.
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
DRAFT – final pending AHRQ approval
How Can These Errors Happen?
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People are fallible
Medicine is still treated as an art, not a science
Systems do not catch mistakes before they reach the patient
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
DRAFT – final pending AHRQ approval
System Factors Impact Safety14
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Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
Institutional
DRAFT – final pending AHRQ approval
Safety is a Property of the System
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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
DRAFT – final pending AHRQ approval
Standardize When You Can
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DRAFT – final pending AHRQ approval
Create Independent Checks
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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
DRAFT – final pending AHRQ approval
Communication Breakdowns
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DRAFT – final pending AHRQ approval
Basic Process of Communication21
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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
DRAFT – final pending AHRQ approval
What is a defect?
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Anything that happens that
you do not want to happen again.
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
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
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
DRAFT – final pending AHRQ approval
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?
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
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
DRAFT – final pending AHRQ approval
SSI Specific PSSA Sample Results 22
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Percentage of Responses (%)
How will the next patient be harmed?
DRAFT – final pending AHRQ approval
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
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 Rounds
New staff orientation
Regularly scheduled staff meetings (for nurses, anesthesiologists, surgeons, etc.)
Lunch & Learn sessions
Special educator sessions
Make video available in break room
Hang up SOS factsheet in break room, restroom, etc.
Annual recertification requirements
Hospital Intranet
Others?
Next Steps
DRAFT – final pending AHRQ approval28
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
DRAFT – final pending AHRQ approval29
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
DRAFT – final pending AHRQ approval30
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
DRAFT – final pending AHRQ approval31
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
DRAFT – final pending AHRQ approval32
Questions?
DRAFT – final pending AHRQ approval
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