Transcript Patient Safety

Does Patient
Centered Care
Enhance Quality and
Safety?
Human Factors, System Issues
System Solutions
1
© 2010 Planetree, Inc.
Objectives of Presentation

Provide concepts of how the Planetree philosophy can
support system changes to enhance a culture of quality and
safety

Understand safety implications related to human performance

Discuss how a patient centered approach can enhance patient
and family involvement and patient safety

Present outcome measures to demonstrate that a Planetree
patient centered environment not only supports a culture of
quality but also improves patient and employee satisfaction,
and the bottom line
2
What Started Safety Awareness?
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1999 - To Err is Human – IOM
Study showed adverse events happen in 2.9 to
3.7 percent of hospitalizations
Extrapolated over 33.6 million admissions per
year = 44,000-98,000 deaths due to medical
error per year
Poor communication and a lack of teamwork
was identified as a root cause of most safety
problems
3
11 Years After the IOM
“To Err is Human…” Report:
What Has Changed?
4
Safety Hazard Probabilities
(events per million opportunities)
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Acquiring HIV from 1 unit of transfused blood
All heads on 20 coin tosses
Death of commercial airline passenger
Death: general anesthesia
Death: motor vehicle
Preventable hospital deaths
0.7
1.0
2.4
7.5
187
208
Orlikoff,J. Orlikoff and Associates, Inc. Chicago, IL. Jan. 2010
5
Cost of Medical Errors in U.S.

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$17 billion costs associated with
preventable errors (IOM, 1999)
In the past, third party payers have
paid regardless of outcome – changed
as of 10/2008!
Central Line associated bloodstream
infections resulted in an average loss
per case of $26,839 in 2006

Shannon et al, “Economics of Central-Line Associated
Bloodstream Infections” American Journal of Medical Quality
Supplement to Vol.21, No.6 Nov/Dec 2006
6
National Health Expenditures per Capita,
Average spending on health per capita ($US PPP)
1980– 2007
8000
United States
Canada
France
Germany
Netherlands
United Kingdom
7000
6000
5000
4000
3000
2000
1000
0
1980
1984
1988
1992
1996
2000
2004
7
Data: OECD Health Data 2009 (June 2009).
What are the “Other”
Cost of Errors?

Errors may be career ending events
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Trust issues and safety concerns on part of
the consumers and payers
Frustrated consumers
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Caregivers don’t intend to harm
Silence often surrounds issues which may
result in malpractice claims
Sensational negative media coverage
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News Headlines
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SEPT. 2006: “HOSPITAL CHANGES PROCEDURES
AFTER PREEMIE DEATHS”:
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NOV. 2007: “HOSPITAL REPEATS WRONG-SIDED
BRAIN SURGERY”:
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Three preemies die after they receive adult doses of heparin at a hospital
in Indianapolis
“For the third time this year, doctors at Rhode Island Hospital have
operated on the wrong side of a patient’s head – an action that has
brought about censure from the state Department of Health and a
$50,000 fine.”
SEPT. 2010: “BABY DIES AT SEATTLE CHILDREN’S
HOSPITAL AFTER OVERDOSE”:
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…a hospital nurse gave her 10 times the proper dose of a medication,
calcium chloride. Five days later, on Sept. 19, after suffering a brain
hemorrhage, the baby died.
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State of Colorado
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Local TV news coverage on prevention of
central line infections
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Discussed use of central line bundle
Shortly thereafter, legislators in the State
received a “slew” of e-mails from constituents
demanding use of the central line bundle be
made into law!
10
Put it in Perspective

25% of US patients state they have experienced a medical
error - 50% of those resulting in serious harm

42% of health care workers (HCW) state they have been
personally involved in a medical error

HCW’s state they fear becoming a patient
 Seek the best MD – not the MD on call
 Seek out high volume places for complicated surgeries
 Seek out clinicians with at least 10 years experience
(experienced but not burned out)
 Avoid hospitalization in July – new interns, medical and
nursing students (now proven by research)
11
What is Patient Safety

Freedom from accidental injury through:

Systems and processes that decrease the
likelihood of mistakes
and
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Systems and processes that increase the
likelihood of prompt identification and
correction of errors and mistakes before
they cause harm to a patient
12
What is High Quality Care?
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IOM defines quality as:
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“The degree to which health care services for
individuals and populations increase the likelihood
of desired health outcomes and are consistent with
current professional knowledge.”
High quality (evidence based) medicine
allows for variation based on patient need, not
on physician preferences (patient focused)
13
Evidence Based Care Bundles
Hospital Infections are Preventable!
FACT - 80,000 CLABIs per year, cause about 28,000 deaths
In 103 ICUs in Michigan median CLABI rate per 1,000 catheter days
declined from 2.7 to ZERO
HOW? - It’s simple
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Hand washing;
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Full Barrier precautions;
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Chlorhexidine use;
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Avoid using the femoral site;
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Removing unneeded catheters.
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Provonost, et al. New England Journal of Medicine, Dec 28, 2006.
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IHI- 5 Million Lives Saved
Campaign
Interventions targeted at harm:
 Prevent Pressure Ulcers...
 Reduce MDRO/MRSA Infections…
 Prevent Harm from Medications...
 Deliver Evidence-Based Care for CHF, AMI,
Pneumonia…
 Prevent ventilator pneumonia
 Prevent central line infections
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16
“New” Reality of US Healthcare
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Evidence Based Care – Core Measures
Medicare/insurance no longer pays for
defined “never events” (10/08)
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National versus Local Standards
Public reporting of quality data and
safety events - transparency
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AHRQ measures reported to the public - 2010
Patient Centered Care
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What is Patient Centered Care?
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Defined by the IOM:
“…care that is respectful of
and responsive to individual
patient preferences, needs
and values, and ensuring
that patient values guide all
clinical decisions.“
New 2011 TJC Standards
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Opportunities for Improvement
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Communication challenged
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Fragmented health care system
Complex systems within hospitals
Lack of standardization
Hierarchies produce steep authority gradients
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Product of our success
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Advanced technology, rapid changes
Necessary knowledge exceeds limits to human capacity
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Need better teamwork and communication
> 6000 meds, >4000 treatments to choose from
Professional craftsman model
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No longer effective
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Professional Craftsman Model
“The Old Way”
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With extensive training
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Eminence based training – not always
evidence based
Came “special privileges”
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Full autonomy= full responsibility
Creates a steep authority gradient
Others have been there only to assist
the MD in the past
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No recognized group decision making
Results in the ‘Perfection Myth’
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Safety Implications Related to the
‘Perfection Myth’
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Safety depends on individuals - myth
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Error is due to carelessness – myth
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Safety really depends on teamwork and communication
More often a system or process error
We have responded in the past with peer review, “be safer
next time”, more education, 5 rights
Punishment results in fewer errors - myth
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System Improvements should be the focus
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Dysfunctional Response to Error
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Justification/rationalization
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Dishonesty with patients
Cover-up/Non-reporting
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“Complications happen”
Blame the patients
Fear loss of reputation
Healthcare workers look the
other way when colleagues
error
22
Who Is Watching Out For Patients?
• 46% of physicians failed to report at least one
serious medical error, even though 93% of them
said they should report ALL significant medical
errors they observe.
• 45% said they did not report impaired or
incompetent colleague physicians even though 96%
said they should
-
ANNALS OF INTERNAL MEDICINE, DEC. 4, 2007
• 67% of physicians have not been involved in
collaborative efforts to improve quality
–
COMMONWEALTH FUND NATIONAL SURVEY OF PHYSICIANS, 2007
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A Different (Planetree) Approach
Caring for the Caregivers
 Leadership support for safety
 Non-punitive reporting systems
 Set up systems and processes for safety
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Redundancy and double checks
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Standardization of processes
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Medication administration vs. blood transfusion
Checklists, pre-printed orders
Find out about work-arounds
Multidisciplinary quality committees
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Caring for the Caregivers
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Teamwork and communication support
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Robust reporting systems with feedback
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Enhanced communication models
Errors recognized as system failures
Mutual Support – I have your back
Nurse Residency Programs
Plan for and educate about limitations of
human performance
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Plan for the ‘Human Factor’
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Humans make mistakes
 Fatigue, interruptions,
distractions, etc
Overestimate abilities,
underestimate limitations
Goal is to keep inevitable
mistakes from becoming
consequential
Reliable systems combined
with effective communication
is best practice
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Human Limitations
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Limited memory capacity–5 to 7 pieces of
information in short term memory
Negative effects of stress –increased error
rates, tunnel vision
Negative influence of fatigue
Limited ability to multitask
Variable judgments and perceptions
27
Human Error is Inevitable
Because:
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Inherent human limitations
Complex, unsafe systems
Safety is often assumed, not assured
We count on the expert individual
“It won’t happen to me” or “it doesn’t
happen here” attitude
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Build on human factor skills
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Standardized (SBAR) communication
Telephone order read-backs
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Create redundancies, double checks
Situational awareness
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Starbucks figured it out
Time-outs, include the patient (patient centered)
Decrease interruptions
Debriefings after emergencies
Patient Centered focus
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Bedside report including the patient/family
Hourly rounding
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A Different (Planetree) Approach
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Patient centered approach
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Knowledge about condition and
choices
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Care partners
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Access to medical records
Access to information –
library/literature searches
Health literacy
Another “ear to hear”
Patient and Family Advisory
Council
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Learn from their experiences
30
Planetree
Patient Centered Care and Safety
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“The patient is one of the most important allies in reducing
medical errors.”
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“Research indicates that when patients actively participate in
their overall healthcare management, medical errors are
reduced.”
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ISMP Medication Safety Alert Oct.2004
ISMP Medication Safety Alert Nov. 2004
Patients who have a clear understanding of their instructions,
including how to take their medicines and when to make
follow-up appointments, are 30 percent less likely to be
readmitted or visit the emergency department

February 3, 2009, Annals of Internal Medicine
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Planetree Criteria Promote
Quality and Safety
Planetree promotes a healing partnership
between patients and caregivers.
It’s a model of care that is committed to
enhancing healthcare from the
patient perspective.
Empowers caregivers to do what is right
for the patient.
360° data shows us that it is working!
32
Surgical Care Improvement
Process Measures
Valley View SCIP Perfect Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Q2 2007
Q3 2007
Q4 2007
Q1 2008
Q2 2008
Q3 2008
Q4
2008
Q1
2009
Q2
2009
Q3
2009
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Teamwork works!
D-T-B times improved!
34
VVH Culture of Safety Survey
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Survey done July 2010
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Statistical improvements from 2008
Standardized AHRQ survey
Designed to measure 4 major areas
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Overall perceptions of safety
Overall patient safety grade
Frequency of event reporting
Number of events reported
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36
Valley View Healthgrades™
Award
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Valley View Hospital is rated
among the top 5% in patient
satisfaction scores

The Planetree patient
centered philosophy actively
supports programs to meet
patient and family needs
37
“What Is the Likelihood of
Recommending This Hospital?”
100%
90%
93%
80%
70%
96%
97%
63%
60%
2000
2006
2008
2010
50%
40%
30%
20%
10%
0%
% Ranking
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VVH and Planetree Comparison
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Turnover Rate:
All Nurses On Payroll
25% 24.88%
20.00%
20%
15%
12.13%
10%
7.35%
4.50%
5%
2.70%
0%
1998
2000
2002
2003
2008
2010
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Growth in Equity
120,000,000
100,000,000
80,000,000
60,000,000
40,000,000
20,000,000
2004
2005
2006
2007
2008
2009
Total Net Assets
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Lessons learned

Safety and quality is not created by counting and
control measures
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We thought competent, careful clinicians were
sufficient to create safety
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We have learned that stories, complex dialogue, and
teamwork create safety
We have learned safety requires leadership, a supportive
environment, a system focus, and solid teamwork
Quality and patient safety are supported in a Planetree
patient centered environment and the Planetree
philosophy promotes a ‘generative’ culture
44
How Different Organizational
Cultures Handle Safety Information
Pathological
Culture
Bureaucratic
Culture
Generative
Culture
 Don’t want to know
 May not find out
 Actively seek it
 Messengers
(Whistle blowers) are shot
 Messengers are
listened to if they
arrive
 Messengers are
trained and rewarded
 Failure is punished
or concealed
 Failure leads to
local repairs
 Failures lead to farreaching reforms
 New ideas are
actively discouraged
 New ideas often
present problems
 New ideas are
welcomed
45
Planetree Creates
A Culture of Quality and Safety
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An accountable culture
A culture of learning
A culture of partnership
A just culture
Mutual Trust
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The system trusts that you will call out
You must trust that the system will listen
46