Upload
bennett-bryce-webb
View
219
Download
1
Tags:
Embed Size (px)
Citation preview
Patient Safety Matters Matters
MattersMatters Challenges and Opportunities
2006
San Antonio 2005
11th European Forum 2006. Prague.
WONCAWONCAAHRQResource Center
How we see and deal with these matters And why are others Interested in our work?
We are aboutWe are aboutPlacing Patient Safety at Placing Patient Safety at
the of Medical the of Medical EducationEducation
andandPracticePractice
CONTENT OF THIS AND THE OTHER THREE CONTENT OF THIS AND THE OTHER THREE PRESENTATIONSPRESENTATIONS
•Our Mission, Driving principles, Premises, and Implications•The Burden of Lack of Safety on the Nation
•The Opportunity
•Our approach to lightening the Burden
Main Areas of our Activity Education/training Safety Practice Enhancement Formation of Culture & TRM
Co
vere
d i
n t
he
oth
er t
hre
e p
rese
nta
tio
ns
Covered in this presentation
Our Innovative Approaches
•Culture of safety
Singh: April 2005
Current Situation
Singh: April 2005
FearFear
Kill the messenger(denial; shift the blame)
Filter the data(game the system)
Micromanage(Barking up the wrong tree)
Scherkenbach’s Cycle of Fear, 1991
1
Current Strategies for identifying safety problems:
Error reports• Can provide rich information• Under-reporting is the norm• Gradual shift towards a culture of safety will help
improve rates of reporting• Promising work is being done in this area
• Errors reports are a valuable source of info but do not yet provide the whole picture
© Gurdev Singh 2007
2
Current Strategies for identifying safety problems:
Practice Profiles• Many physicians ignore them• Disregard uniqueness of individual practices• A cause of division between ‘winners’ and ‘losers’ • A cause of poor morale
Audits• Useful, objective way of measuring performance• Most are based on documentation – a limited view• Tend to focus on a specific area
© Gurdev Singh 2007
Need for Change in Strategy
SS
© Gurdev Singh 2007
Various Various (overlapping)(overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety are:for Improving in Patient Safety are:
Punitive action directed against individualsPunitive action directed against individuals
Avoid
© Gurdev Singh 2007
Punitive action directed against individualsPunitive action directed against individuals
Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.
Can help considerably
Various (Various (overlapping)overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety are:for Improving in Patient Safety are:
© Gurdev Singh 2007
Punitive action directed against individualsPunitive action directed against individuals
Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.Process RedesignProcess Redesign
Helps even more
Various Various (overlapping)(overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety for Improving in Patient Safety
are:are:
© Gurdev Singh 2007
Punitive action directed against individualsPunitive action directed against individuals
Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.Process RedesignProcess RedesignTechnical and Technological Technical and Technological
System EnhancementSystem Enhancement
These lead to significant
improvements
Various Various (overlapping)(overlapping) Possible Strategies Possible Strategies for Improving in Patient Safety are:for Improving in Patient Safety are:
© Gurdev Singh 2007
Punitive action directed against individualsPunitive action directed against individuals
Counseling and retraining Staff/Pt.Counseling and retraining Staff/Pt.Process RedesignProcess RedesignTechnical and Technological Technical and Technological
System EnhancementSystem EnhancementCultural ChangesCultural Changes
These are the most effective
andsustainable
and theyaugment the above
four
Various (Various (overlapping)overlapping) Possible Possible Strategies for Improving in Patient Strategies for Improving in Patient
Safety are:Safety are:
© Gurdev Singh 2007
Scherkenback’s Cycle of Fear, 1991
Culture of SafetyCulture of SafetyWill helpWill help
break this Cycle break this Cycle
withwith
Self-empowered Self-empowered and and
Self-motivated Self-motivated teamsteams
Kill the messenger
(denial; shift the blame)
Filter t
he data
(gam
e the syste
m)
Micromanage
(bark at the wrong tree)
© Gurdev Singh 2007
© Gurdev Singh 2007© Gurdev Singh 2007
So how do we form
theSafety
Culture ?
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared Common vision
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision Make SAFETY Leadership’s Priority and every ones’
responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision Make SAFETY Leadership’s
Priority and every ones’responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors
visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision
Make SAFETY Leadership’s Priority and every ones’
responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision
Make SAFETY Leadership’s Priority and every ones’
responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)Create Non-hierarchical Teams; built on mutual respect, trust, collaboration, cooperation
and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision Make SAFETY Leadership’s
Priority and every ones’responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)
Create Non-hierarchical
Teams; built on mutual respect, trust, collaboration, cooperation
and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.
Facilitate Accurate and Timely Information
e.g exploiting relational databases and decision support systems for safe healthcare with particular
attention to care transitions
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision
Make SAFETY Leadership’s Priority and every ones’
responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)
Create Non-hierarchical
Teams; built on mutual respect, trust, collaboration, cooperation
and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.
Facilitate Accurate and Timely Information
e.g exploiting relational databases and decision support systems for safe healthcare with particular
attention to care transitions
Create Learning Environment in which error reporting (preferably voluntary) is non-punitive, confidential and accessible to all staff and patients with no restrictions on format
© Gurdev Singh 2007© Gurdev Singh 2007
Create Learning Environment in which error reporting (preferably voluntary) is non-punitive,
confidential and accessible to all staff and patients with no restrictions on format
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision Make SAFETY Leadership’s
Priority and every ones’responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)
Create Non-hierarchical
Teams; built on mutual respect, trust, collaboration, cooperation
and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.
Create Awareness of the Value of Quality that
leads to patient and staff job satisfaction, that energizes and
empowers the workers to improve Quality, leading ultimately to
increased profitability (i.e. use Humanistic approach to safety
management)
Facilitate Accurate and Timely Information
e.g exploiting relational databases and decision support systems for safe healthcare with particular
attention to care transitions
© Gurdev Singh 2007© Gurdev Singh 2007
Framework of Interactive Contributors to the Construct of Culture of Patient Safety
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision Make SAFETY Leadership’s Priority and every ones’
responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)Create Non-hierarchical
Teams; built on mutual respect, trust, collaboration, cooperation
and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.
Create Awareness of the Value of Quality that leads to patient and staff job
satisfaction, that energizes andempowers the workers to improve
quality leading ultimately to increased profitability (i.e. use Humanistic approach to safety
management)
Create Learning Environment in which error reporting (preferably voluntary) is non-punitive,
confidential and accessible to all staff and patients with no restrictions on format
Facilitate Accurate and Timely Information
e.g exploiting relational databases and decision support systems for safe healthcare with particular
attention to care transitions
© Gurdev Singh 2007
© Gurdev Singh 2007© Gurdev Singh 2007
Adopt Systems (Holistic)Approach: Address
fragmentation and decentralization to capture
and understand
complexity of the system,to create a shared
Common vision
Make SAFETY Leadership’s Priority and every ones’
responsibility. Provide adequate and competent human resources
and develop procedures for identifyingand dealing with unsafe practices, and provide resources for analysis
and system redesign
Design the System for Recovery, making errors visible and detectable, making it hard to carry out irreversible
actions but easy to reverse inadvertent actions, as well
as building barriers and redundancies
Adopt Proactive Approach by adopting
prospective tools of systems analysis (FMEA ) and exploiting
technology (e.g. EMR with inductive and deductive decision
support systems)Create Non-hierarchical
Teams; built on mutual respect, trust, collaboration, cooperation
and clear delegation of responsibility as well as incentive to use initiative for unforeseen situations with minimum stress.
Create Awareness of the Value of Quality that leads to patient and staff job
satisfaction, that energizes andempowers the workers to improve
quality leading ultimately to increased profitability (i.e. use Humanistic approach to safety
management)
Create Learning Environment in which error reporting (preferably voluntary) is non-punitive,
confidential and accessible to all staff and patients with no restrictions on format
Facilitate Accurate and Timely Information
e.g exploiting relational databases and decision support systems for safe healthcare with particular
attention to care transitions
Manifestation ofSafety Climate:Expressing itself in
Measurable Attitudes
and Perceptions
Framework of Interactive Contributors to the Construct of Culture of Patient Safety: Manifesting as Safety Climate, which Expresses itself (partly) in Measurable Attitudes and
Perceptions with Numerous Cybernetic loops with the Culture.© Gurdev Singh 2007
That is all very well but we have limited $$$$$
G and R Singh 2008
TRM/crm
P4P
P a y e r
Empowered ProvidersForm Self-empowered and
Motivated Team•Receptive to external data
•Provides preparedness for P4P•It is prospective
•Internal measurements – privacy•Makes info. useful at the point of care
•Patient centered•Forms culture of Safety/Quality
•Cost effective quality improvement •Can improves patient satisfaction
•Increase clinician satisfaction•Provides change management tools
•May reduce malpractice•….
Resistant ProvidersNot enthusiastic
•Resistance to external data•Resistance to change
•Culture of blame•Avoidance of high-risk patients
•Concern with ‘indicators’•Unintended –ve consequences
•May undermine wholesome/multi- disciplinary approach•Compromises Clinician-Patient
Relation•May not address co-morbidities
•……
Top Down
Bottom Up
Large proportion of all the organizations (outside H.Care)that were earlier adopters of P4P have already dropped it !
The four laws of economic incentives Top Down
1. Salary Do as little as possible for as few people as possible
2. Capitation Do as little as possible for as many people as possible
3. FFS Do as much as possible, whether or not it helps the patient
4. Quality p4p Carry out a limited range of highly commendable$$tasks, but nothing else
$$$$$$$$$$$
From Martin Rowland Singh: April 2005
The Transcendent Law of economic incentive:Bottom Up
Create Adaptive Practices with Self-empowered and
Self-motivated Teams Embedded in a Culture of Safety
This approach has received AHRQ support (R21 and R18) Singh 2005
Affordable Excellence in Quality
Why not ask them what they see?
ALL workers“Swimming in the Water”
can each see various partsat various times
Humanistic=Pursuit ofExcellence
95%
5%
Co
mp
/Su
pp
lem
enta
ry
REPORTSPROFILES
AUDITS=Mechanistic
Let us adopt an eclectic approach
This is
Team Resource Management(=CRM)
This is Prospective
• Treat each ‘practice/setting’ as a unique micro-system to help it thrive; through trust, mutual respect and collaboration between all ‘agents’ (“strange attractors” that produce order in disorder/uncertainty).
• Culture of safety has to be established that encourages empowerment, ownership, and raises morale–shift from blame culture.
G and R Singh
Proposed cyclical approach:
1. Assess/MeasureBaseline
Safety state
2. IdentifyMost significant
System Problems-
Overall view of methodology for safety improvement(based on FMEA)
3. Establish team based feasible
solutions to prioritized hazards
4. Implement team based solutions
A, G and R Singh
acc
ess
Assessment
Plan
Implementation
Review& Learn
1A
1P
1I1F
1RPATIENTBeliefsPreferencesFamily, FriendsCommunity
1: Office
Feedback
Macro-System of Primary Care Office Domain
Based on understanding of:
G and R Singh 2001
Medication Management Micro-system
Patient/Caregiver
Script
Office
Patient/Caregiver Medication
Home
Pharmacist
Patient/Caregiver
Pharmacy
Nurse
Doc
Recept.
Lab
Phone/Fax
Chart
and understanding of:
Int. to
H.
Org.
0
100
1stQtr
3rdQtr
Assessment
Plan
Implementation
Macro-System
Feedback
Review &Learn
Chart/EMR
Micro-System
SEMI-P Instrument
R & G Singh: Jan. 2003
Anonymous Error Survey Example page
Hazard Matrix
1002420.50Severe (=100%)
204.800.400.10Moderate (=20%)
51.200.100.03Mild(=5%)
10.240.020.01Minimal (=1%)
FrequentOccasionalUncommonRemoteSeverity (s)
Probability (p)
G and R Singh
1. Assess/MeasureBaseline
Safety state
2. IdentifyMost significant
System Problems-
Overall view of Methodology for Safety Enhancement
3. Establish team based feasible
solutions to prioritized hazards
4. Implement team based solutions
G and R Singh
Prioritization
Prioritization is Based on HAZARD RATINGHazard = Probability x Severity
h = p x s
The survey yields qualitative perceptions of probability and severity – these must first be converted to quantitative data:
PROBABILITY (p): its numerical value was derived from the descriptive perception by taking into account the number of patients seen in the corresponding descriptive period
SEVERITY (s): its numerical value was obtained by adopting a risk aversive attitude
-
2. IdentifyMost significantSystem Problems
2
G and R Singh
Results2. IdentifyMost significantSystem Problems
-
All the compiled results and analysis from the first step were circulated to all the staff. Sample :
8.54Doesn’t provide accurate info about meds taken
11.37Delay in seeking medical attention
13.13Masks symptoms by inappropriate self-treatmentPatient
(Assessment)
2.04Reading from wrong chart
3.53Incomplete/not-updated chart
3.90Failure to update chart adequatelyNurse-Chart
Interaction
1.67Inadequate patient education about disease
1.74Inadequate patient education about treatment
1.81Misunderstanding b/c patient in a hurryNurse-Patient
Interaction
1.38Not using available resources for help
3.05Nurse fatigued, stressed, ill
10.95Nurse in a hurry
Nurse
1.71Receptionist fatigued, stressed, ill
2.10Long wait in office
2.33Misfiled Record
Reception
Mean Hazard Score
ItemArea
2
G and R Singh
0
10
20
30
40
50
60
70
80
90
100
Severe Moderate Mild Minimal
Qualitative Severity of Consequence
Qua
ntita
tive
Sev
erity
of
Con
sequ
ence Risk Preferring
Indifference to risk
Risk Averse adopted
Very high risk aversiveness
Conversion of descriptive/qualitative to quantitative values of severity ‘s’
G and R Singh
e.g.ResultsS
SFollowing the initiation of this onFollowing the initiation of this on--going process, a number of going process, a number of
other quality improvement interventions have been designed other quality improvement interventions have been designed and implemented that are not directly related to the Survey and implemented that are not directly related to the Survey results, but may results, but may reflect a shift in the Culture and a greater reflect a shift in the Culture and a greater awareness of the importance of medical errorsawareness of the importance of medical errors. Examples of . Examples of some of these quality improvement measures include:some of these quality improvement measures include:
• The development of a look up table for drawing up doses of parenteral Morphine.
• Better tracking of patients receiving Coumadin therapy, and their blood test results.
• Revision to the policy on Administration of Medications and Immunizations by nursing staff
• Revisions to the Medication Refill Policy and a change in the format of the Medication List kept in the chart to improve its clarity..
4. Implementation of Team-based solutions
-4
G and R Singh
e.g. Results 3. Establish team-based feasible
solutions to prioritized hazards
In subsequent weeks the team devised feasible solutions to hazards identified in THEIR practiceincorporating proven safety principles and practices
Description of the solutions to hazards in First Priority list follows:
1. Patient delays seeking medical attention / masks signs by inappropriate self-treatment.A plan was made for the Medical staff to create patient educationmaterials that can be included in New Patient introductory materials, and also can be handed to specific patients at the discretion of the providers.Specifically it was decided to focus on the problem of patients delaying seeking attention or inappropriately self treating Chest Pain(that might represent an acute cardiac event) and Neurological symptoms (that might represent a stroke).
3
G and R Singh
Results3. Establish team-
based feasible solutions to
prioritized hazards
Cont..
Description of the solutions to hazards in First Priority list follows:
3. Nurse Provider Interaction: Misunderstanding because nurse in a hurry:Two solutions were devised. Firstly, the Providers agreed to utilize a Flag system (which was already in place outside each exam room) which allows them to alert the Nurse that there are Orders for the Nurse to carry out. Secondly, the providers agreed to always give orders in a written form so as to avoid misunderstandings and potential errors.
3
G and R Singh
G and R Singh 2004
0
100
1stQtr
3rdQtr
Assessment
Plan
Implementation
Macro-System
Feedback
Review &Learn
SEMI-P Instrument
Chart/EMR
Micro-System
SEMI-P InstrumentSEMI-P Instrument
Informed by important safety principles, Informed by important safety principles, strategies andstrategies and
equipment featuresequipment features
CO
ST
CO
ST
LOW SAFETY
HIGH SAFETY
DECREASING RISK/HAZARD RATINGn
Hazard Rating of the System = severity of consequence (S) x probability of occurrence (P)0
n n n
= (S) x (P) = Hazard Factor = HF; where n is the number of entities and processeso o o
INTERPLAY BETWEEN SAFETY-BASED QUALITY AND COSTS IN THE WHOLE SYSTEM UNDER STUDY
OBJECTIVE
TOTAL COST = Cp + Cs
Cs = Costs of safety investments and maintenance of the system
Cp = Tangible and intangible costs of harm to patients andstaff in the system
Achieved through
prioritized cost-effective interventions in the system
Achieved through communication, patient education and stress management
G and R Singh
PREMISEPREMISE
Office Staff “Swimming in the Water”
can each see various partsat various times
REPORTS
PLUSREPORTS
PLUS
Survey of Errors and Consequences Leads toSurvey of Errors and Consequences Leads toThe Design of Targeted Interventions by the The Design of Targeted Interventions by the
Energized Self Empowered Clinic TeamEnergized Self Empowered Clinic Team
Why not ask them what they see?
Error Reportsare the
Tip of the IcebergThey allow us to look at the tip in great detail
Supported by the US AHRQ
Enabled by HIT
Our past experiences with
this methodology
•FM Practices•Post-operative pain management
•Falls management•SNF
SS
G and R Singh
Our experience with this approach:Our experience with this approach:• Filling out the survey:Filling out the survey:
– Helps make everyone more aware / conscious of problemsHelps make everyone more aware / conscious of problems– Helps make people more safety consciousHelps make people more safety conscious
• Seeing the results:Seeing the results:– Helps people to see other peoples’ perspectivesHelps people to see other peoples’ perspectives– Helps in identifying priorities for improvementHelps in identifying priorities for improvement
R & G Singh: Aug. 2002
Advantages of this Humanistic Advantages of this Humanistic Approach:Approach:
• Creates awareness among the staff of the Creates awareness among the staff of the value of qualityvalue of quality• Leads to improvement in patient and staff Leads to improvement in patient and staff satisfactionsatisfaction• Energizes the empowered workers to maintain and continually Energizes the empowered workers to maintain and continually
improve qualityimprove quality• Has potential to reduceHas potential to reduce litigation litigation• Can lead ultimately to Can lead ultimately to increased profitabilityincreased profitability..
Findings of Strategic Planning InstituteFindings of Strategic Planning Institute “ “Relative perceived service quality”Relative perceived service quality”
R & G Singh: Aug. 2002
FORTUNE June, 2006
FOR
About 2 trillion
Likely to provide the biggest
Our Aspiration
Transfer approach across all the domains