James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Leveraging the Recent Advances in
Improvement Science to Eradicate AKI
James M. Anderson Center for Health Systems Excellence
Omni Netherlands, Downtown Cincinnati
September 28, 2012
Uma Kotagal, MBBS, MScSVP, Quality, Safety and TransformationExecutive Director, James M. Anderson Center for Health Systems Excellence
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
523 Bed Medical CenterAdmissions/Year – 32,981900,000 outpatient visits$143 million externally funded research$ 1.3 billion dollar endowment
12,000+ employeesSurgical Procedures – 31,000 cases (20% Inpt)17% average annual growth over past decadeNational /International partnerships and affiliates
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Core Business strategy at Cincinnati Children’s
• Research-Conduct research to generate new knowledge that changes the paradigm-
• Quality Improvement-Reliably apply new and past knowledge ( evidence) to transform outcomes
James M. Anderson Center for Health Systems Excellence
Knowledge for Improvement
Profound Knowledge
Subject Matter Knowledge
Improvement
Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement.
James M. Anderson Center for Health Systems Excellence
5
Appreciation of a system
Understanding
Variation
Theory of Knowledge Psycholog
y
Value
s
Deming’s System of Profound Knowledge
James M. Anderson Center for Health Systems Excellence
Appreciation of a System
Theory of Knowledge Psychology
UnderstandingVariation
Profound Knowledge: Theory of Knowledge
James M. Anderson Center for Health Systems Excellence
Being the Best at Getting Better• Focus on the outcomes• Patients and families as Partners• Integration and alignment
• Theory of knowledge, Building a learning system• Respecting the science
• Capacity and capability• Transparency and Trust
• Learning from other industries• Prediction and management
• Executing with a sense of urgency
James M. Anderson Center for Health Systems Excellence
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Source: Chart Review of Random Sample (20 Charts)Chart Updated APR 16 2012 by Tracey Bracke, AC
This document is part of the quality assessment activities of Cincinnati Children’s Hospital Medical Center and, as such, it is a confidential document not subject to discovery pursuant to Ohio Revised Code Section 2305.25 and 2305.251. Any committees involved in the review of this document, as well as those individuals preparing and submitting information to such committees, claim all privileges and protection afforded by ORC Sections 2305.25, 2305.251 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individual or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.
James M. Anderson Center for Health Systems Excellence
Managing by Prediction:Patient Safety
James M. Anderson Center for Health Systems Excellence
The Elements of Prediction• MEASURABILITY OF OUTCOME – Will it be clear
if the outcome happens or not?
• VANTAGE – Is the person making the prediction in a position to observe the predictions and context?
• IMMINENCE – Is the event to occur in the next week or years away? Is the prediction before the event?
• CONTEXT – Is the context clear to the person predicting?
• PRE-INCIDENT INDICATORS (PINs) – Are there detectable pre-incident indicators that will reliably occur before the outcome?
• EXPERIENCE – Does the predictor have experience with the specific topic involved?
• COMPARABALE EVENTS – Is it possible to study outcomes similar to the one being predicted?
• OBJECTIVITY – Is the person who is predicting objective enough to believe either outcome is possible?
• INVESTMENT – To what degree is the person predicting invested in the outcome?
• REPLICABILITY – Is it practical to test the exact issue being predicted in another situation?
• KNOWLEDGE – Does the person making the prediction have accurate knowledge of the topic? Is the knowledge relevant and accurate?
The Gift of Fear and Other Survival Signals that Protect Us from Violence: Gavin De Becker, Dell Publishing, 1997
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Sensitivity to Operations Beyond reducing harm:Moving toward Eliminating Harm
James M. Anderson Center for Health Systems Excellence
Eliminating Events of Harm
Active Errors
by individuals result in initiating action(s)
EVENTS ofHARM
Multiple Barriers - technology, processes, and people - designed to stop active errors (our “defense in depth”)
Latent Weaknesses
in barriers
Adapted from James Reason, Managing the Risks of Organizational Accidents, 1997
PREVENT
The ErrorsDETECT & CORRECT
The System Weaknesses
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Serious Safety EventEvent that reaches the patient and results in death,life-threatening consequences, or serious physical or psychological injuryCause Analysis Level: RCA
Precursor Safety EventEvent that reaches the patient and results inminimal to no harmCause Analysis Level: ACA or RCA
Near MissEvent that almost happened - theerror was caught by one last detectionbarrierCause Analysis Level: Trend, ACA
PrecursorSafetyEvents
SeriousSafetyEvents
Near Miss
SafetyEventClassificationSEC
SM
Variation from standard of carethat results in:
© 2006, HPI, LLC
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Serious Safety Event Reduction Key Driver Analysis
Outcomes Key Drivers
Intervention/Change Concepts
Reduce Serious Safety
Events0.2/10,000 Adjusted
Patient Days by 6/30/10
Lessons Learned Program
Improved Safety Governance
Error Prevention System
Cause Analysis Program
Specific Tactical Interventions
•Safety Stories•Transparency•Reinforce Culture Change•Spread story beyond organization•Patient Safety blog •Share all Action plans
•Patient Safety Oversight Group•Cabinet Leadership •CSI annual goals•CCHMC Board focus
• Error Prevention Training •Adoption of Behaviors•Safety Coaches•Procedural Safety•Simulation training•Leadership Behaviors•Situation Awareness •Family Engagement
•RCA- continuous improvement•Transition to Action•Common Cause data to drive Strategy•Effective Action Plans
• 100% UP in OR•UP for all procedures•IV infiltrate reduction•Monitor reliability pilot•Announce and Count
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems ExcellenceOutcome Key Drivers
Interventions
Effective Error
PreventionSystem
Error Prevention training
Safety Coach program
Procedural Safety
Simulation Training
Leadership Behaviors
•Leadership training*•Staff training*•Community MD training•New staff training (achieve 95%)
•Initial pilot units*•Spread to all units*•Monthly Safety Coach support•Focused Safety Coach enhancements •Unit Level Plans
•UP in OR*•UP throughout system
•Initial focus in ED*•Expand capability of Sim Center•Pilot expansion*•In-situ across IP
•Increased event reporting•Use of Lessons Learned in microsystem•Support safety Coaches•Unit level Safety outcomes
Situation Awareness •Patient SA across IP
•Microsystem SA spread•Organization SA pilot
Family Engagement •Family Engagement Bundle spread
•MRT Activation: revise
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Serious Safety Events per 10,000 Adj. Patient DaysRolling 12-Month Average
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Ju
lA
ug
Se
pO
ct
No
vD
ec
Ja
nF
eb
Ma
rA
pr
Ma
yJ
un
Ju
lA
ug
Se
pO
ct
No
vD
ec
Ja
nF
eb
Ma
rA
pr
Ma
yJ
un
Ju
lA
ug
Se
pO
ct
No
vD
ec
Ja
nF
eb
Ma
rA
pr
Ma
yJ
un
Ju
lA
ug
Se
pO
ct
No
vD
ec
Ja
nF
eb
Ma
rA
pr
Ma
yJ
un
FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Ev
en
ts p
er
10
,00
0 A
dj.
Pa
tie
nt
Da
ys
SSEs per 10,000 Adj. Patient Days Baseline [ 1.0 (FY05-06) ]
Fiscal Year Goals (FY07=0.75 / FY08=0.50 / FY09=0.20) Threshold for Significant Change
** The narrowing thresholds in FY2005-FY2007 reflect increasing census. Adjusted patient days for FY07 were 27% higher than for FY05.
** Each point reflects the previous 12 months. Threshold line denotes significant difference from baseline for those 12 months (p=0.05).
aSSERT BeganJuly 2006
Chart Updated Through 28Feb10 by Bob Carpenter, Legal Dept. Source: Legal Dept.
Desired Direction of Change
Error Prevention Training Simulation Training Expands
Safety Coach Program
Patient SafetyTracker
Tenants ofSurgical SafetyaSSERT begins
SurgicalSafety Begins
James M. Anderson Center for Health Systems Excellence
Total Number of Times each Safety Element Failed(FY07 – Jan. 2010)
Failure Type Count% of times this failure
occurred
Coordination of Care 13 45%
Situation Awareness 13 45%
Reliable Escalation 7 24%
Family Engagement 6 21%
None of the 4 above 11 38%
SSE COMMON CAUSESRoot Cause Analyses
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Identifying, Mitigating, and Escalating Patients at Risk
Situation Awareness
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Journey to High Reliability: HROs
• Preoccupation with Failure
• Reluctance to Simplify Interpretations
• Commitment to Resilience
• Deference to Expertise
• Sensitivity to Operations– Find loopholes in system’s defenses, barriers and safeguards on the frontline.
Maintain Situation Awareness
Background
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
James M. Anderson Center for Health Systems Excellence
Situation Awareness?
James M. Anderson Center for Health Systems Excellence
• Simple Definition:– Knowing what is going on around you.– Having a notion of what is important.– Anticipation of possible future consequences
of the current situation.
Dr. Mica Endsley (1995)
What is Situation Awareness (SA)?
James M. Anderson Center for Health Systems Excellence
So how do we improve SA at CCHMC?
• Identify patients at risk.• Mitigate risk with team on unit.• Escalate risk that is not fully addressed.
Identifying, Mitigating, and Escalating Patients at Risk
James M. Anderson Center for Health Systems Excellence
Situation Awareness
3. Anticipate“Projection”
Decide
2. Recognize &Understand
“Comprehension”
Act
1. Gather Information“Perception”
↑HR, ↑diarrhea,parent concern
Recognize dehydration
Progress toshock if
untreated
Situation Awareness Process
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Situation Awareness
3. Anticipate“Projection”
Decide
1. Gather Information“Perception”
2. Recognize &Understand
“Comprehension”
Act
Miss ImportantInformation
Systematically Identify High Risk Patients
Miss Context asInfo Not Integrated
Communicate EachRisk to Watchstander
WrongPrediction
Predict/Mitigate/Escalate as Team
WrongDecision!
RightDecision!
Hypotheses to Improve SA
James M. Anderson Center for Health Systems Excellence
• PEWS >5• Family raises a concern• Therapy unusual for this team• “Watcher patient”• Communication amongst team
not adequate
Prediction:Patients at Immediate
Risk
James M. Anderson Center for Health Systems Excellence
Bedside nurse
InternWatchstander
Senior Resident
WatchstanderPCF/Manager
Safety Team(MPS and SOD)
at 800, 1600 & 100
Family concerns
High risk therapies
Watcher
PEWS>5
Communication concern
MRT
Reliable escalation of riskRapid assessment and communication with primary team
Attending
Bedside Team
Microsystem Team
OrganizationTeam
Situation Awareness Model
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Situation Awareness Algorithm. Illustrates the tool used during education and early phases and the specific questions and communication pathways.
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Robust Planning Tool
• Elements of “Robust Plan”– Identifying the problem or
concern– Making responsible parties
aware– Forming a plan– Predicting an expected
outcome within a fixed amount of time
– Deciding on an escalation and contingency plan if outcome is not met in time
Identify the Patient, Make a Specific Plan
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Process Measure Run Charts illustrating the percentage of units by week that escalate risk on ≥90% of shifts .
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Process Measure Run Charts illustrating the percentage of units by week that identify ≥90% of patients at risk each shift .
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Not Fully Addressed SA Bundle Concerns
0
20
40
60
80
100
120
03/2
7/10
04/0
3/10
04/1
0/10
04/1
7/10
04/2
4/10
05/0
1/10
05/0
8/10
05/1
5/10
05/2
2/10
05/2
9/10
06/0
5/10
06/1
2/10
06/1
9/10
06/2
6/10
07/0
3/10
07/1
0/10
07/1
7/10
07/2
4/10
07/3
1/10
08/0
7/10
08/1
4/10
08/2
1/10
08/2
8/10
09/0
4/10
09/1
1/10
09/1
8/10
Week Ending Date
Es
cala
tio
ns
Escalations Average Weekly Escalations Control Limits
5/2/10 Change in data collection process
James M. Anderson Center for Health Systems Excellence
0
1
2
3
4
5
6
7
8
9
10
Jan-
10
n=
704
0
Fe
b-1
0 n
=6
671
Mar
-10
n=
70
67
Ap
r-1
0 n
=6
599
May
-10
n=
66
89
Jun-
10
n=
636
1
Jul-1
0 n
=6
356
Au
g-1
0 n
=6
850
Se
p-1
0 n
=6
742
Oct
-10
n=
698
3
No
v-1
0 n
=6
443
De
c-1
0 n
=6
075
Jan-
11
n=
654
4
Fe
b 1
1
n=6
793
Mar
11
n=
73
56
Ap
r 1
1 n
=6
864
May
11
n=
699
8
Jun
11
n=
652
8
Jul 1
1
n=6
501
Au
g 1
1 n
=6
794
Se
p 1
1 n
=6
721
Oct
11
n=
727
5
No
v 1
1 n
=6
767
De
c 1
1 n
=6
662
Jan
12
n=
740
0
Fe
b 1
2
n=7
401
Mar
12
n=
79
54
Ap
r 1
2 n
=7
374
May
12
n=
735
4
Jun
12
n=
731
4
Jul 1
2
n=7
024
Au
g 1
2 n
=6
192
Ra
te p
er
10
,00
0 N
on
-IC
U B
as
e In
pat
ien
t D
ays
Rate of UNSAFE TransfersUNrecognized Situation Awareness Failure events
Per 10,000 Non-ICU Base Inpatient Days
Rate Median Goal
Updated through August 31 2012 by K. SimonJames M. Anderson Center for Health Systme s Excellence
James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Hospital Wide System for Safety
Floor Huddles ICU HuddlesED HuddlePeriOp Huddle
Institutional Wide Bed Huddle – Capacity Management
Individual Room / Floor / System Predictions – Capacity and Safety
Institutional Wide Safety Call
System Prediction – Mitigation Strategy
Pharmacy Security
Pt. Transport Housekeeping
3 Times - Every Day
Leadership Outcomes and Prediction MeetingCEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Facilities Pt Experience
Hospital Wide System for Safety
Floor Huddles ICU HuddlesED HuddlePeriOp Huddle
Institutional Wide Bed Huddle – Capacity Management
Individual Room / Floor / System Predictions – Capacity and Safety
Institutional Wide Safety Call
System Prediction – Mitigation Strategy
Pharmacy Security
Pt. Transport Housekeeping
3 Times - Every Day
Leadership Outcomes and Prediction MeetingCEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Facilities Pt Experience
Hospital Wide System for Safety
Floor Huddles ICU HuddlesED HuddlePeriOp Huddle
Institutional Wide Bed Huddle – Capacity Management
Individual Room / Floor / System Predictions – Capacity and Safety
Institutional Wide Safety Call
System Prediction – Mitigation Strategy
Pharmacy Security
Pt. Transport Housekeeping
3 Times - Every Day
Leadership Outcomes and Prediction MeetingCEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Facilities Pt Experience
Hospital Wide System for Safety
Floor Huddles ICU HuddlesED HuddlePeriOp Huddle
Institutional Wide Bed Huddle – Capacity Management
Individual Room / Floor / System Predictions – Capacity and Safety
Institutional Wide Safety Call
System Prediction – Mitigation Strategy
Pharmacy Security
Pt. Transport Housekeeping
3 Times - Every Day
Leadership Outcomes and Prediction MeetingCEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Facilities Pt Experience
Mitigate risk on unit
Escalate risk that is not fully
addressed
Predict course of most at risk
patients
Identifypatients at risk
Learn from each event
Systematically & Reliably
James M. Anderson Center for Health Systems Excellence
BEING THE BEST AT GETTING BETTER
James M. Anderson Center for Health Systems Excellence
To learn more about our work visit:
www.cincinnatichildrens.org/andersoncenter