Partnering for QualityCreating Reliability for Healthcare

Peter Pronovost, MD, PhDJohns Hopkins University

Objectives

• To understand the need for creating reliability in healthcare

• To understand a model for creating reliability in healthcare

• To consider how to organize patient safety efforts

• To explore a vision for the future of patient safety

RAND Study Confirms Continued Quality Gap

10.5Alcohol dependence

22.8Hip fracture

40.7Urinary tract infection

45.2Headaches

45.4Diabetes mellitus

48.6Hyperlipidemia

53.0Benign prostatic hyperplasia

53.5Asthma

53.9Colorectal cancer

57.2Orthopedic conditions

57.7Depression

64.7Hypertension

68.0Coronary artery disease

68.5Low back pain

Percentage of

Recommended Care Received

Condition

McGlynn et al, NEJM 2003; 348(26):2635-2645

Central Mandate

Local Wisdom

Scientifically Sound Feasible

xx

Concurrent Retrospective

Automatic Desired state

Manual ICU data system

Current state

Data Collection for Safety and Quality

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 honest am I

• How kind am I

• How tall am I

• How good is the quality of care we provide

More than 5 years after IOM report

• No significant improvements

-40% say quality of care is worse than 5 years ago

- 38% feel it is the same

- Only 10% feel it has improved

• How do we know patients are safer?

Model to Improve Reliability of Care• Pick an important clinical area• Identify what should we do?

– principles of evidence-based medicine• Measure if you are doing it• Understand the process and context of work• Ensure patients get what they should

– Engage– Educate– Execute (reduce complexity, create redundancy, learn from

defects)• Evaluate whether outcomes are improved

Health Services Research, 2006; Circulation (in press)

Creating Reliable Health Care

Executive Leaders

Team Leaders

Staff

Engage(adaptive)

How Do I Make the World a Better Place?

Educate(technical)

What Do I Need to Know?

Execute(adaptive)

What Do I Need to Do?

Evaluate(technical)

How Will I Know I Made a Difference?

© Quality and Safety Research Group, Johns Hopkins University

Ensure patients get what they should

• Summarize strategies in toolkit

• Engage– Make harm visible– Watch Josie video– Partner with other discipline experts– Tell stories– Post performance

Ensure patients get what they should

• Educate on evidence supporting the intervention – original literature, concise summaries and slide

presentations – conference calls, newsletters, printed educational materials

• Execute – Simplify the system: protocols, order sets etc– Create redundancies: daily goals and others– Learn from defects

• Evaluate– Validated tools and dedicated data collection

Evaluate whether outcomes are improved

• Rigorous methods to minimize risk of inaccurate conclusions

• When inferences are made about the benefits of an intervention without acknowledging limitations, it is likely the inferences will be accepted as truth

• Consumers may believe the claims/ could be hazardous, at a minimum is misleading

Understand the process and context of work

• Observe staff performing the interventions to identify where the process may break down

• “Walk the process” to identify barriers in providing the intervention

• Listen to staff concerns regarding the intervention and identify what they stand to gain or lose from the improvement effort

Organizing Safety work

• Evaluating Progress in Patient Safety

• Translating evidence into practice (TRIP)

• Identifying and mitigating hazards

• Improving culture and communication

• Linking organizational characteristics to patient safety

As Leaders, How Can We Improve the Quality of Our Studies?

• First, have a clear and articulated QI plan (including hypothesis/objective, study design, sample size and explicit intervention and outcome measures)

As Leaders, How Can We Improve the Quality of Our Studies?

• Second, use data collection forms and procedures that have been tested for reliability

• Third, provide adequate training, supervision and quality assurance for individuals collecting the data and using the tools

As Leaders, How Can We Improve the Quality of Our Studies?

• Fourth: ensure data collected is appropriately managed to minimze the risk for data entry errors and support accurate analysis

• Fifth: Make certain you have the requisite knowledge and skill to appropriately describe, conduct and report the analyses.– If you don’t have the in-house resources, partner

with someone who does (local college or community resources)

As Leaders, How Can We Improve the Quality of Our Studies?

• Finally, Ensure that limitations and potential biases are transparently reported for all quality improvement projects

Vision for improving the effectiveness and efficiency of patient safety efforts

• Develop GAAP safety scorecard

• Create TRIP programs

• Create CAST in healthcare

• Understand how to improve culture and communication

• Link organizational characteristics to outcome

1. Identify Hazards

2. (

3.

3. Mitigate Risk

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 level s 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.

(Design, Pilot Test, Implement)

Requirements

• Build Capacity

• Create learning communities

• Develop sustainable financial model

Next Steps

• Commit to TPSC Collaborative

• State wide learning from Mistakes

• State wide Safety Culture Assessment and improvement

• Capacity Building

• Share what you learn globally