Transcript CPSI Strategies and Activities

Patient Safety
Past, Present, Future
Breakfast With the Chiefs
February 1, 2007
Philip Hassen
Chief Executive Officer
Presentation Overview
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Introduction to Patient Safety and CPSI
Nature of the Problem
Evolution of Patient Safety
Systems Approach vs.
Medical/Community Approach
Current Activities and Goals
Conclusion
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Mission
To provide national leadership in building and
advancing a safer Canadian health system
Vision
We envision a Canadian health system where:
• Patients, providers, governments and others work together to build and
advance a safer health system;
• Providers take pride in their ability to deliver the safest and highest quality
of care possible; and
• Every Canadian in need of healthcare can be confident that the care they
receive is the safest in the world.
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Definitions
Patient Safety:
The reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices
shown to lead to optimal patient outcomes.
Canadian Patient Safety Dictionary, 2003
Adverse Event:
An adverse event is an unintended injury or complication
which results in disability, death or prolonged hospital stay,
and is caused by health-care management.
Wilson et al
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Evolution of Patient Safety
‘Will we put the methods of science to work in the
evaluation of our practices, or must we admit that no
matter how much we read, study, practice and take
pains, when it comes to a show-down of the results of
our treatment, no one could tell the difference between
what we have accomplished and results of some genial
charlatan…?”
Codman, 1915
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What Patient Safety Is and Is Not
• It is not what most of us were thinking about 10
years ago
• It is not what ‘we have always done’
• It is the most significant change in the
healthcare system in over a century
• It is a new applied science
• It has forever changed the face of modern
healthcare
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What We Know
Canadian Institute for Health Information
(2004)
• One in nine adults contract infection in hospital.
• One in nine patients receive wrong medication or
wrong dose.
• More deaths after experiencing adverse events in
hospital than deaths from breast cancer, motor
vehicle and HIV combined.
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Milestones of the Modern Era
1991
Harvard Medical Practice Study
1995 Quality in Australian Health Care Study
1996 Annenberg conferences begin
1999 Colorado / Utah Study
1999 IOM Report: To Err is Human
2000 BMA/BMJ London Conference on Medical Error
2000 SAEM: San Francisco Conference on EM Error
2001 British study
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2001-3
2001
2002
2004
2006
Halifax Symposia on Medical Error
RCPSC National Steering Committee on Patient Safety
RCPSC Report: Building a Safer System
Canadian Patient Safety Institute
6th Canadian Symposium on Patient Safety (Vancouver)
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Medical Error Citations
Medical Error Citations collated by the National Patient Safety Foundation
for the period 1939-98.
120
80
60
40
20
96
93
90
87
84
81
78
75
72
69
66
63
59
51
0
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Citations
100
Year
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Adverse Events
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Delayed or missed diagnoses
Medication errors
Wrong side surgery
Wrong patient surgery
Equipment failure
Patient identity
Transfusion errors
Mislabeled specimen
Patient falls
Time delay errors
Laboratory errors
Radiology errors
Procedural error
• Lost, delayed, or failures to follow up
reports
• Retention of foreign object following
surgery
• Contamination of drugs, equipment
• Intravascular air embolism
• Failure to treat neonatal
hyperbilirubinemia
• Stage lll or lV pressure ulcers acquired
after admission
• Wrong gas delivery
• Deaths associated with restraints or
bedrails
• Sexual or physical assault
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Why Do Adverse Events Happen?
• In any system or organization that involves
humans, error is inevitable because there is a
wide variation in performance both within and
between people
• Evidence is accumulating that some human
dispositions towards error are hard-wired
• Only a small proportion of error is egregious
• Ambient conditions and systemic design
increase the likelihood of error
• Error has been described as the ‘essential
friction’ within all systems
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Sources of System Error
Adverse Events
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Overall culture
Education/Training/Experience
System design / HFE
Resource availability
Demand/Volume
Throughput Impedance
Shift-work/schedules
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A Culture of Safety
31,033 Pilots, Surgeons, Nurses and Residents Surveyed*
*Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross
sectional surveys. BrMedJour, 3-18-2000.
% Positive Responses from:
Pilots
Medical
Is there a negative impact of fatigue on your
performance?
74%
30%
Do you reject advice from juniors?
3%
45%
Is error analysis system-wide?
100%
30%
Do you think you make mistakes?
100%
30%
Easy to discuss/report mistakes?
100%
56%
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Comparative Reliability Between
Industries
Difficulty with Referral
PPM
1,000,000
100,000
10,000
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Low
Back TX
1000
100
Mammography Screening
••
Tax Advice
(phone-in) (140,000 PPM)
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Post Heart
Medication
Attack
Medications Accuracy in
General
Airline Baggage Handling
Domestic
Airline Flight
Fatality Rate
(0.43 PPM)
10
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1
DEFECTS
SIGMA
50%
1
31%
2
7%
1%
0.02%
3
4
5
Sigma Scale of Measure
0.0003%
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Source: Institute for Healthcare Improvement
Imagine:
$15 billion in annual purchases hand-written on slips of
paper
The Canadian prescription drug industry
1 billion service events scheduled manually over the phone
Annual diagnostic test events in Canada
An industry that does not increase productivity
The healthcare industry in Canada comprises almost 10% of the economy
A service industry that injured 7.5% of its customers through
preventable errors (30% of injuries resulting in permanent
impairment, 5-10% resulting in death)
Hospital care in Canada
THEN WE HAVE HUMAN FACTORS
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Human Factors
“Health care is the only industry that does
not believe that fatigue diminishes
performance.”
Lucian Leape
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Human Factors
Fatigue
• 24 hours without sleep is equivalent to a blood
alcohol level of 0.10 – a 30% decrease in cognitive
processing
• Nurses are 3 times more likely to make mistakes
after 12 hours on the job
• Interns made 30% more errors in ICU patients
when on traditional 24 hour call schedules
• The best countermeasure for fatigue is teamwork
–more people in the movie
• 3 major disasters related to night time workers:
Exxon Valdez, Chernobyl, and Three Mile Island.
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation
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Association Between Evening Admissions and Higher
Mortality Rates in the Pediatric Intensive Care Unit
Yeseli Arias, Doublas S. Taylor, and James P. Marcin
Pediatrics 2004; 113: 530-534
4.5
4
4.1
3.5
3.9
3
2.5
Day
Night
2
1.8
1.5
1
0.5
0
0.9
1.2
Cardiac
Disease
Cardiac
Arrest
1.9
0.9
0.4
Sepsis
Time of
Birth*
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Human Factors
Multitasking, Interruptions, Distractions
• Humans are poor multi-taskers
• Drivers on cell phones have 50% more
accidents, 25% of traffic accidents are
“distracted drivers”
• Interruptions and distractions increase
error rates
• Humans need very formal cues to get back
on task when interrupted and distracted
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation
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Human Factors
Inherent Human Limitations
• Limited memory capacity – 5-7 pieces of
information in short term memory
• Negative effects of stress – error rates
– Tunnel vision
• Negative influence of fatigue and other
physiological factors
• Limited ability to multitask – cell phones and
driving
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation
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Patient Safety: Barriers to Action
• Difficulty recognizing errors
• Lack of information systems to identify errors
• Relationship of trust with providers
• Access is more urgent in Canada
• Leadership turnover
• Fragmentation of care delivery hampers systems
thinking
Patient Safety: Barriers to Action
• Poor capital investment framework favours short
term needs
• Shortages of clinical professionals
• Concern about liability
• Jurisdictional conflicts
• Simplistic approach to building the EHR
• Culture of patient safety is lacking
Systems Approach to Patient Safety
Measurement and
Evaluation
EHR
Education and
Professional
Development
Legal/Regulatory
System
Changes to
Create a
Culture of
Safety
Information
and Communication
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A Systems Approach
“The systems approach is not about
changing the human condition but
rather the conditions under
which humans work.”
J.T. Reason, 2001
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Reason’s Swiss Cheese Model
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CPSI Strategies and Activities
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Adverse Event Reporting and
Learning System
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Root Cause Analysis
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National Disclosure Guidelines
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Safer Healthcare Now!
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Development of a Canadian Adverse Events
Reporting and Learning System (CAERLS)
A major initiative in the 2006/07 CPSI Action Plan is to explore the
development of a Canadian Adverse Event Reporting & Learning System to
enable a patient safety knowledge base, create a repository and facilitate
knowledge transfer to inspire innovation and safety improvement.
Activity to date includes:
1.
The synthesis of findings on adverse event reporting and learning
systems related to:
• international site visits
• an extensive literature search and review
• a comprehensive review of applicable Canadian legislation and policy.
2.
Development and circulation of a consultation paper outlining
recommended options for a non-punitive national adverse event
reporting and learning system so that the information can
be sorted, integrated, evaluated and acted upon in a highly
coordinated and timely manner.
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The Canadian Root Cause
Analysis Framework
What is Root Cause Analysis?
• An analytic tool that can be used to perform a comprehensive,
system-system based review of critical incidents. 1
History
• In January of 2005 CPSI partnered with ISMP Canada and
Saskatchewan Health, to begin work on the development of the
Framework.
Goals of the partnership
• To standardize information and processes related to RCA in Canada.
• To utilize those with known expertise in use of the process and
knowledge transfer of the tool to assist with the development of the
framework.
1 Hoffman,
C., Beard P., Greenall,J., U,D., & White, J. (2006).
Canadian Root Cause Analysis Framework. Edmonton AB: Canadian Patient Safety Institute
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National Guidelines for Disclosure
of Adverse Events
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National Working Group
Project Charter – full endorsement
Background Document
Literature Search and Review
Final Draft – Feb 2007
Nationwide Consultation – Mar – April 2007
Nationwide Endorsement – May – Aug 2007
Publication and Distribution – October 2007
(Halifax 7)
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Safer Healthcare Now!
Interventions
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Deploying rapid response teams
Improved care for acute myocardial infarction
Prevention of adverse drug effects
Prevention of central line-associated
bloodstream infection
Prevention of surgical site infection
Prevention of ventilator associated Pneumonia
Retrieved from www.saferhealthcarenow.ca or
www.soinsplussursmaintenant.ca
Toll free#: 1-866-421-6933
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Campaign Structure
Campaign Support
SHN National Steering Committee
Secretariat - CPSI
CIHI
Clinical Support
CCHSA
Operations
Teams
Western
Node
Patients
Canadian
ICU
Collaborative
Peer
Support
Network
Quebe
c
Node
Ontario
Node
CAPHC
Measurement
Working Group & CMT
IHI
Atlantic
Node
Other
Canadian
Faculty
ISMP
Canada
Education & Resource
Working Group
Partner
Network
Communication
Working Group
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West Ontario Atlantic Quebec
Total
Healthcare
Delivery
Organizations
[includes hospitals,
agencies, services
and regions (with
one or more
hospitals
participating)]
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98
23
10
176
*As of January, 2007
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Teams Continue to Enroll
Saferhealthcare Overview Total # Enrolled Teams September 2005 to January 2007
600
541
579
491
500
443
403
400
296
300
200
118
100
0
Total # of Teams EnrolledTeams
Sep-05
Nov-05
Mar-06
Jun-06
Aug-06
Oct-06
Jan-07
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Ventilator Associated Pneumonia (VAP)
Calgary Health Region
RGH - VAP Incidence by confirmed date
x Chart
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UCL = 46.11
VAP rate (VAP cases/1000 vent days)
40
30
Mean = 10.30
20
10
Goal 8.4
LCL = 0
0
May- Jun-04 Jul-04 Aug04
04
Sep- Oct-04 Nov04
04
Dec- Jan-05 Feb04
05
Mar- Apr-05 May- Jun-05 Jul-05 Aug05
05
05
Sep05
Month
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Ventilator Associated Pneumonia (VAP)
St. Paul’s Hospital (SK)
400
350
300
250
200
150
100
50
0
Sep- 30-05
Nov-30-05
Sep-9-03
Aug-8-04
May-11-05
Jun-14-01
Mar-16-02
June -15-00
Sep-12-00
Dec-20-99
Mar-31-00
Jul-3-99
Nov-1-99
No new cases
reported to date
Mar-5-99
May-31-99
Number of Days between
cases
Days between VAP cases
229 days since last reported VAP
Month
VAP rate per 1000
10
8
6
VAP/1000
4
2
Month
Dec
Aug-
Apr-05
Dec-
Aug-
Apr-04
Dec-
Aug-
Apr-03
Dec-
Aug-
0
Apr-02
VAP rate per 1000 vent.
days
SPH Monthly VAP reports
14
12
10
8
6
Jan-Nov
4
2
0
1999- 2000- 2001- 2002- 2003- 20042000 2001 2002 2003 2004 2005
VAP rate per
1000
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Preventing Central Line Infections
COLLABORATIVE'S CUMULATIVE CRBSI RATES/1000 LINE DAYS
6 Pediatric ICU's
7.0
National Nosocomial Infections Surveillance System (NNIS) Rate
6.0
Rate per 1000 line days .
5.0
Pediatric Teams Join
Canadian ICU Collaborative
4.0
3.0
2.0
1.0
0.0
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
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Rapid Response Team
University of Alberta
Pre-implementation
Post-implementation
# Cardiac
Arrests
7 (4.0 per 100 separations)
1 (0.8 per 100 separations)
Total # calls
ICU
ALOS
10.2
6.4
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Source: ICU Collaborative
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CPSI Strategies and Activities
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Research
Professional Development
Simulation
National Hand Hygiene Campaign
Patient Safety Competencies Project
Executive Patient Safety Series
Canadian Patient Safety Officer Course
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CPSI Strategies and Activities
Research - 2005
– With CIHR, CHSRF and safety leaders safety
research priorities
– Launched 2005 CPSI grants competition
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327 registered projects
125 full applications received
57 peer-reviewed
28 funded ($1.9M)
– Co-funded with CHSRF two REISS programs
• Pediatric and Adult Acute Care, Family Medicine
– Two Projects Funded with CIHR
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CPSI Strategies and Activities
Research - 2006/07
– Launched 2006/07 CPSI grants competition
• 64 full applications received
• 35 peer-reviewed
• 15 funded ($1.4M)
– Launched with CIHR a Patient Safety Priority
Announcement
• Grants
• Fellowships
– Partner in the “Listening for Direction” health services
research priority setting initiative with CHSRF, CIHR,
CADTH, CH, CIHI, Health Canada, Statistics Canada
– Partnered with CIHR, CADTH, CIHI, Statistics Canada,
CHSRF to study post marketing surveillance and
effectiveness
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CPSI Strategies and Activities
Professional Development
- Leading the Safety Process
In partnership with the CMA and the CMPA, CPSI is
developing a workshop in which participants will learn:
– the key best practice approaches to patient safety
– how to build a culture of safety & reporting while
maintaining professional accountability
– how to disclose adverse events to patients
– Participants will also practice the effective
communication skills and techniques when confronted
with critical incidents
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CPSI Strategies and Activities
Simulation in Canada
Goal: To facilitate the development of a national simulation
strategy for healthcare
Objectives
• To create a national vehicle for the promotion and
endorsement of simulation including an infrastructure
for collaboration
• To endorse team – focused simulation education
Phases
Phase 1:
Endorse and Support
Phase 2:
Educate
Phase 3:
Evaluate
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CPSI Strategies and Activities
National Hand Hygiene Campaign
The Canadian Patient Safety Institute, the Canadian Council for Health
Services Accreditation, the Public Health Agency of Canada and the
Community and Hospital Infection Control Association are working
together to support, supplement and integrate existing hand hygiene
initiatives locally, regionally and provincially, by developing and
implementing a hand hygiene campaign across Canada.
Campaign Goal:
•To promote the importance of hand hygiene in reducing the
spread of healthcare associated infections in Canada
Campaign Objective:
•To respond to the needs of healthcare organizations for capacity building,
leadership development, and/or the production of tools to help promote
hand hygiene
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CPSI Strategies and Activities
Patient Safety Competencies Project
Objectives:
• Identify the key knowledge, skills and attitudes
related to patient safety competencies for all
healthcare workers
• Develop a simple, flexible framework that will
act as a benchmark for training, educating and
assessing healthcare professionals in patient
safety
• Help make patient safety competencies easy for
everyone to understand and apply
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CPSI Strategies and Activities
Executive Patient Safety Series
Objectives:
• Describe how you can better fulfill your
responsibilities and accountabilities for patient
safety at the Board/Executive level;
• Understand the methods to effect a cultural shift in
your organization to improve patient safety;
• Create and share safety practices that can be
adapted and established in your organization; and
• Position safety in the context of quality in your
organization.
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CPSI Strategies and Activities
Canadian Patient Safety Officer Course
With the help of faculty experts, this course will be delivered through
interactive workshops, networking and presentations by patient safety
leaders for healthcare professionals and leaders involved in patient safety
(patient safety officers, clinical managers and physicians)
Overall objectives:
• Provide the skills to create, implement, and maintain a vigorous and
focused patient safety program
• Help develop detailed, customized patient safety strategies and
implementation plans
Dates: September 24-28, 2007
Location: The Kingbridge Centre, Toronto, Ontario
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Other Important Tools
• Resource Crew Management Briefings
• S-B-A-R
– Situation
– Background
– Assessment
– Recommendation
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Patient Safety
Is It Getting Better?
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What is HSMR?
• HSMR track changes in hospital mortality
rates in order to:
– Reduce avoidable deaths in hospitals
– Improve quality of care
• Developed in the UK in mid-1990s by Sir
Brian Jarman of Imperial College
• Used in hospitals worldwide (i.e. UK,
Sweden, Holland and US)
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HSMR is easy to interpret
• Equal to 100
– No difference between facility’s mortality
rate and average rate
• More than 100
– Facility’s mortality rate is higher than the
average rate
• Less than 100
– Facility’s mortality rate is lower than the
average rate
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Much has Been Done …
Trend in Age-Adjusted 30-Day In-Hospital
Death Rate
Excludes NL, QC, BC
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What Does Average Mean?
(Results from Baker/Norton)
Deaths among
patients with
preventable adverse
events
Extra hospital days
associated with
adverse events
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Efforts to Date
(Preliminary based on data as of March 2006)
> 3,200 more lives
saved between
Apr 04-Dec 05
vs. 03/04
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But Variations Persist
Distribution of HSMR for facilities with at least 2000 discharges, FY
2004/05 – Adapted international method
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Number of Facilities
25
20
15
10
5
0
41-60
61-70
71-80
81-90
91-100
101-110
111-120
121-130
131-140
141-150
151-160
HSMR
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Human Error – the New View
The point of an investigation is not to
find where people went wrong.
It is to understand why their
assessments and actions made sense
at the time.
Sidney Dekker (2002); The Field Guide to Human Error Investigations
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Human Error – the New View
HUMAN ERRORS ARE
SYMPTOMS OF DEEPER
TROUBLE
Sidney Dekker (2002); The Field Guide to Human Error Investigations
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Conclusion
Safe and Reliable Organizations
• Accept that accidents are inevitable and failure will
occur
• Accept that impact of failure can be minimized
• Promote a safety culture
• Listen to and support front-line workers
• Establish a framework that recognizes costs of failure
and benefits of reliability
• Involve managers in communicating overall picture
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Conclusion
Safe and Reliable Organizations
• Train managers to recognize and respond to system
abnormalities
• Become adaptive – learn quickly and efficiently from
adverse events
• Make knowledge about problems available
throughout organization
• Design redundancy to create more opportunity to
detect and correct
• Avoid shaming, blaming and organizational hubris
• Don’t micro-manage – allow decision migration
- Croskerry, EPSS Nov 2006
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Conclusion
Seven Steps to Patient Safety
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2.
3.
4.
5.
6.
7.
Lead and support your staff
Foster a culture of safety
Promote reporting
Involve patients and the public
Implement solutions to reduce / avoid harm
Learn and share safety solutions
Integrate your safety management activity
Adapted from: National Patient Safety Agency for the National Health Service
“Seven Steps to Patient Safety – An Overview Guide for NHS Staff”
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“Culture eats strategy for lunch
over & over again”
Marc Bard
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High Reliability Organizations are Pre-occupied
with the Possibility of Failure
“…there are some
patients we cannot
help, there are none
we cannot harm...”
Arthur Bloomfield, M.D.
Quality of Healthcare in America Project 2003
-----Dr. Ken Stahl