Transcript Use Technology to Improve Safety

Do No Harm: Culture, Technology,
Teamwork and Design Change
Nancy G. Pratt RN, MSN,
SVP, Clinical Effectiveness
Sharp HealthCare
February 5, 2007
Sharp’s Strategic Plan for Patient Safety
Develop a Culture of Safety
Use Technology to Improve Safety
Address Human Factors: Teamwork and Communication
Redesign the Processes
Reduce
Harm by
50% over 5
years
Culture
Human
Factors
Design
Technology
Strategic Priorities: Patient Safety
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Implement a Culture of Safety
Anonymous reporting
Collaboration: San Diego Patient Safety Consortium
Adverse Events Program
Teamwork and Communication
Team Resource Management
Standard Work Processes
Use Technology to Improve Safety
Bar Coding
Electronic Safety Triggers
Electronic variance reporting
Smart Pumps – IV, PCA, Syringe
Redesign for Safety
Human Factors Engineering
Design for Six Sigma
Product, supply, process review
JCAHO National Patient Safety Goals
Six Sigma Projects: Patient Safety
Six Sigma Projects
Status
Medication Safety
Done
Pharmacy Order Cycle Time
Done
SMH Discharge Project
Underway
SCV Discharge to SNF
Underway
SGH Discharge Project
Underway
SHC Cerner CPOE Paper Lite
Started
ROMACC (Reconciliation of Medications)
Started
Alternate Actual Process
Physician
gives
order
RN can’t
get med
out of
Pyxis
RN writes
order &
faxes
to
Pharmacy
Fax doesn’t go
through!
Pharmacist not
available
Drug not available
RN faxes & calls
pharmacy again!
Onset of
Complaints!
Pharmacy Tech
delivers med
someplace in SICU
RN Calls pharmacy,
faxes order again!!
Fills out standard
pharmacy
complaint – QVR!
Pharmacy informs
RN med has been
there for 2 hours
Pharmacy Order
Cycle
Time
Orders
by Hour
Pharmacy Staffing Not Matched to Medication Order Volume
# Medication
Orders
18
16
8
7
6
Orders
14
12
10
5
Pharmacy
Staffing
4
8
3
6
2
4
1
2
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hour
Pharmacist Staffing
Time of Day
Avg Number of Orders
Staff in Pharmacy
20
Pharmacy Order Cycle Time
Histogram (with Normal Curve) of Fax to Verification Time by Series
-200
aBefore
0
200
400
600
800
After
Baseline
After Initial
Improves
120
90
Frequency
60
30
Well After
zLast
After Pharmacy IT
System Changed
120
After Fax
Server
Installed
90
60
30
0
-200
0
200
400
600
800
Fax to Verification Time
Panel variable: Series
0
aBefore
Mean 81.57
StDev 132.4
N
155
A fter
Mean 39.66
StDev 50.53
N
129
W ell A fter
Mean 81.66
StDev 185.1
N
80
zLast
Mean 22.60
StDev 31.57
N
187
Pharmacy Order Cycle Time
Minutes
150
120
90
60
30
0
Figure 7.5-9 Pharmacy Turnaround Time
Improvement at Sharp Memorial - SICU
132
Better
82
40
54
23
51
20
12
32
Mean
Median
Std Deviation of
Turnaround Time Turnaround Time Turnaround Time
Goal < 30 minutes
Pre-Intervention
After Initial Improve
Post Final Improve
Medication Safety Project: Decrease Interruptions
RN Prompted
to give med
RN interprets
MAR (5Rs)
RN performs
preadministration
assessment /
checks allergies
RN washes
hands
RN procures
med/IV &
supplies
(5Rs)
RN preps
med
RN
identifies
patient
Med Admin Flow
Map
(Ideal)
RN
explains
med to pt
Average time
~ 7 mins
RN
prepares to
admin med
(final 5Rs)
RN gives
med
RN washes
hands
RN evals effects of
med
RN
documents
med
RN preps
med
RN Prompted
to give med
RN interprets
MAR (5Rs)
Phone call
Order is
questionable
RN performs
preadministration
assessment /
checks allergies
RN washes
hands
Need to
clarify
Call MD;
Wait;
Get
clarification
Unexpected
nsg task
RN procures
med/IV &
supplies
(5Rs)
Can’t find med;
look in 4 places;
call pharm
RN
identifies
patient
Wait in line
Phone call
RN
explains
med to pt
RN prepares
to admin med
(final 5Rs)
Med Admin
Flow Map
(More real)
Average time
~ 20 mins
Unexpected
nsg task
Locate Missing
supply
RN gives
med
RN washes
hands
Phone call
RN
documents
med
RN
evals
effects
of med
Linen
25
24
23
22
21
20
19
18
17
15
14
13 1&2
10
11 1&2
MD
30
P #1
MD
CR
Lead
Office
31
P #2
Supplies
16
Doc
Doc
Rm
Utility Hall
29 1&2
26
Nurse Station #2
27
Kitchen
28 1&2
Kitchen
Mg
32 1&2
33 1&2
34
35
36
37
38
3
4
5
6
7
8
9
1. Waited in line to get meds @ 9:00
2. One med grayed out – not here, one gray ed at – in refrigerator
3. Search refrigerator
4. Went to P #1, found 1 med – MVI still missing, tapped drawer to get cubie to open
5. Two meds left to find – may be in room. Crushed meds in paper cups
6. Piston syringe in room – No date – went to supply room to get another
7. Found MVI but NO med cups - ? Refrigerator MVI
8. Searched room for fiber or med cup – on bedside table – no way to administer
9. Back to med room
10.Back to room
11.Mixed meds in cup in admin – DONE 0920
Medication Delivery Total Time – 13 minutes
What Does the Literature Tell Us?
Top High Risk Situations Causing Sentinel Events
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Distractions before or during administration of meds or treatment
High alert drugs used without double-checks
Multi-tasking
Care provided under a human-error-prone situation (dark, noisy, shift
change) without appropriate compensatory actions
Reason, JT. Understanding adverse events: human factors. In Vincent
CA (ed) Clinical Risk Management. London: BMJ Pub; 1995
Medication Safety Action Plan
Create a standard environment for medication room design
and processes
5’S’ Principles
- Sort
- Shine
- Simplify
- Standardize
- Sustain
Minimize interruptions and distractions during medication
administration
– Respect med admin as a critical activity
– Divert and discourage unnecessary calls
– Encourage all disciplines to limit interruptions Create Scripting
examples for nurses
– Evaluate workload demands during high volume med admin times
Medication Safety Action Plan
Develop a standard guideline for
medication preparation and administration
–
–
–
–
–
–
–
Avoid conversations in med room
Discourage interruptions/distractions
Verify using 7 “Rights”
Prepare and administer to 1 pt at a time
Independent double check insulin, heparin, warfarin
Use MAR or Pyxis label to verify 7 ‘R’s
Document
24
06
09
12
17
21
Number of ‘Unnecessary’ Interruptions During
Med Pass: Pre and Post*
4
3.5
3.8
4
p=0.000
3
2.5
2
1.5
2.2
0.7
1
0.5
0
Pre (n=14)
*No statistical
difference in number or
route of meds given
Mean
1
0.8
Post (n=29)
Median
SD
SGH 5E Pilot Med Pass Time
Pre and Post*
16
14
15.1 15
11.6
12
10
Minutes 8
6
4
2
0
*No statistical
difference in number or
route of meds given
p=0.037
10
5.9
4.7
Pre (n=14)
Mean
Post (n=29)
Median
SD
Emergency Department: RME
• ED patients expect quick service and to be seen
by an ED doctor, regardless of diagnosis
• 40% of ED pts are non-emergent
• Rapid Medical Exam (RME) designed to promptly
and appropriately “treat & release”
• Issues: long waits, space, multiple entry points,
flow, communication…
ED Waits Decrease Satisfaction
Patient Satisfaction
Overall Satisfaction (scale: 0-100)
Goal 86.3
90.0
89.3
86.5
86.9
85.2
84.3
80.8
80.9
79.6
<0.5h 0.5h-1h 1h-1.5h 1.5h-2h 2h-2.5h 2.5h-3h 3h-3.5h 3.5h-4h 4h +
(n=10) (n=6) (n=23) (n=37) (n=59) (n=46) (n=96) (n=48) (n=404)
Hours Held in ED
Growth of ED Visits
• 1992: 12 beds = 16,640 visits. 2006: 22 bed =45,456 visits.
• 173% increase in visits since current ED was opened in 1992.
• 83% increase in beds over same period.
50,000
45,000
40,000
35,000
30,000
25,000
FY
92
FY
93
FY
94
FY
95
FY
96
FY
97
FY
98
FY
99
FY
00
FY
01
FY
02
FY
03
FY
04
FY
05
FY
06
20,000
15,000
ED Outpatient Overall Satisfaction
(scale 0-100)
Mean
31,622
Volume
45,956
40,506
42,867
81.1
81.8
82.5
82.2
FY03
FY04
FY05
FY06
35,531
76.6
FY02
Bottlenecks in the ED
PHLEBOTOMY
TRIAGE
LOBBY
RME
Lack of open ED
beds creates
bottlenecks. Many
patients wait in
front lobby area.
Key Process Steps
Patient and
family
Arrives
Triage
Standing
Orders
See
podium? Fill
out reg.
form
Go to Triage
Coordinator
“behind the
glass”
Triage
Coordinator
Visitor- send
back?
Visitor?
Patient?
Security
Triage: ESI?
Standing
Orders
variable.
Patients
Wait
Patients to
Lab/ x-ray/
triage one/
two. More
orders put in?
Patients
Wait
Patients
called back
to RME or to
bed.
Respond to
waiting
patient’s
questions?
RME triage criteria
and bounce back
process.
RME Project Goals
1. Take vitals of all ESI level 2-3 patients in lobby
every 90 min 90% of time (baseline: 0%)
2. “Arrival noticed quickly” satisfaction = 85th
percentile (baseline 18% Dec-06)
3. Establish RME triage standard to set stage for
RME cycle time project
ED RME Outcomes
• Goal: Vitals on all ESI level 2-3 patients in lobby every 90
min 90% of time (baseline: 0%). Improvements:
– Guard providing safe environment
– LVN assigned to check vitals
– Designed EmStat report to monitor lobby patients
ED RME Outcomes
ED Outpatient Satisfaction with "Wait
before arrival noticed"
%tile Rank (N=888 facilities)
Mean Rating (0-100)
90.0
Goal: 80th %tile
82.2
80%
85.1
84.8
35%
35%
Feb-07
(n=74)
Mar-07
(n=64)
82.0
19%
18%
Dec-06
(n=52)
Jan-07
(n=61)
Apr 1-18
(n=25)
Reconciliation of medications across
the continuum of care
RoMACC at Grossmont Hospital
Project Description / Vision:
Implement a ‘Lean’ RoMACC process that demonstrates
value, not just in terms of patient safety but in efficiency for
practitioners.
Start Date: September 2006 Go Live: December 5th
Participants:
Sponsor:
Michele Tarbet
MD Partner/ Process Owner:
Dr. Margaret Elizondo
End Date: March 2007
Champion/Green Belt:
Julie McCoy
Jackie Parson
Black Belt:
Kurt Hanft
Next Sustain and Improve!
Reconciliation of medications across
the continuum of care
RoMACC Measurement Method:
Discharge:
Physician
Unit clerk
writes the
Discharge Orders
and Addresses the
Discharge
Reconciliation.
verifies the
reconciliation has
been addressed
and enters a
discharge order
Process Measure
Reconciliation of medications across
the continuum of care
RoMACC and Discharge Measurement:
 % RoMACC Complete
 Carecast Discharge Order Entry Compliance
 Number Of Discharges
 Time to Discharge a Patient
 Average Time of Day a Patient Leaves.
Combined projects
Reconciliation of medications across
the continuum of care
RoMACC at Grossmont Hospital
Carecast Discharge Order Entry Compliance
100%
60%
40%
85%
3
4
67%
80%
%
84%
36%
20%
# of DC's
0%
10000
0
1
2
2245
8266
7614
540
2
3
4
1
RoMACC Complete
85%
100%
80%
%
60%
94%
97%
75%
System
Goal
57%
40%
20%
0%
06 December 5th31st
07 Jan, Feb, Mar
07 April, May, June
07 July 2-8
Continuous Improvement – Above System Goal of 75%
Examples of Patient Safety Improvements:
Use Technology to Improve Safety
Bar Coding
Electronic Safety Triggers
Electronic variance reporting
Smart Pumps – IV, PCA, Syringe
Innovation with our partners: Cerner
Bar Code Implementation (Roche)
Real Time Event Triggers “On Watch” (Clinicomp)
Electronic Quality Variance Reporting (Peminic)
Wireless Smart Pumps CQI data (Cardinal)
Standardization of IV infusion concentrations (SDPSC)
Enteral Tubing connections (Viasys, FDA, AHA)
System Reprogramming:
Safety Achieved Quarter 1 2006
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
in
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70
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50
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# of Events
Pareto of Reprogrammings > 3X Max
Events
% of Total
n=145
Alaris Guardrails
Tubing Misconnections
Bag/Bottle of
Enteral
Feeding
Feeding Bag
Tubing Set
l
Enteral Feeding Tube
Patient Safety Strategy
• Redesign for Safety
• Human Factors Engineering
• Design for Six Sigma
• Product, supply, process review
• JCAHO National Patient Safety Goals
Patient Safety Actions
• Products:
–
–
–
–
–
–
–
–
–
Insulin Syringe
Dopamine Drip Bottle versus Bag
Enteral Feeding Bag versus Bottle
Heparin Flush versus Therapeutic infusion
Anesthesia Tray for Epidural
Cat Scan Contrast Injectors
IV PICC Line Cap Leaking (CLC 2000)
Insulin and Heparin Infusions – standardized
Endotracheal Tube with Sub-glotic suction
San Diego’s Health Care Leader
Malcolm Baldrige
National Site Visit, 2006
Gold Eureka Award, 2006
Silver Eureka Award, 2005
Bronze Eureka Award, 2004
Excellence in Patient
Safety and Health Care
Quality, 2006
Best place to work, 2004
Best Integrated Health-Care
Network in California, 2007
100 Most Wired
Hospitals, 1999-2006
Magnet Status
Sharp Grossmont
IDG's Computerworld,
2006
Torch Award for Marketplace Ethics