marc – network 5 5 diamond patient safety program decreasing patient & provider conflict...
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MARC – Network 5 5 Diamond Patient Safety Program
Decreasing Patient & Provider ConflictBasics of Patient-Centered Care
2008
Basics of Patient – Basics of Patient – Centered CareCentered Care
Basics of Patient – Basics of Patient – Centered CareCentered Care
A Safe Environment . . A Safe Environment . . . .Jack Moore, MD, Washington Hospital Center, Network 5 Medical Review Board Chairman
A Working Access . . .A Working Access . . .Robert Lee, MD, Chung W. Lee, MD, PCYao-Foli Sekyema, MD, Danville Urologic ClinicJim Seymour, Dialysis Patient, MARC Patient Advisory Committee
Clean Hands . . .Clean Hands . . .Valerie Riley, RN, Fresenius Medical Care
A Safe Environment . . A Safe Environment . . . .Jack Moore, MD, Washington Hospital Center, Network 5 Medical Review Board Chairman
A Working Access . . .A Working Access . . .Robert Lee, MD, Chung W. Lee, MD, PCYao-Foli Sekyema, MD, Danville Urologic ClinicJim Seymour, Dialysis Patient, MARC Patient Advisory Committee
Clean Hands . . .Clean Hands . . .Valerie Riley, RN, Fresenius Medical Care
Patient Safety Issues & Activities in Network 5
May 2, 2003Jack Moore, MD
Gathered Information
in 2002 and 2003 In 2002 . . .• Surveyed facility staff
22% overall response rate In 2003 . . .
• Surveyed facility staff 31% overall response rate
• Questionnaire to each unit (via Adm.) 40% response rate
Top 5 Safety Issues - Same in Both Years
255
197
99 93 89
0255075
100125150175200225250275
# T
ime
s R
esp
on
de
nts
S
ele
cte
d Is
sue
AccessEvent
Excess BloodLoss
ViolentPatients
Blood-fluidExposure
MedicationErrors
Top Patient Safety Issues in Dialysis Clinics Identified by Network 5 Renal Community
2002 and 2003 Compared
2003 2002
2003 Patient Safety Issues Ranked
Top Patient Safety Issues Identified by Network 5 Renal Community in 2003
25
43
44
60
79
85
89
93
99
197
255
0 25 50 75 100 125 150 175 200 225 250 275
Other
Needle Sticks
H20 System
Dialyzer Error
Equip. Failure
Pt. Falls
Med. Errors
Bld/f luid Exp.
Violent Pts.
Excess Bld. Loss
Access Event
# Times Respondents Selected Issue
Response Rate by Discipline
Response Rate by Discipline and Contribution to Overall - 2003
54%136/253
34%68/199
25%70/279 21%
45/218
20%41/201
31%360/1150
0%
10%
20%
30%
40%
50%
60%
Nurse Other Administrator Physician Patient Overall
Res
pons
e R
ate
of E
ach
Dis
cipl
ine
0%
20%
40%
60%
80%
100% Contribution of D
iscipline to Overall R
esponse
Response Rate of Discipline % of Total Responses
Top 3 Patient Safety Issues by Discipline
0%
20%
40%
60%
80%
100%
AllResponses
Doctors Nurses Admins Patients Other Staff
Access Event Excess Blood Loss Violent/Abusive Pts
Medication Error Equipment Malfunction
Patient Safety Activities Conducted by Network 5
Facilities
106100
74
58
30 26 2518 5
0
20
40
60
80
100
120
Review Reports Staff Education Patient Education Distribute Educational
Materials
Patient Safety Team Improvement Projects Patient Safety
Program
Visited Safety Website Other
# of
Unit
s Co
nduc
ting
Activ
ity
“Access Event”“Access Event”Top Patient Safety Issue 2
Years
For later discussion . . .
How do you define an access-related event ?
Bad stick ? Infection ?? ? ?
A Working AccessA Working Access
K-DOQI Guidelines & MARC GoalsK-DOQI Guidelines & MARC Goals
What They Say . . .What They Say . . .
Where We Are . . .Where We Are . . .
andand
What Activities Are What Activities Are
PlannedPlanned
At least 50% of all incident HD patients (adults At least 50% of all incident HD patients (adults 18) should have an A-V fistula. 18) should have an A-V fistula.
25% in NW 5 per CPM data from 425% in NW 5 per CPM data from 4thth qtr. 2001 qtr. 2001 (more recent data on incident patients not available)(more recent data on incident patients not available)
29%
49%
27%
13%
0%
10%
20%
30%
40%
50%
60%
13 7 14 6 9 4 5 11 10 15 US 8 12 2 3 17 18 1 16
Network Numbers
DOQI Recommended Level 50%
At least 40% of all prevalent HD patients At least 40% of all prevalent HD patients (adults (adults 18) should have an A-V fistula. 18) should have an A-V fistula.
46%
31%25%23%
0%
10%
20%
30%
40%
50%
14 13 5 4 6 9 7 8 11 US 3 10 17 12 15 18 2 16 1Network Numbers
DOQI Recommended Level 40%
25% in NW 5 per CPM data from 425% in NW 5 per CPM data from 4thth quarter 2001 quarter 2001
27% in NW 5 per CDC Survey from Dec. 2002 27% in NW 5 per CDC Survey from Dec. 2002 (Comparative data from CDC Survey not yet available)(Comparative data from CDC Survey not yet available)
100% of facilities must employ a prospective 100% of facilities must employ a prospective monitoring program for A-V accesses monitoring program for A-V accesses ((grafts & grafts & fistulafistula)), which utilizes intra-access flow, and/or static , which utilizes intra-access flow, and/or static venous pressures, and/or dynamic venous pressures. venous pressures, and/or dynamic venous pressures.
71%
51%44%
25%
0%
20%
40%
60%
80%
100%
6 1 18 15 13 5 4 7 US 3 11 2 9 12 16 14 10 8 17
Network Numbers
MARC Goal 100%
44% in NW 5 per CPM data from 444% in NW 5 per CPM data from 4thth qtr. 2001 qtr. 2001 (only patients with AVG included)(only patients with AVG included)
Less than 10% of all prevalent HD patients Less than 10% of all prevalent HD patients (adults (adults 18) should be maintained on catheters as 18) should be maintained on catheters as their permanent chronic dialysis access.their permanent chronic dialysis access.
28% in NW 5 per CPM data from 428% in NW 5 per CPM data from 4thth qtr. 2001 qtr. 2001
20% 20% 90 days 90 days per CPM data from 4 per CPM data from 4thth qtr. qtr.
20012001
26% per CDC Survey December 200226% per CDC Survey December 2002
Patients Dialyzing via Catheter Patients Dialyzing via Catheter 90 Days 90 DaysNetwork 5 Compared to Other Networks & the USNetwork 5 Compared to Other Networks & the US
CPM Data from 4th Qtr. 2001CPM Data from 4th Qtr. 2001
13%
19%
30%
20%
0%
10%
20%
30%
40%
16 17 2 14 18 8 1 15 11 US 5 10 12 6 13 4 7 9 3
Network Numbers
DOQI Recommended Level < 10%
Catheter Reduction ProjectCatheter Reduction Project 47 facilities were required to participate47 facilities were required to participate Goal was to reduce catheter use by 50%Goal was to reduce catheter use by 50% Baseline data from July 2002Baseline data from July 2002 Re-Measurement data from December 2002Re-Measurement data from December 2002 Interventions includedInterventions included
Educational workshopEducational workshop Clinical algorithmsClinical algorithms Tools to useTools to use All can be downloaded from MARC websiteAll can be downloaded from MARC website
Preliminary ResultsPreliminary Results
At re-measurement, facilities that . . .
Used a written access plan on all patients
Conducted staff education sessions and/or used a catheter referral algorithm
. . . made larger reductions in the overall percent of patients dialyzing via catheter
Preliminary ResultsPreliminary Results, continued, continued
Process IndicatorsProcess Indicators Catheter patients assessed for alternative access Catheter patients assessed for alternative access
using the intervention toolsusing the intervention tools Improved from 14.6% to 74.8%Improved from 14.6% to 74.8% 60.2% absolute change in rate60.2% absolute change in rate Statistically significant @ p < 0.0001 levelStatistically significant @ p < 0.0001 level
Long-term catheter patients referred to a surgeon Long-term catheter patients referred to a surgeon for alternative access placementfor alternative access placement Decreased from 81.9% to 80.6%, but not statistically Decreased from 81.9% to 80.6%, but not statistically
significant change at remains highsignificant change at remains high
Preliminary ResultsPreliminary Results, continued, continued
Outcome IndicatorsOutcome Indicators
% patients dialyzing via catheter% patients dialyzing via catheter Improved from 37.1% to 33.6%Improved from 37.1% to 33.6%
Statistically significant @ p < 0.01 levelStatistically significant @ p < 0.01 level
% patients dialyzing via catheter % patients dialyzing via catheter 90 days 90 days Improved from 28.4% to 26.2%Improved from 28.4% to 26.2%
Almost statistically significant @ p < 0.05 levelAlmost statistically significant @ p < 0.05 level
Future ActivitiesFuture ActivitiesFocused on Vascular AccessFocused on Vascular Access
National QIP to increase AVFsNational QIP to increase AVFs All Networks, CMS & IHIAll Networks, CMS & IHI (Institute for Healthcare (Institute for Healthcare
Improvement)Improvement)
Collaborative Project - Partners RecruitedCollaborative Project - Partners Recruited
Key Role for Med. Directors, Nephrologists, Key Role for Med. Directors, Nephrologists, Vascular Surgeons, & Facility Staff Vascular Surgeons, & Facility Staff
Likely a multi-year projectLikely a multi-year project
More Activities . . .More Activities . . .
NW 5 Vascular Access CommitteeNW 5 Vascular Access Committee Develop interactive website for vascular access Develop interactive website for vascular access
case studies to demonstrate patient safety issuescase studies to demonstrate patient safety issues
Identify vascular surgeons used by NW 5 renal Identify vascular surgeons used by NW 5 renal
community for partnering opportunitiescommunity for partnering opportunities
Educational opportunitiesEducational opportunities
Develop model for training & spreadDevelop model for training & spread
Surgical Aspects . . .Surgical Aspects . . .Robert Lee, MD, Chung W. Lee, MD, PCRobert Lee, MD, Chung W. Lee, MD, PC
Patient Perspective . . .Patient Perspective . . .Jim Seymour, Dialysis Patient, Patient Advisory Jim Seymour, Dialysis Patient, Patient Advisory
CommitteeCommittee
Facility Vascular Access Program . . Facility Vascular Access Program . . ..Yao-Foli Sekyema, MD, Danville Urologic ClinicYao-Foli Sekyema, MD, Danville Urologic Clinic
Clean Hands & CDC’s Campaign . . .Clean Hands & CDC’s Campaign . . .Valerie Riley, RN, Fresenius Medical CareValerie Riley, RN, Fresenius Medical Care
Define “access event” . . .Define “access event” . . .Jack Moore, MD, Washington Hospital Center, MRB ChairJack Moore, MD, Washington Hospital Center, MRB Chair