safety and quality in dermatology
DESCRIPTION
TRANSCRIPT
Safety and Quality in Dermatology
Alice Watson MD MPHApril 14th 2010
I have no relevant disclosures
Putting safety in context…a story
• Does this story surprise you?• Could this ever happen again?• Could this happen in your practice?
To err is human
• 1999 report by IOM • Widespread media and political attention• The scale of medical errors
–1 000 000 Americans injured each year–98 000 Americans die each year
Swallowing a bitter pill
• Care providers are smart people who take pride in doing the right thing for patients
• …..so how can we be harming so many people?
Stages of acceptance
• The data are wrong• The data are right, but it is not a problem• The data are right, it is a problem; but it is not
my problem• I accept the burden of improvement
Why do we have a problem?• Medical care is incredibly
complex– Over 20 steps in the biopsy
pathway– Handoffs between individuals
and departments– Each has an inherent failure
rate
• How reliable do we need to be?– 90%– 99%
No. ofSteps
Probability of Success of each step
1
25
50
100
0.95 0.990
0.999 0.999999
0.95 0.990 0.999 0.9999
0.28 0.78 0.98 0.998
0.08 0.61 0.95 0.995
0.006 0.37 0.90 0.99
The Swiss Cheese Model
• More layers of protection• Smaller holes
It is not enough to be a great clinician or surgeon….
We are accountable for the outcome not just our step in the process
Why do we have a problem?
• Our current mindset and skill set are not compatible with optimal performance–Individual vs. system–Reactive not proactive
Myths around safety
• Perfection myth– ‘If I just try harder, I will not make any mistakes’
• Punishment myth– ‘If we punish people when they make mistakes
they will make fewer of them’
• Performance myth– ‘I will measure success by my actions not the
ultimate outcomes’
The “system” Provider
Finding the right balance
This is not an option…
External Drivers of Change
• Payment reform– No reimbursement for preventable complications– Outcome based reimbursement (P4P)– Tiering of providers based on quality measures
• Accreditation / Licensure issues– Formal accreditations standards may become a requirement
in all practice settings– MOC requirement to evaluate performance in practice
• Malpractice cases punishing providers when things go wrong
How does this relate to dermatology?
• Focus to date has been hospital setting… but most care is delivered in ambulatory setting– Many handoffs– Multiple providers
• Dermatology encompasses a broad range of practice..and therefore potential for error– Surgery, laser, light, immunomodulatory drugs…
• Dermatology utilizes a range of providers
AAD Efforts to Date
• 2008: Taskforce on Patient Safety and Quality• 2009: Committee on Patient Safety and
Quality– Data measurement– Patient safety– Medical errors
Key questions
• Do we deliver care that is safe and free from error?
• Do we deliver care of the highest quality?
• If not, what can we do to get there?
It wasn’t an error – just a near miss
The patient was harmed so someone
must be at fault
What are errors?
• An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome (AHRQ)
• Framework for error– Slips vs. mistakes– Active vs. latent error
KEY POINT: not all errors result in harm to patients
Error spectrum
HarmNo harm
Near miss / Close call
What are adverse events?
• An injury caused by medical care• Adverse events are relatively rare compared
to errors
KEY POINT: adverse events can occur in the absence of an error
Adverse event spectrum
No errorError
How do the two relate?
Error Adverse event
Errors in Dermatology
• Survey study• Data points
– Demographics (personal and practice)– Most recent error and its consequences– Most serious error
• Goals– Define scope of error in dermatology practice– Identify priorities for improvement
Respondents
• 150 respondents– 63% male– 60% >50 years old– 60% group / solo
practice
• Area of specialty
Classification system• Assessment
– History / Exam• Error in Hx / Exam• Omission in Hx/Exam
– Investigations• Preanalytic error• Analytic error• Post analytic error
– Diagnosis• Incorrect diagnosis – error in clinical judgment• Incorrect diagnosis – failure to review test results• Incorrect diagnosis – inappropriate interpretation of test results
• Intervention• Administrative• Communication
What was reported?
• Assessment errors – 41% of total– 90% related to investigations– Biopsy pathway-related
• Intervention errors – 44% of total– 54% related to medication– 46% related to procedures
Investigation errors• ‘Wrong biopsy site location on pathology specimen’
(27 variations on a theme)
• ‘A biopsy specimen was lost somewhere between the patient and the processing. I don't know for sure if the specimen did not make it into the bottle or if it was lost at the lab’
• ‘When a patient's chart was pulled for another reason, I found a path report from 2 months earlier the chart that had not been seen by me or reported to the patient. It was a basal cell skin cancer’
Medication errors
• Administration error by patient (3) or provider (7)
• Wrong drug or dose dispensed (10)• Monitoring error (2)• Prescribing errors e.g. give drug despite
known allergy / CI (6)
Procedural Errors• Surgical (20 of which wrong site surgery -5)
– ‘I removed the wrong site on a young woman's scalp. She had an atypical nevus on the crown and I erroneously removed a different lesion nearby’
• Laser (6)– ‘I used a CO2 laser which was slightly different and got
scarring which led to a lawsuit’
• Phototherapy (4)– ‘Malfunction in on/off timer with light therapy unit-
patient not removed from machine. Patient severely burned (approximately 20 times normal exposure)’
Measures of QualityType of measure
Description Examples Strengths Weaknesses
Outcome Measure the end results of care
- 5-year survival rate amongst patients with melanoma- Surgical infection rate following out-patient procedures- Quality of life in a patient with psoriasis
- Ultimate end-product of clinical care- Hard to manipulate- Promote innovation around how to get there
- Often not perceived to be under physician control-Multifactorial-Prone to create perverse incentive- Long term horizon- Can be hard to define or to capture
Process Measure performance at different steps within the care pathway
- Wait time for clinic appointment for patients with pigmented lesion- Proportion of patients advised to perform monthly skin self-examination
- May directly impact patient experience- Short time course- Closely linked to provider actions- Easy to identify remedial action required
- Open to manipulation- May correlate poorly with clinical outcomes- Can lead to ‘quick-fixes’ rather than comprehensive solutions- May become outdated as new technology introduced
Structural Measure system-level adjuncts to multiple care processes
- Implementation of an EMR- Staff training in CPR
- May impact multiple care pathways- Can lead to step change improvements in clinical effectiveness- Promote safe environment for patients
- Often costly as large-ticket items- May require extensive training to ensure efficiency gains
Quality of care in dermatology
• Challenges– No objective markers e.g. BP, A1c– Need to risk adjust
• Who better to lead the process?• Performance measures taskforce
– Melanoma measures / PQRI– Bone protection
Ready for a challenge?
1. Start the dialogue2. Introduce a checklist3. Pick something to improve
Start the Dialogue
• Why?– Culture of openness is
critical to safety– You want to hear about
problems in your practice
– Learn from near-misses in order to avert disasters
Note: Openness ratings performed blind to error rate* Judged by interviewees’ opinion, leadership style, attire etc. ** Actual and potential adverse drug eventsSource: Edmondson (2004) Qual & Safety Healthcare
Source:British Airways (NPSA adapted)
British Airways air safety reports, 1994-99
Total events
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1994 1995 1996 1997 1998 1999
High/medium risk events
0
20
40
60
80
100
120
140
Total reported events
Number of reported events: high and medium risk
Start the dialogue
• How?– Add this to the agenda of your next practice
meeting– Send out an email to staff asking for feedback– Ask patients and their families for comments
This is not culture change…!
Remember…
• View feedback constructively
• Show people you listen and that things can change
Introduce a checklist
• Why?– Simple and effective
driver of change– Empowers all members
of the team– Raises the baseline of
acceptable performance
Example from the ICU
• 5 actions to reduce catheter related bloodstream infections– Handwashing– Full barrier precautions during insertion of line– Cleaning skin with chlorhexidine– Avoid femoral site– Remove unnecessary catheters
Pronovost et al NEJM 2006
Introduce a checklist
• How?– Sit down with team and write out what is
expected– Empower people to call out when anything is
missed• Examples
– Biopsy checklist– Laser safety– Medication specific e.g. accutane
Pick something to improve
• Why?– Knowing your numbers
changes behavior– Provides focus and sense
of accomplishment– Allows investigation into
root causes of a problem
‘If you cannot measure it, you cannot manage it’
Don Berwick
Pick something to improve
• How– Pick something people care
about– Set an aspirational goal– Measure – change - measure
• Examples– Sharps injury prevention– Wound infection– Waiting time
Remember…
• Don’t just aim to be average – set a high bar• Do something small now rather than
something big in the future - don’t let perfect be the enemy of good!
• You know all you need to get started
