measuring progress in patient safety
DESCRIPTION
Measuring Progress in Patient Safety. Peter Pronovost, MD, PhD, FCCM Johns Hopkins University. Exercise Please answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average. How smart am I How hard do I work How kind am I How tall am I - PowerPoint PPT PresentationTRANSCRIPT
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Measuring Progress in Patient Safety
Peter Pronovost, MD, PhD, FCCMJohns Hopkins University
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ExercisePlease answer each question with a score of 1 to 5.
1 is below average, 3 is average and 5 is above average
• How smart am I• How hard do I work• How kind am I• How tall am I• How good is the quality of care we provide
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Improving Sepsis Care
(n= 19 ICUs)Mortality
13.1
21.9
41.8
0.0
10.0
20.0
30.0
40.0
50.0
Oct - Dec2003
Mar - May2004
July - Sept2004
%
69% Reduction (p < 0.001)
ICU LOS
6.27.6
10.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Oct - Dec2003
Mar - May2004
July - Sept2004
Day
s
36% Reduction (NS)
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Improving Sepsis Care
(n= 19 ICUs)Mortality
13.1
21.9
41.8
0.0
10.0
20.0
30.0
40.0
50.0
Oct - Dec2003
Mar - May2004
July - Sept2004
%
69% Reduction (p < 0.001)
ICU LOS
6.27.6
10.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Oct - Dec2003
Mar - May2004
July - Sept2004
Day
s
36% Reduction (NS)
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Central Mandate
Local Wisdom
Scientifically Sound Feasible
xx
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Structure
ContextHave we created a culture of safety?
Process Outcome
Have we reduced the likelihood of harm?
How often do we do what we are supposed to?
How often do we harm?
Conceptual model for measuring safety
IT
Adapted from Donebedian
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Keystone ICU Safety Dashboard
2004 2006
How often did we harm (BSI) 2.8/1000 0
How often do we do what we should
66% 95%
How often did we learn from mistakes
100s 100s
% Needs improvement in Safety climateTeamwork climate
84%82%
43%42%
Pronovost JAMA 2007
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Translating EvidenceInto Practice
* Envision the problemwithin the larger health
care system
* Engage collaborativemulti-disciplinaryteams centrally(stages 1,2,&3)
and locally(stage 4)
1. Summarize the Evidence
Convert interventions to behaviors
2. Identify local barriers toimplementation: understandthe process and context of
work
3. Measure Performance
4. Ensure all patientsreceive the interventions
Identify Interventions associatedwith improved outcomes
Select interventions with the largestbenefit and lowest barriers to use
Enlist all stakeholders to shareconcerns and identify potentialgains/losses associated withintervention implementation
Observe staff performing theinterventions
"Walk the process" to identifydefects in each step of intervention
implementation
Measure Baseline Performance
Develop and pilot test measures
Select Measures(process and/or outcome)
Engage
Explain why the interventions are
important
Execute
Design an intervention “toolkit” targeted to barriers employing standardization,
independent checks and reminders, and learning from mistakes
Educate
Share the evidence supporting the interventions
Evaluate
Regularly assess performance
measures
Pronovost BMJ 2008
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Comprehensive Unit-based Safety Program (CUSP)
1. Educate staff on science of safety http://www.jhsph.edu/ctlt/training/patient_safety.html
2. Identify defects3. Assign executive to adopt unit4. Learn from one defect per quarter and implement
teamwork tools
Pronovost J, Pronovost J, Patient Safety,Patient Safety, 20052005
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What can be measured as a valid rate?
• Rate requires– Numerator- event– Denominator- those at risk for event– Surveillance for events and those at risk
• Minimal and Known Error– Random error– Systematic error
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Sources Variation in Safety measures
• True variation in Safety• V data quality/definition/methods of
collection• V case mix• V historical rates• Chance
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Measuring Preventable Harm
• Measure rate or counts directly– High sensitivity low specificity
• Estimate observed/expected (O/E)– Low sensitivity and specificity
• Link process and outcome– High specificity and moderate sensitivity
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Process Measures
• Validity of the construct• Validity of how we measure construct
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It is Ok to have non-rate measures
Self reported measures are generally not valid as rates
A common mistake is interpreting a non-rate measure as a valid rate
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Learning from Mistakes
• What happened?• Why did it happen (system lenses)• What could you do to reduce risk• How to you know risk was reduced
– Create policy/process/procedure– Ensure staff know policy– Evaluate if policy is used correctly
Pronovost 2005 JCJQI
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•Identify Hazards•(
3. Mitigate Risks
2. Analyze & Prioritize Hazards
4. Evaluate Effectiveness of Risk Reduction
Patient Safety Learning Communities
Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control.
Pronovost Health affairs in press
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GYN/OB JHOC Medicine Neurosciences Oncology Ophthalmology
FAC: Fetal Assessment Center/OB Ultrasound
GSS - Shared Specialty Suite
Asthma & Allergy - Allergy & Clinical Immunology BRU GSS - Medical Oncology GSS - Wilmer 110
GSS - GYN/OB 420 JHOPC - Express Testing Asthma & Allergy - Pulmonary EMU IPOP Clinic - HIPOP
Location GSS - Wilmer Laser Center
GSS - GYN/REI JHOPC - OR Asthma & Allergy - Rheumatology JHOPC Neurosciences IPOP Clinic - IPOP
Location WECP & ER
HAL-2 JHOPC - PACU Blalock 4 - Endoscopy MEY 8 (12) Weinberg OPD - 1st Floor Wilmer OR
JHOPC GYN/OB WM - Shared Specialty Suite Blalock 5 Echo Lab (2) MEY 9 (5) Weinberg OPD - 2nd Floor Wilmer PACU
MCE Cardiac CT NCCU7 WGA 5 (5) Wilmer White Marsh
NEL-2 Nursery CCP-5 (5) WGB 5 Wilmer: Other - E Balt Divisions
NEL-2 Obstetric OR CCU-5 (7) WGC-5 (3) Wilmer: Other - Satellites
NEL-2 PACU CVC WGD 5
Nelson Harvey 2 CVIL- CardioVascular Interventional Lab
OSL-2 Dialysis Unit
OSL-3 Nursery GSS - Internal Medicine
OSL-3 HAL-5 (5)
WGB-4 HAL-8 (7)
Hospitalist Unit (5)
JHOPC - Exec Health & Travel Clinic
JHOPC - Medicine Clinics
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CAST• Each contributing factor rate
– importance of the problem and contributing factors in causing the accident
– importance of the problem and contributing factors in future accidents
• Each Intervention rate– How well the intervention solves the problem or mitigates
the contributing factors for the accident– Rates the team belief that the intervention will be
implemented and executed as intended
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What is Culture*?:
“The way we do things around here”
*aka Climate
1 attitude = opinion…everyone’s attitude = culture
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–Disagreements in the ICU are appropriately resolved (i.e., not who is right, but what is best for the patient)–Our doctors and nurses work together as a well coordinated team
Teamwork climate: perceived quality of collaboration between the personnel in this unit
–Trainees in my discipline are adequately supervised–This hospital deals constructively with problem personnel
Working conditions: perceived quality of the work environment and logistical support (staffing, training, etc.)
–I am less effective at work when fatigued–When my workload becomes excessive, my performance is impaired
Stress recognition: acknowledgement of how performance is influenced by stressors (permitted to be human)
–Hospital management supports my daily efforts in the ICU–Hospital management does not knowingly compromise the safety of patients
Perceptions of management: approval of managerial action
–I would feel safe being treated in this ICU–Medical errors are handled appropriately in this ICU
Safety climate: perceptions of a strong and proactive commitment to patient safety in this unit
–I like my job–This hospital is a good place to work
Job satisfaction: positivity about the work experience
Example itemsFactor: Definition
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Executive Perceptions vs. Frontline Perceptions:
Executives overestimate:Teamwork Climate 4XSafety Climate 2.5X
Executive Confidence vs. Executive Accuracy:-Often wrong but rarely in doubt…-Currently no incoming data-streams-Halo Effects-Frontline data fills the gap
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* * * * * *
* Statistically Significant
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64 Teamwork Climate 200667 Teamwork Climate 2007
71 Teamwork Climate 2008
62 Teamwork Climate 2005
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60 Safety Climate 200665 Safety Climate 200770 Safety Climate 2008
59 Safety Climate 2005
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CSIC
U T1
CSIC
U T2
0
10
20
30
40
50
60
70
80
90
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% o
f res
pond
ents
with
in a
n IC
U th
at a
gree
#4. “I Would Feel Safe Being Treated Here As A Patient.”
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CSIC
U T1
CSIC
U T2
0
10
20
30
40
50
60
70
80
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C S IC U
T 2
% o
f res
pond
ents
with
in a
n IC
U th
at a
gree
#3. “Nurse Input Is Well Received In This ICU.”
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CSIC
U T2
CSIC
U T1
0
10
20
30
40
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60
70
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% o
f res
pond
ents
with
in a
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at a
gree
#26. “In This ICU, It Is Difficult To Speak Up If I Perceive A Problem With Patient Care.”
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CSIC
U T1
CSIC
U T2
0
10
20
30
40
50
60
70
80
90
100
% o
f res
pond
ents
with
in a
n IC
U th
at a
gree
#32. “Disagreements In This ICU Are Resolved Appropriately (i.e. not who is right, but what is best for the patient).”
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Questions for Reflection
• How do you know you are safer?• How will you become more efficient in
your measurement efforts?• How will you better tap into local wisdom?
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Focus and Execute
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