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On the CUSP: STOP BSIOn the CUSP: STOP BSIThe Science of Improving Patient The Science of Improving Patient

SafetySafety

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Immersion Call OverviewImmersion Call Overview

Week 1: Project overview

Week 2: Science of Improving Patient Safety

Week 3: Eliminating CLABSI

Week 4: The Comprehensive Unit-Based Safety Program (CUSP)

Week 5: Building a Team

Week 6: Physician Engagement

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Learning ObjectivesLearning Objectives

• To recognize that every system is designed to achieve the results it gets

• To identify the basic principles of safe design that apply to both technical and team work

• To discuss how teams make wise decisions

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The Marvel of Modern MedicineThe Marvel of Modern Medicine

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ConditionCondition % of Recommended Care Received

Low back pain 68.5

Coronary artery disease 68.0

Hypertension 64.7

Depression 57.7

Orthopedic conditions 57.2

Colorectal cancer 53.9

Asthma 53.5

Benign prostatic hyperplasia 53.0

Hyperlipidemia 48.6

Diabetes mellitus 45.4

Headaches 45.2

Urinary tract infection 40.7

Hip fracture 22.8

Alcohol dependence 10.5

RAND Study Confirms Continued Quality RAND Study Confirms Continued Quality Gap Gap

1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.

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The Problem is LargeThe Problem is Large• In U.S. Healthcare system

– 7% of patients suffer a medication error 2

– On average, every patient admitted to an ICU suffers an adverse event 3,4

– 44,000- 98,000 people die in hospitals each year as the result of

medical errors 5

– Nearly 100,000 deaths from HAIs 6

– Estimated 30,000 to 62,000 deaths from CLABSIs 7

– Cost of HAIs is $28-33 billion 7

• 8 countries report similar findings to the U.S.2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 19953. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.6. Klevens M, Edwards J, Richards C, et al., PHR, 20077. Ending Health Care-Associated Infections, AHRQ, 2009.

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How Can These Errors How Can These Errors Happen?Happen?

• People are fallible• Medicine is still treated as an art, not

science• Need to view the delivery of healthcare as

a science• Need systems that catch mistakes before

they reach the patient

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Understanding the Science of Understanding the Science of SafetySafety

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How Can We Improve?How Can We Improve?Understand the Science of SafetyUnderstand the Science of Safety

• Every system is perfectly designed to achieve the results it gets

• Understand principles of safe design – standardize, create checklists, learn when things go wrong

• Recognize these principles apply to technical and team work

• Teams make wise decisions when there is diverse and independent input

Caregivers are not to blameCaregivers are not to blame

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SystemSystem FailureFailure LeadingLeading toto ThisThis

ErrorError

Catheter pulled withPatient sitting

Communication betweenresident and nurse

Lack of protocol For catheter removal

Inadequate trainingand supervision

Patient suffers

Venous air embolism

8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.9. Reason J, Hobbs A., 2000.

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System Factors Impact SafetySystem Factors Impact Safety

HospitalHospital

Departmental FactorsDepartmental Factors

Work EnvironmentWork Environment

Team FactorsTeam Factors

Individual ProviderIndividual Provider

Task FactorsTask Factors

Patient CharacteristicsPatient Characteristics

InstitutionalInstitutional

10. Adapted from Vincent C, Taylor- Adams S, Stanhope N., BMJ, 1998.

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Evidence Regarding the Impact of ICU Evidence Regarding the Impact of ICU Organization on PerformanceOrganization on Performance

• Physicians11

• Nurses12

• Pharmacists13

11. Pronovost P, Angus D, Dorman T, et al., JAMA, 2002.12. Pronovost P, Dang D, Dorman T, et al., ECP, 2001.13. Pronovost P, Jenckes M, Dorman T, et al., JAMA, 1999.

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Fatal Aviation Accidents per Fatal Aviation Accidents per Million DeparturesMillion Departures

14. Statistical Summary of Commercial Jet Airplane Accidents, Aviation Safety Boeing Commercial Airplanes, July 2009.

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Principles of Safe DesignPrinciples of Safe Design

• Standardize – Eliminate steps if possible

• Create independent checks

• Learn when things go wrong– What happened– Why– What did you do to reduce risk– How do you know it worked

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StandardizeStandardize

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Line Cart Contents – 4 DrawersLine Cart Contents – 4 Drawers

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Eliminate StepsEliminate Steps

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Create Independent ChecksCreate Independent Checks

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2 Year Results from 103 2 Year Results from 103 ICUsICUs

Time periodTime period Median CRBSI rateMedian CRBSI rate Incidence rate ratioIncidence rate ratio

BaselineBaseline 2.7 1

Peri-interventionPeri-intervention 1.6 0.76

0-3 months0-3 months 0 0.62

4-6 months4-6 months 0 0.56

7-9 months7-9 months 0 0.47

10-12 months10-12 months 0 0.42

13-15 months13-15 months 0 0.37

16-18 months16-18 months 0 0.34

15. Pronovost P, Needham D, Berenholtz S et al., N Engl J Med, 2006.

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Principles of Safe Design Apply to Principles of Safe Design Apply to Technical and Team WorkTechnical and Team Work

Basic Components and Process of Basic Components and Process of CommunicationCommunication

16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.

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ents

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team

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ICU Physicians and ICU RN ICU Physicians and ICU RN CollaborationCollaboration

17. ICUSRS Data from Needham D, Thompson D, Holzmueller C, et al., Crit Care Med, 2004.

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Teamwork ToolsTeamwork Tools

• Staff Safety Assessment• Daily goals• AM briefing• Shadowing• Barrier Identification and

Mitigation• Learning from Defects

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Systems Systems

• Every system is designed to achieve the results it gets

• To improve performance we need to change systems

• Start with pilot test one patient, one day, one physician, one room

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Teams Make Wise Decisions When There Teams Make Wise Decisions When There is Diverse and Independent Inputis Diverse and Independent Input

• Wisdom of Crowds

• Alternate between convergent and divergent thinking

• Get from the dance floor to the balcony level

18. Heifetz R, Leadership Without Easy Answers,1994.

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Don’t Play Man DownDon’t Play Man Down

When you feel something say When you feel something say somethingsomething

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RecapRecap

• Develop lenses to see systems • Work to standardize one process• Infuse these principles of standardization and

independent checks in other processes• Don’t play man down

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Action ItemsAction Items

• Have all members of the CUSP/CLABSI Team view the Science of Improving Patient Safety video

• Put together a roster of who on your unit needs to view the Science of Safety video

• Develop a plan to have all staff on your unit view the Science of Improving Patient Safety video– Assess what technologies you have available for staff

to view– Identify times for viewing it (e.g., staff meetings,

individual admin hours)

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Works ConsultedWorks Consulted1. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the

United States. N Engl J Med. 2003;348 (26): 2635-45.2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential

adverse drug events. JAMA. 1995;274(1):29-34. 3. Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in

the intensive care unit. Crit Care Med. 23:294-300,1995.4. Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse

events in medical care. Lancet. 349:309-313,1997.5. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System.

Washington, DC: National Acad Pr; 1999.6. Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections

and Deaths in U.S. Hospitals, 2002. PHR.122:160-166,2007. 7. Ending Health Care-Associated Infections, AHRQ, Rockville,MD, 2009.

http://www.ahrq.gov/qual/haicusp.htm.8. Pronovost P, Wu A, Sexton J, et al. Acute decompensation after removing a central line:

practical approaches to increasing safety in the intensive care unit. Ann Int Med. 2004;140(12):1025-1033.

9. Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000.

10.Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998; 316: 1154–7.

11.Pronovost P, Angus D, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162.

12.Pronovost P, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective clinical practice: ECP. 2001;4(5):199-206.

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Works ConsultedWorks Consulted13.Pronovost P, Jenckes M, Dorman T, et al. Organizational characteristics of intensive

care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7.14.Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations

1959-2008. Boeing News Releases/Statements. July 2009. Aviation Safety Boeing Commercial Airplanes, Web. 21 Jan 2010. <www.boeing.com/news/techissues/pdf/statsum.pdf>.

15.Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32.

16.Dayton E, Henriksen K. Communication Failure: Basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007; 33(1): 34-47.

17.Needham D, Thompson D, Holzmueller C, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32:2227-33.

18.Heifetz R, Leadership Without Easy Answers, President and Fellows of Harvard College,1994.