11

Does Patient Does Patient Centered Care Centered Care

Enhance Quality and Enhance Quality and Safety?Safety?

Human Factors, System IssuesHuman Factors, System Issues

System SolutionsSystem Solutions

© 2010 Planetree, Inc.

22

Objectives of PresentationObjectives of Presentation Provide concepts of how the Planetree philosophy can support Provide concepts of how the Planetree philosophy can support

system changes to enhance a culture of quality and safetysystem changes to enhance a culture of quality and safety

Understand safety implications related to human performance Understand safety implications related to human performance

Discuss how a patient centered approach can enhance patient Discuss how a patient centered approach can enhance patient and family involvement and patient safetyand family involvement and patient safety

Present outcome measures to demonstrate that a Planetree Present outcome measures to demonstrate that a Planetree patient centered environment not only supports a culture of patient centered environment not only supports a culture of quality but also improves patient and employee satisfaction, quality but also improves patient and employee satisfaction, and the bottom lineand the bottom line

33

What Started Safety Awareness? What Started Safety Awareness?

1999 - To Err is Human – IOM1999 - To Err is Human – IOM Study showed adverse events happen in 2.9 to Study showed adverse events happen in 2.9 to

3.7 percent of hospitalizations3.7 percent of hospitalizations Extrapolated over 33.6 million admissions per Extrapolated over 33.6 million admissions per

year = 44,000-98,000 deaths due to medical year = 44,000-98,000 deaths due to medical error per yearerror per year

Poor communication and a lack of teamwork Poor communication and a lack of teamwork was identified as a root cause of most safety was identified as a root cause of most safety problemsproblems

44

11 Years After the IOM 11 Years After the IOM “To Err is Human…” Report:“To Err is Human…” Report:

What Has Changed?What Has Changed?

55

Safety Hazard ProbabilitiesSafety Hazard Probabilities(events per million opportunities)(events per million opportunities)

Acquiring HIV from 1 unit of transfused blood 0.7Acquiring HIV from 1 unit of transfused blood 0.7 All heads on 20 coin tossesAll heads on 20 coin tosses 1.0 1.0 Death of commercial airline passenger 2.4Death of commercial airline passenger 2.4 Death: general anesthesiaDeath: general anesthesia 7.5 7.5 Death: motor vehicleDeath: motor vehicle 187 187 Preventable hospital deathsPreventable hospital deaths 208 208

Orlikoff,J. Orlikoff and Associates, Inc. Chicago, IL. Jan. 2010Orlikoff,J. Orlikoff and Associates, Inc. Chicago, IL. Jan. 2010

66

Cost of Medical Errors in U.S.Cost of Medical Errors in U.S.

$17 billion costs associated with $17 billion costs associated with preventable errors (IOM, 1999)preventable errors (IOM, 1999)

In the past, third party payers have In the past, third party payers have paid regardless of outcome – changed paid regardless of outcome – changed as of 10/2008!as of 10/2008!

Central Line associated bloodstream infections resulted in an average loss per case of $26,839 in 2006

Shannon et al, “Economics of Central-Line Associated Bloodstream Infections” American Journal of Medical Quality Supplement to Vol.21, No.6 Nov/Dec 2006

77

National Health Expenditures per Capita, National Health Expenditures per Capita, 1980– 2007 1980– 2007

Data: OECD Health Data 2009 (June 2009).

Average spending on health per capita ($US PPP)

0

1000

2000

3000

4000

5000

6000

7000

8000

1980 1984 1988 1992 1996 2000 2004

United States

Canada

France

Germany

Netherlands

United Kingdom

88

What are the “Other” What are the “Other” Cost of Errors? Cost of Errors?

Errors may be career ending eventsErrors may be career ending events Caregivers don’t intend to harmCaregivers don’t intend to harm

Trust issues and safety concerns on part of Trust issues and safety concerns on part of the consumers and payersthe consumers and payers

Frustrated consumersFrustrated consumers Silence often surrounds issues which may Silence often surrounds issues which may

result in malpractice claimsresult in malpractice claims Sensational negative media coverageSensational negative media coverage

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News HeadlinesNews Headlines SEPT. 2006: “SEPT. 2006: “HOSPITAL CHANGES PROCEDURES HOSPITAL CHANGES PROCEDURES

AFTER PREEMIE DEATHSAFTER PREEMIE DEATHS”:”: Three preemies die after they receive adult doses of heparin at a hospital Three preemies die after they receive adult doses of heparin at a hospital

in Indianapolisin Indianapolis

NOV. 2007: “NOV. 2007: “HOSPITAL REPEATS WRONG-SIDED HOSPITAL REPEATS WRONG-SIDED BRAIN SURGERYBRAIN SURGERY”:”: ““For the For the third timethird time this year, doctors at Rhode Island Hospital have this year, doctors at Rhode Island Hospital have

operated on the wrong side of a patient’s head – an action that has operated on the wrong side of a patient’s head – an action that has brought about censure from the state Department of Health and a brought about censure from the state Department of Health and a $50,000 fine.”$50,000 fine.”

SEPT. 2010SEPT. 2010: “BABY DIES AT SEATTLE CHILDREN’S : “BABY DIES AT SEATTLE CHILDREN’S HOSPITAL AFTER OVERDOSE”:HOSPITAL AFTER OVERDOSE”: ……a hospital nurse gave her 10 times the proper dose of a medication, a hospital nurse gave her 10 times the proper dose of a medication,

calcium chloride. Five days later, on Sept. 19, after suffering a brain calcium chloride. Five days later, on Sept. 19, after suffering a brain hemorrhage, the baby died.hemorrhage, the baby died.

1010

State of Colorado State of Colorado

Local TV news coverage on prevention of Local TV news coverage on prevention of central line infectionscentral line infections Discussed use of central line bundleDiscussed use of central line bundle

Shortly thereafter, legislators in the State Shortly thereafter, legislators in the State received a “slew” of e-mails from constituents received a “slew” of e-mails from constituents demanding use of the central line bundle be demanding use of the central line bundle be made into law!made into law!

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Put it in PerspectivePut it in Perspective 25% of US patients state they have experienced a medical 25% of US patients state they have experienced a medical

error - 50% of those resulting in serious harmerror - 50% of those resulting in serious harm

42% of health care workers (HCW) state they have been 42% of health care workers (HCW) state they have been personally involved in a medical errorpersonally involved in a medical error

HCW’s state they fear becoming a patientHCW’s state they fear becoming a patient Seek the best MD – not the MD on callSeek the best MD – not the MD on call Seek out high volume places for complicated surgeriesSeek out high volume places for complicated surgeries Seek out clinicians with at least 10 years experience Seek out clinicians with at least 10 years experience

(experienced but not burned out)(experienced but not burned out) Avoid hospitalization in July – new interns, medical and Avoid hospitalization in July – new interns, medical and

nursing students (now proven by research)nursing students (now proven by research)

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What is Patient SafetyWhat is Patient Safety Freedom from accidental injury through:Freedom from accidental injury through:

Systems and processesSystems and processes that decrease the that decrease the likelihood of mistakeslikelihood of mistakes

and and

Systems and processesSystems and processes that increase the that increase the likelihood of prompt identification and likelihood of prompt identification and correction of errors and mistakes before they correction of errors and mistakes before they cause harm to a patientcause harm to a patient

1313

What is High Quality Care?What is High Quality Care?

IOM defines quality as:IOM defines quality as: ““The degree to which health care services for The degree to which health care services for

individuals and populations increase the likelihood individuals and populations increase the likelihood of desired health outcomes and are consistent with of desired health outcomes and are consistent with current professional knowledge.” current professional knowledge.”

High quality High quality (evidence based)(evidence based) medicine medicine allows for variation based on patient need, not allows for variation based on patient need, not on on physicianphysician preferences (patient focused) preferences (patient focused)

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Evidence Based Care Bundles Evidence Based Care Bundles Hospital Infections are Hospital Infections are PreventablePreventable!!

FACT - 80,000 CLABIs per year, cause about 28,000 deaths

In In 103 ICUs103 ICUs in Michigan median CLABI rate per 1,000 catheter days in Michigan median CLABI rate per 1,000 catheter days declined from 2.7 to declined from 2.7 to ZEROZERO

HOW? - It’s simple Hand washing; Full Barrier precautions; Chlorhexidine use; Avoid using the femoral site; Removing unneeded catheters.

Provonost, et al. New England Journal of Medicine, Dec 28, 2006.

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IHI- 5 Million Lives Saved IHI- 5 Million Lives Saved CampaignCampaign

Interventions targeted at harm:Interventions targeted at harm: Prevent Pressure Ulcers... Prevent Pressure Ulcers... Reduce MDRO/MRSA Infections…Reduce MDRO/MRSA Infections… Prevent Harm from Medications... Prevent Harm from Medications... Deliver Evidence-Based Care for CHF, AMI, Deliver Evidence-Based Care for CHF, AMI,

Pneumonia…Pneumonia… Prevent ventilator pneumoniaPrevent ventilator pneumonia Prevent central line infectionsPrevent central line infections

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““New” Reality of US HealthcareNew” Reality of US Healthcare

Evidence Based Care – Core MeasuresEvidence Based Care – Core Measures Medicare/insuranceMedicare/insurance no longer pays for no longer pays for

defined “never events” (10/08)defined “never events” (10/08) National versus Local StandardsNational versus Local Standards Public reporting of quality data and Public reporting of quality data and

safety events - transparencysafety events - transparency AHRQ measures reported to the public - 2010AHRQ measures reported to the public - 2010

Patient Centered CarePatient Centered Care

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What is Patient Centered Care?What is Patient Centered Care?

Defined by the IOM:Defined by the IOM:

“… “…care that is respectful of care that is respectful of and responsive to individual and responsive to individual patient preferences, needs patient preferences, needs and values, and ensuring and values, and ensuring that patient values guide all that patient values guide all clinical decisions.“clinical decisions.“

New 2011 TJC StandardsNew 2011 TJC Standards

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Opportunities for ImprovementOpportunities for Improvement Communication challenged Communication challenged

Fragmented health care system Fragmented health care system Complex systems within hospitalsComplex systems within hospitals Lack of standardizationLack of standardization Hierarchies produce steep authority gradientsHierarchies produce steep authority gradients

Need better teamwork and communicationNeed better teamwork and communication Product of our successProduct of our success

Advanced technology, rapid changes Advanced technology, rapid changes Necessary knowledge exceeds limits to human capacity Necessary knowledge exceeds limits to human capacity

> 6000 meds, >4000 treatments to choose from> 6000 meds, >4000 treatments to choose from Professional craftsman model Professional craftsman model

No longer effectiveNo longer effective

2020

Professional Craftsman ModelProfessional Craftsman Model“The Old Way”“The Old Way”

Results in the ‘Perfection Myth’Results in the ‘Perfection Myth’

With extensive trainingWith extensive training Eminence based training – not Eminence based training – not

always evidence basedalways evidence based Came “special privileges” Came “special privileges”

Full autonomy= full responsibilityFull autonomy= full responsibility Creates a steep authority gradientCreates a steep authority gradient Others have been there only to Others have been there only to assistassist

the MD in the pastthe MD in the past No recognized group decision makingNo recognized group decision making

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Safety Implications Related to the Safety Implications Related to the ‘Perfection Myth’‘Perfection Myth’

Safety depends on individuals - myth Safety depends on individuals - myth Safety really depends on teamwork and communicationSafety really depends on teamwork and communication

Error is due to carelessness – mythError is due to carelessness – myth More often a system or process errorMore often a system or process error We have responded in the past with peer review, “be safer We have responded in the past with peer review, “be safer

next time”, more education, 5 rightsnext time”, more education, 5 rights Punishment results in fewer errors - myth Punishment results in fewer errors - myth

System Improvements should be the focusSystem Improvements should be the focus

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Dysfunctional Response to Error Dysfunctional Response to Error

Justification/rationalizationJustification/rationalization ““Complications happen”Complications happen” Blame the patients Blame the patients

Dishonesty with patientsDishonesty with patients Cover-up/Non-reportingCover-up/Non-reporting

Fear loss of reputationFear loss of reputation Healthcare workers look the Healthcare workers look the

other way when colleagues other way when colleagues errorerror

2323

Who Is Watching Out For Patients?Who Is Watching Out For Patients?

• 46% of physicians failed to report at least one serious medical error, even though 93% of them said they should report ALL significant medical errors they observe.

• 45% said they did not report impaired or incompetent colleague physicians even though 96% said they should

- ANNALS OF INTERNAL MEDICINE, DEC. 4, 2007

• 67% of physicians have not been involved in collaborative efforts to improve quality

– COMMONWEALTH FUND NATIONAL SURVEY OF PHYSICIANS, 2007

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A Different (Planetree) ApproachA Different (Planetree) Approach

Caring for the CaregiversCaring for the Caregivers Leadership support for safety Leadership support for safety Non-punitive reporting systemsNon-punitive reporting systems Set up systems and processes for safetySet up systems and processes for safety

Redundancy and double checksRedundancy and double checks Medication administration vs. blood transfusionMedication administration vs. blood transfusion

Standardization of processes Standardization of processes Checklists, pre-printed ordersChecklists, pre-printed orders Find out about work-aroundsFind out about work-arounds

Multidisciplinary quality committees Multidisciplinary quality committees

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Caring for the CaregiversCaring for the Caregivers

Teamwork and communication supportTeamwork and communication support Enhanced communication modelsEnhanced communication models

Robust reporting systems with feedbackRobust reporting systems with feedback Errors recognized as system failuresErrors recognized as system failures

Mutual Support – I have your backMutual Support – I have your back Nurse Residency ProgramsNurse Residency Programs Plan for and educate about limitations of Plan for and educate about limitations of

human performancehuman performance

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Plan for the ‘Human Factor’Plan for the ‘Human Factor’

Humans make mistakesHumans make mistakes Fatigue, interruptions, Fatigue, interruptions,

distractions, etcdistractions, etc Overestimate abilities, Overestimate abilities,

underestimate limitationsunderestimate limitations Goal is to keep inevitable Goal is to keep inevitable

mistakes from becoming mistakes from becoming consequential consequential

Reliable systems combined Reliable systems combined with effective communication with effective communication is best practiceis best practice

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Human LimitationsHuman Limitations

Limited memory capacity–5 to 7 pieces of Limited memory capacity–5 to 7 pieces of information in short term memoryinformation in short term memory

Negative effects of stress –increased error Negative effects of stress –increased error rates, tunnel visionrates, tunnel vision

Negative influence of fatigue Negative influence of fatigue Limited ability to multitaskLimited ability to multitask Variable judgments and perceptionsVariable judgments and perceptions

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Human Error is Inevitable Human Error is Inevitable Because:Because:

Inherent human limitationsInherent human limitations Complex, unsafe systemsComplex, unsafe systems Safety is often assumed, not assuredSafety is often assumed, not assured We count on the expert individualWe count on the expert individual ““It won’t happen to me” or “it doesn’t It won’t happen to me” or “it doesn’t

happen here” attitudehappen here” attitude

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Build on human factor skillsBuild on human factor skills Standardized (SBAR) communicationStandardized (SBAR) communication Telephone order read-backsTelephone order read-backs

Starbucks figured it outStarbucks figured it out Create redundancies, double checks Create redundancies, double checks Situational awarenessSituational awareness

Time-outs, include the patient (patient centered)Time-outs, include the patient (patient centered) Decrease interruptions Decrease interruptions

Debriefings after emergenciesDebriefings after emergencies Patient Centered focusPatient Centered focus

Bedside report including the patient/familyBedside report including the patient/family Hourly roundingHourly rounding

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A Different (Planetree) ApproachA Different (Planetree) Approach

Patient centered approachPatient centered approach Knowledge about condition and Knowledge about condition and

choiceschoices Access to medical recordsAccess to medical records Access to information – Access to information –

library/literature searcheslibrary/literature searches Health literacyHealth literacy

Care partnersCare partners Another “ear to hear”Another “ear to hear”

Patient and Family Advisory Patient and Family Advisory CouncilCouncil

Learn from their experiencesLearn from their experiences

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Planetree Planetree Patient Centered Care and SafetyPatient Centered Care and Safety

““The patient is one of the most important allies in reducing The patient is one of the most important allies in reducing medical errors.” medical errors.”

ISMP Medication Safety Alert Oct.2004ISMP Medication Safety Alert Oct.2004

““Research indicates that when patients actively participate in Research indicates that when patients actively participate in their overall healthcare management, medical errors are their overall healthcare management, medical errors are reduced.”reduced.”

ISMP Medication Safety Alert Nov. 2004ISMP Medication Safety Alert Nov. 2004

Patients who have a clear understanding of their instructions, Patients who have a clear understanding of their instructions, including how to take their medicines and when to make including how to take their medicines and when to make follow-up appointments, are 30 percent less likely to be follow-up appointments, are 30 percent less likely to be readmitted or visit the emergency departmentreadmitted or visit the emergency department

February 3, 2009, Annals of Internal MedicineFebruary 3, 2009, Annals of Internal Medicine

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Planetree Criteria Promote Planetree Criteria Promote Quality and SafetyQuality and Safety

Planetree promotes a healing partnership Planetree promotes a healing partnership between patients and caregivers.between patients and caregivers.

It’s a model of care that is committed to It’s a model of care that is committed to enhancing healthcare from the enhancing healthcare from the patient perspective.patient perspective.

Empowers caregivers to do what is right Empowers caregivers to do what is right for the patient. for the patient.

360360°° data shows us that it is working! data shows us that it is working!

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Surgical Care Improvement Surgical Care Improvement Process MeasuresProcess Measures

Valley View SCIP Perfect Care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q2 2007 Q3 2007 Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008

Q1 2009

Q2 2009

Q3 2009

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Teamwork works! Teamwork works! D-T-B times improved!D-T-B times improved!

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VVH Culture of Safety SurveyVVH Culture of Safety Survey

Survey done July 2010Survey done July 2010 Statistical improvements from 2008Statistical improvements from 2008

Standardized AHRQ surveyStandardized AHRQ survey Designed to measure 4 major areasDesigned to measure 4 major areas

Overall perceptions of safetyOverall perceptions of safety Overall patient safety gradeOverall patient safety grade Frequency of event reportingFrequency of event reporting Number of events reportedNumber of events reported

3636

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Valley View HealthgradesValley View Healthgrades™™ AwardAward

Valley View Hospital is rated Valley View Hospital is rated among the top 5% in patient among the top 5% in patient satisfaction scoressatisfaction scores

The Planetree patient The Planetree patient centered philosophy actively centered philosophy actively supports programs to meet supports programs to meet patient and family needs patient and family needs

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““What Is the Likelihood of What Is the Likelihood of Recommending This Hospital?”Recommending This Hospital?”

63%93% 96% 97%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Ranking

2000200620082010

393939

VVH and Planetree ComparisonVVH and Planetree Comparison

4040

4141

4242

Turnover Rate:Turnover Rate:All Nurses On PayrollAll Nurses On Payroll

2.70%

24.88%

20.00%

12.13%

7.35%

4.50%

0%

5%

10%

15%

20%

25%

1998 2000 2002 2003 2008 2010

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Growth in EquityGrowth in Equity

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

2004 2005 2006 2007 2008 2009

Total Net Assets

4444

Lessons learnedLessons learned

Safety and quality is not created by counting and Safety and quality is not created by counting and control measurescontrol measures We have learned that stories, complex dialogue, and We have learned that stories, complex dialogue, and

teamwork create safetyteamwork create safety We thought competent, careful clinicians were We thought competent, careful clinicians were

sufficient to create safetysufficient to create safety We have learned safety requires leadership, a supportive We have learned safety requires leadership, a supportive

environment, a system focus, and solid teamworkenvironment, a system focus, and solid teamwork Quality and patient safety are supported in a Planetree Quality and patient safety are supported in a Planetree

patient centered environment and the Planetree patient centered environment and the Planetree philosophy promotes a ‘generative’ culturephilosophy promotes a ‘generative’ culture

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How Different OrganizationalHow Different Organizational

Cultures Handle Safety InformationCultures Handle Safety Information Pathological

CultureBureaucratic

CultureGenerative

Culture

        Don’t want to know 

        May not find out

        Actively seek it

       Messengers(Whistle blowers) are shot 

       Messengers are listened to if they arrive

       Messengers are trained and rewarded

       Failure is punished or concealed 

       Failure leads to local repairs

       Failures lead to far-reaching reforms

       New ideas are actively discouraged

       New ideas often present problems

       New ideas are welcomed

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Planetree Creates Planetree Creates A Culture of Quality and SafetyA Culture of Quality and Safety

An accountable cultureAn accountable culture A culture of learningA culture of learning A culture of partnershipA culture of partnership A just cultureA just culture Mutual Trust Mutual Trust

The system trusts that you will call outThe system trusts that you will call out You must trust that the system will listenYou must trust that the system will listen