quality & safety at hadassah a progress report mayer brezis, md mph professor of medicine,...
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Quality & Safety Quality & Safety at Hadassahat Hadassah
A Progress ReportA Progress Report Mayer Brezis, MD MPHMayer Brezis, MD MPH
Professor of MedicineProfessor of Medicine , ,Center of Quality & SafetyCenter of Quality & Safety
Chairman, Quality & Safety CommitteeChairman, Quality & Safety Committee
Yoel Donchin, MD, Nurit Porat, RNYoel Donchin, MD, Nurit Porat, RN
• Students ProjectsStudents Projects
• Institution-wide ProjectsInstitution-wide Projects
• Educational ActivitiesEducational Activities
• National ImpactNational Impact
Quality & Safety at HadassahQuality & Safety at Hadassah
Making Health Making Health Care Safer: A Care Safer: A
Critical Analysis Critical Analysis of Patient Safety of Patient Safety
PracticesPracticesEvidence ReportEvidence Report
Agency for Agency for Healthcare Healthcare Research & Research &
QualityQualitywww.ahrq.gov/www.ahrq.gov/clinic/ptsafetyclinic/ptsafety
Venous Venous Thromboembolism in Thromboembolism in
NeurosurgeryNeurosurgery
Dr. G. Rosenthal, S. Goldman RN, Prof. F. Dr. G. Rosenthal, S. Goldman RN, Prof. F. Umanski, Prof. D. Varone, Dr. Y Weiss Umanski, Prof. D. Varone, Dr. Y Weiss
Departments of Neurosurgery, Hematology, Departments of Neurosurgery, Hematology, Central Management, Center for Quality & SafetyCentral Management, Center for Quality & Safety
Hadassah University HospitalHadassah University HospitalJerusalem, IsraelJerusalem, Israel
•58 year-old woman underwent 58 year-old woman underwent resection of meningiomaresection of meningioma
•On post-op day 2, sudden On post-op day 2, sudden onset of respiratory distressonset of respiratory distress
•Chest CT demonstrates Chest CT demonstrates massive pulmonary embolismmassive pulmonary embolism
•Vena cava filter inserted & Vena cava filter inserted & anticoagulation initiatedanticoagulation initiated
•On post-op day 6 sudden onset On post-op day 6 sudden onset of severe headache and of severe headache and vomitingvomiting
Post-op CT Follow-up CT
10
05
0
2
4
6
8
10
12
1st Control Intervention 2nd Control
Cas
es o
f VTE
10/239 4%
0/94 0%
5/75 7%
Control
Cases o
f th
rom
bo-
em
bolism•5 months (2003)•10 cases of thromboembolism•7 vena cava filters inserted•Extended ICU & hospital stays
10
05
0
2
4
6
8
10
12
1st Control Intervention 2nd Control
Cas
es o
f VTE
10/239 4%
0/94 0%
5/75 7%
July 2003: Introduction of
intermittent pneumatic
compression devices
Cases o
f th
rom
bo-
em
bolism
Control
Intervention
10
05
0
2
4
6
8
10
12
1st Control Intervention 2nd Control
Cas
es o
f VTE
10/239 4%
0/94 0%
5/75 7%
Cases o
f th
rom
bo-
em
bolism
Control
Intervention
10
05
0
2
4
6
8
10
12
1st Control Intervention 2nd Control
Cas
es o
f VTE
10/239 4%
0/94 0%
5/75 7%
Control InterventionControl
Intervention
Cases o
f th
rom
bo-
em
bolism
Control
Quality can Quality can
reduce reduce
morbidity & morbidity &
save costssave costs
ConclusionConclusion::
Quality indicators for Quality indicators for the management of the management of myocardial infarctionmyocardial infarction
M. Cohen, Dr. A. Pollack, Prof. A. Weiss, Prof. C. M. Cohen, Dr. A. Pollack, Prof. A. Weiss, Prof. C. Lotan Lotan
Intensive Cardiac Units, Division of Cardiology & Intensive Cardiac Units, Division of Cardiology & Department of Medicine, Mt. Scopus & Ein Kerem Department of Medicine, Mt. Scopus & Ein Kerem
Hadassah University HospitalHadassah University HospitalJerusalem, IsraelJerusalem, Israel
Quality indicators for myocardial infarction, Hadassah vs. US data
HadassahHadassah ((%%) 89 90 50 83 69 44’ 102’
Peterson R, JAMA 2004;291:195
HadassahHadassah
• Evidence-basedEvidence-based
• System-mindedSystem-minded
Quality in Health CareQuality in Health Care
Will the pathology
result get lost?
86
88
90
92
94
96
98
2001 2002 2003
Percent of patients having
received the result of their skin biopsy
p<0.05
A clinic-based intervention (led by the head nurse, A clinic-based intervention (led by the head nurse, involving both physicians & patients)involving both physicians & patients)
An institution-wide intervention: electronic alerts sent to An institution-wide intervention: electronic alerts sent to physician’s computer whenever a pathology report is physician’s computer whenever a pathology report is ready ready
4%
failed malignancy reports
0%1%
Will the pathology result get lost?
P. Topol, RN, Dr. A. Zlotogorski, Prof. A. Ingbar, Dr. A. Mali, T. Friedman, RN, M. Benhur, N.
Porat, RN
Departments of Dermatology, Pathology, Information Systems, Nursing and Quality &
Safety Committee
How can we make sure the
patient gets the result?
This quality improvement
project, awarded prize of best poster at the
meeting of the Israeli Society for
Quality in Medicine, is
posted at the dermatology clinic as a reminder for
both patients, nurses and physicians
Quality & Safety Committee Quality & Safety Committee Subcommittee for Medication Subcommittee for Medication
ErrorsErrors
Quality & Safety Committee Quality & Safety Committee Subcommittee for Medication Subcommittee for Medication
ErrorsErrors
Specific Specific labels for labels for lines to lines to
patients - to patients - to avoid mix avoid mix
upup
Screen from software asking: “Would you approve this
prescription?”
Interactive software to learn prescribing for new physicians
• Evidence-basedEvidence-based
• System-mindedSystem-minded
Quality in Health CareQuality in Health Care
• Patient-centeredPatient-centered
Palliative Care in General Palliative Care in General Internal Medicine: A successful Internal Medicine: A successful
pilot intervention among pilot intervention among elderly patients with life elderly patients with life threatening illness and threatening illness and
impaired cognitionimpaired cognition
S. Gottsman, RN, MA et al.S. Gottsman, RN, MA et al.Head Nurse, Medicine B, Mt Head Nurse, Medicine B, Mt
ScopusScopus
Staff-initiated meetings with relatives, to communicate information on patient’s
condition; to listen to their questions and to their
preferences based on patient’s prior wishes – if any had been
expressed; and finally to attempt shared goal setting
and decision making
Intervention
Control ward – no intervention
“Staff did not really consider my opinions”6013*
“I felt not involved in decision making” 5723*
“It upset me that I did not know what was happening”4310*
“I did not receive explanations about alternatives” 5720*
“Relative’s problems were not explained”533*
“I felt uncomfortable with asking questions”5310*
“I was not asked to participate in decisions”6017*
“I felt alone and without support”4317*
“I felt pressured to make decisions”277*
Control
InterventionPercent of relatives agreeing with negative
statements
Is the X-ray interpretation by the junior staff on duty correct?
Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham
Departments of Surgery, Radiology, and Center for Quality & Safety
Emerging methods for quality evaluation
Frontal bone fracture
Hip fracture
Sensitivity )%(
Specificity
)%(
Positive predictive
value)%(
Negative predictive
value)%(
ChestChest (n=54)(n=54)
92(65-100)
93(82-98)
79(52-94)
97(88-100)
Neck Neck (n=19)(n=19)
100(5-100)
100(85-100)
100(5-100)
100(85-100)
PelvisPelvis (n=27)(n=27)
60(18-93)
100(87-100)
100(37-100)
92(75-99)
CT’sCT’s(n=75)(n=75)
94 (81-99)
95(85-99)
94(81-99)
95(85-99)
Validity of X-ray Interpretations in Trauma
mean & 95% CI (confidence interval)
Reliability of X-ray Reliability of X-ray Interpretation on DutyInterpretation on Duty
mean & 95% mean & 95% confidence confidence intervalsintervals
Inter-observer variabilityInter-observer variability
Resident vs. SpecialistResident vs. Specialist
Percent Percent agreementagreement
Kappa Kappa CoefficientCoefficient
SurgerySurgery77%77%0.600.60 ((0.4-0.80.4-0.8))
Pulmonary Pulmonary EmbolismEmbolism95%0.84 (0.7-1.0)(0.7-1.0)
A Senior Resident in Radiology Concluded:
“We need to look at ourselves”
•Students ProjectsStudents Projects•Institution-wide ProjectsInstitution-wide Projects•Educational ActivitiesEducational Activities•National ImpactNational Impact
Summary & Summary & Conclusion Conclusion
Diverse projects attempt to make healthcare at Hadassah more
patient-centered, more evidence-based and more system-minded.
Increased accountability by department heads for quality and
safety may be a key to further successes.
How would an open disclosure policy about mistakes affect
hospital image in public’s eyes?
Damage Damage ImageImage
No No ChangChang
ee
ImproveImprove ImageImage
MD student
Zivan Beer
How would an open disclosure policy about mistakes affect
hospital image in public’s eyes?
p<0.001
Damage Damage ImageImage
No No ChangChang
ee
ImproveImprove ImageImage
MD student
Zivan Beer
N=570
N=115
Risk Risk
management:
management: Extreme
Extreme honesty may be
honesty may be
the best policy
the best policy
(The V.A. Experience)
(The V.A. Experience)
Annals of Internal
Annals of Internal
Medicine ‘99
Medicine ‘99
New position statement by the Ethics Board of the Israeli Medical
Association supports transparency (May 2004)
““Tell the tru
th
Tell the tru
th
and tell it fast”
and tell it fast”
N. Augustine. Crisis Management
N. Augustine. Crisis Management
Harvard Business Review (2000)
Harvard Business Review (2000)
“The physician has an obligation to disclose to the patient
that a mishap has
happened”
IMA Ethics BoardPosition Paper