Quality & Patient Safety TOH

Quality & Patient Safety TOH

Linda Hunter Director, Quality and Patient Safety

2011

Deep River & District Hospital

Pembroke General Hospital

Renfrew Victoria Hospital

Arnprior & District Memorial Hospital

Almonte General Hospital

Carleton Place & District Hospital

Ottawa Area Hospitals - The Ottawa Hospital - Royal Ottawa - CHEO - Montfort

Hawkesbury & District General Hospital

Glengarry Memorial Hospital

Hotel Dieu HospitalCornwall General Hospital

Winchester District Memorial Hospital

Kemptville District Hospital

Perth & Smith's Falls District Hospital

St. Francis Memrial Hospital

- Queensway-Carleton Hospital - Bruyere Continuing Care

Champlain LHIN

Capacity

• ~$1B Operating Budget

• 1,172 Inpatient Beds

• 12,000 Staff

• 1,200 Physicians

The Ottawa HospitalFacts and Figures

Activity

• 46,000 Admissions

• 49,000 Surgical Cases

• 127,000 ED Visits

Patient Volumes

Service Excellence Performance Measurement

Physician Engagement & Accountability

To Become a Top 10% Performer in Quality and Patient Safety in North America

To provide each patient with the world class care, exceptional service and compassion that we

would want for our loved ones

Vision

Our Patients

Our Environment

Our Staff

Our Finances

Our Partners

Commitment to Quality

Working TogetherRespect

for the Individual Compassion

Communication & Community Outreach Plan

AccessWait Times:DI, Hip/Knee, Cancer & ED

EfficiencyALOS-ELOSCPWC

SafetyHSMRHospital Infections:MRSA, VRE & C-Difficile

Outcomes

Milestones& Tactics

Create a culture of compassionate people, world-class careCulture

EffectivenessRe-admission ratesSurg. Site Infections

SatisfactionOverallPainTransition

Patient Experience

Staff Engagement

Enabling environments

Clinical transformations

Information Services Plan

Capital Plan

Operating Plan

Human Resources Plan

Research Plan

Quality Plan

Values

Quality and Performance Measurement

• Define • Align • Prioritize• Measure• Report

Definition of Quality

Providing the patient with appropriate consistent health care in a clean and safe environment in which the patient is treated with respect.

- TOH Board, January 2003, reconfirmed 2008

Defining the Quadrants ACCESS

Patients should be able to get the right care at the right time in the right setting by the right healthcare provider (OHQC)

SAFETY Patients should not be harmed by an accident or mistakes when they receive care (OHQC)

SATISFACTIONHealth services are respectful and responsive to user needs, preferences and expectations (HQCA)

APPROPRIATEEfficient: The hospital should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information (OHQC)

Effective: Patients should receive care that achieves the expected benefit and is based on the best available scientific information (OHQC)

OHQC: Attributes of a High-Performing Health System, Ontario Health Quality Council HQCA: Quality Matrix for Health, Health Quality Council of Alberta

AlignmentWith:• TOH Strategic Direction• Best Practice• Legislation• Accreditation Recommendations • Ministry of Health Mandated Requirements• Future Trends• Others?

Corporate Quality Plan Prioritization

• Corporate in scope• Aligns with TOH mission and vision• Aligns with at least one of the following:

– Addresses issues occurring frequently or to a high volume of patients

– Addresses high risk for patient safety issues– Addresses accreditation or regulatory requirements

• High probability of impact on outcomes/process measurement/indicators

Reporting

• Scorecard• Workplan• Colour coded – green, yellow, red• Trend charts• Others

…to different end stakeholder groups

The Ottawa HospitalCorporate Quality PlanBalanced Scorecard

AccessEmergency Offload (Q)

•90th percentile CTAS 190th percentile CTAS 2-5

Emergency Access Times (Q)•% admitted ED LOS < 8 hrs•% non-admit waiting < 8 hrs for CTAS 1&2•% non-admit wait < 6 hrs, CTAS 3•% non-admit wait < 4 hrs, CTAS 4&5

Number of cancer surgeries (Q)Number of knee surgeries (Q)Number of hip surgeries (Q)Number of cataract procedures (Q)Number of hours MRI delivered (Q)Number of hours CT delivered (Q)

AppropriateEffectiveOttawa Model for Diabetes (Q)Inpatient satisfaction with pain control (Q)

•Medicine•Surgery•Obstetrics and Gynecology•Emergency Department•Rehabilitation

EfficientCost per weighted case (A)% clinical pathways revised (Q)# new clinical pathways / program (Q)

Safety

Ventilator Associated Pneumonia rate (Q)Central Line Infection rate (Q)Surgical Site Infection rate (Q)Hand Hygiene compliance rate (Q)Hip fractures receiving surgery < 48 hours (Q)C Difficile rate (Q)MRSA rate (Q)VRE rate (Q)HSMR (Q)

Satisfaction

NRC-Picker Pt Satisfaction Results (Q)•Medicine•Surgery•Obstetrics and Gynecology•Emergency Department•Same Day Surgery•Rehabilitation•Ambulatory Care

- Data currently available

A - Reported annually

Q - Reported quarterly

Infection Control Dashboard

Hand Hygiene by Unit – Selection Criteria

Statistics Table by Campus

Selection criteria for indicators:– Data is available – Data is timely– Indicator is valid and reliable– Indicator is actionable– Impact on high volume, high cost and high risk

Focus on the vital few versus the trivial many

Indicator Assumptions

Mandatory IndicatorsFor accreditation:• Percentage of patients

receiving medication reconciliation at admission

• MRSA infection rate• C. Diff infection rate• Rate of post surgical infections• Rate of timely administration of

prophylactic antibiotic

Submitted quarterly in each three year cycle

For MOH Public Reporting:• CLI rate • VAP rate• MRSA• C. Diff• VRE• SSI antibx• HH compliance• HSMR• SSCL

Submitted quarterly to annually

2010/2011 Public Reporting Indicators

Updated Jan 2011

Jun-10 Q1 Q1 Q1 Q1 Q1 Q1 Mar-10 Mar-10 FY08-09

Institution/Health Centre CampusC Diff MRSA VRE CLI VAP SSIP SSCC

HH % Before Pt.

Env.

HH % After Pt.

EnvHSMR

TOH

TOH Civic 0.46 0.03 0 1.03 2.63 91.8% 99.6% 65.26 83.4494

TOH General 0.51 0 0 1.04 4.12 98.1% 99.7% 52.12 68.92

TOH HI 0 0 0 0.52 5.54 96.6% 79.31 85.83

TOH Rehab 0 0 0 91.94 93.33

SMH SMH 0.42 0.08 0 1.98 0.74 99.5% 99.1% 33.6 56.71 83

Sunnybrook

Sunnybrook 0.23 0.02 0 0.29 5.69 92.6% 87.9% 61.03 81.61 88

Ortho 0 0 0 0 97.1% 100.0% 53.16 80.13

Hamilton Health Science Centre

McMaster 0 0.04 0 7.52 0 47.1% 61.84 78.76

92 Hamilton 0.19 0.06 0 1.22 1.61 34.4% 66.67 82.34

Henderson 0.14 0 0 0 0 100.0% 64.1% 49.21 71.16

London Health Science Centre

University 0.61 0.2 0 1.48 1.76 98.4% 62.2% 51.64 83.48

103 South St. 0 0 0

Victoria 0.63 0 0.03 2.8 0.78 81.3% 62.1% 57.65 79.91

Mt. Sinai Mt. Sinai 0.21 0.06 0 1.45 1.44 96.9% 97.2% 61.68 75.8 92

Kingston Kgn General 1.33 0.03 0 0.75 4.37 88.1% 96.0% 33.72 48.42 111

UHN

UHN General 0.72 0.03 0 1.77 4.22 76.7% 51.26 76.93

77 Western 0.31 0 0 0.71 3.77 95.5% 99.9% 37.15 65.89

Princess M 0.3 0 0 100.0% 56.26 79.83

Not Eligible

Reporting: Infection Rates

Central Line Bloodstream Infections / 1,000 Line Days

0.00.51.01.52.02.53.03.5

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Apr-

10

May-

10

Jun-1

0

Jul-10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Civic 0.00 0.00 0.00 1.54 0.00 1.63 0.00 1.40 1.92 1.63 0.00 1.51 1.68 0.00

General 2.85 1.51 1.38 0.00 0.00 0.00 3.01 0.00 0.00 2.99 1.55 0.00 0.00 0.00

Target 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

TOH 1.42 0.75 0.71 0.77 0.00 0.74 1.56 0.81 0.88 2.34 0.87 0.74 0.83 0.00

Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10

Ventilator Associated Pneumonia per 1,000 Ventilator Days

0

1

2

3

4

5

6

7

8

Civic 7.59 3.48 3.76 3.23 1.53 2.63 0.00 0.00

General 3.01 3.96 2.55 2.62 1.75 4.12 0.73 1.60

Target 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00

Jan - Mar 09 Apr - Jun 09 Jul - Sep 09 Oct - Dec 09 Jan - Mar 10 Apr - Jun 10 Jul - Sep 10 Oct - Dec 10

Reporting: Central Line Infection – Line Insertions

Hand Hygiene for CLI Insertion

97% 97%100%

96%98% 97%

73%

93%

76%71%

90% 92% 92%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11

Hand Hygiene Target

Maximal Barrier Precautions Used

5% 6%

47%

77% 73%68%

73% 76%69%

62%71%

64% 64%

0%

20%

40%

60%

80%

100%


Full barrier precautions Target

Chlorhexadine Skin Antisepsis

97% 97%98%

89%

96%

100%

94%93%

91%

98%96% 97%

100%

80%

85%

90%

95%

100%


Skin asepsis Target

Optimal Catheter Site Selection

97%100%

98% 98%95%

97%

94%

98%

91%

98% 98%97%

94%

70%

75%

80%

85%

90%

95%

100%


Optimal site selection Target

Reporting: Ventilator Associated Pneumonia

Head of Bed Elevation Over 30 Degrees

97.5%99.0% 98.2%

96.0%

100.0% 100.0%99.0% 98.3% 98.2%

100.0%

95.3%

97.7%95.8%

85%

90%

95%

100%

Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11

HOB Elevated Goal

Use of EVAC ETT

90.0%87.8%

96.4% 96.0%92.8% 94.5%

89.9% 91.7% 93.6% 94.4% 93.0%

81.4%

92.4%

60%

70%

80%

90%

100%


EVAC ETT Goal

Daily Sedation Vacation

85.0%

79.6%

94.6%

85.0%

94.8%96.7% 96.0%

92.6%94.5% 94.4% 94.2%

96.5% 96.6%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


Sedation Vacation Goal

Use of Oral vs Nasal Tubes

73.8%79.6%

92.9% 95.0% 94.8% 92.3%87.9%

92.6% 91.8% 93.1% 95.3% 95.3% 95.8%

40%

50%

60%

70%

80%

90%

100%


OG Tube Goal

Patient Safety Indicators on the Infonet

Insanity is doing the same thing over and over again and expecting a

different result.

-Albert Einstein

It’s not the data.It’s what you do with it.

Quality Monitoring

Model of a work system

Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P. Alvarado, C. J., Smith, M., and Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Healthcare, 15(Suppl I), i50-i58.

UW-Madison Systems Engineering Initiative for Patient Safety (SEIPS)

Definitions

• Patient safety is defined as the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes.

• Patient Safety Culture is defined as a commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.

(CPSI, 2008)

CPSI – The Safety CompetenciesFramework which includes 6 core domains that provide for safer patient care:

Domain 1: Contribute to a Culture of Patient SafetyDomain 2: Work in Teams for Patient SafetyDomain 3: Communicate Effectively for Patient SafetyDomain 4: Manage Safety RisksDomain 5: Optimize Human and Environmental FactorsDomain 6: Recognize, Respond to and Disclose Adverse Events

Visit CPSI – Safety Competencies www.safetycomp.ca for complete framework information.

Fostering Patient Safety Culture at TOHNeed:

• A vision of where we want to go• Senior leadership buy-in• Actions to get us there• Passionate clinicians and support staff• Accountabilities defined• An action plan to move forward

The Survey on Patient Safety Culture (AHRQ) was launched in August 2006, and offered to all staff, physicians and volunteers at TOH.

A second survey, the Patient Safety Culture in Healthcare Organizations Survey, a tool developed by Stanford and modified by York University and supported by AC was run on four TOH inpatient units the following year. Further surveys were done in 2010 and 2011.

There were six survey items where the large majority of staff members responded the same way in both surveys. (i.e. there was very little variation in responses); these include:

• Asking for help is a sign of incompetence (93% disagree)• If I make mistake, and nobody notices, I do not tell anyone (95% disagree)• I will suffer negative consequence if I report a patient safety problem (86%

disagree; 9% neutral)• I engage in unsafe practices in order to get the job done (95% disagree)• I report the errors I make (86% often/always; 11% occasionally)• I learn from errors made by my colleagues (81% often/always; 16% occasionally)

Patient Safety Culture Surveys at TOH

Develop a Culture of Safety

• Relay safety reports at shift changes• Create an adverse event respond team• Re-enact adverse events• Appoint a patient safety champion for every area/unit• Simulate possible adverse events• Involve patients in safety initiatives• Create a reporting system (PSLS)• Designate a patient safety officer• Conduct safety briefings• Provide feedback to frontline staff• Conduct patient safety walkabouts (rounds)

Comparison of Patient Safety Culture Surveys

Patient Safety Culture in Healthcare Organizations Survey (n 109)

Survey on Patient Safety Culture (n 738)

Both sets of survey results reflect staff with direct patient interaction only.

Required Organizational Practices

Adverse Event Reporting

Focus on how we can prevent and intercept errors

Statistical data that can be analyzed to determine trends

Understand and improve practices that promote a safe care environment for patients

Response

Detection

Analysis

Definitions

A reportable incident is … any unusual occurrence that is inconsistent with the routine care of a patient; or that adversely affects patients, volunteers, visitors or hospital property; or an unexpected negative treatment outcome.

e.g. falls, med errors, equipment problems, lab incidents

Injury does not have to occur for an event to be reportable (“near misses”)

More definitions

As defined in TOH Critical Incident Review Policy and in accordance with the Public Hospitals Act a “Critical Incident” means any unintended event that occurs when a patient receives treatment in the hospital:

(a) that results in death, or serious disability, injury or harm to the patient, and (b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing the treatment.

As defined in TOH Patient / Visitor Incident Reporting Policy a “Serious Incident” is one that results in a fracture, haemorrhage, aspiration, serious drug variance/reaction or death, transfer to a critical care area, increased length of stay or admission to hospital.

Patient Safety Learning System (PSLS)

Identify

Event

Report/Record

Analyze/Classify

Escalate

Causal Analysis

Corrective Action

Learn & Educate

Voluntary reportingElectronic triggers

Patient Safety Learning System

TOH Risk ManagementQuality CoordinatorsData Warehouse Department Head/Clinical ExpertsSeverity of risk or AE will determine work flow

TOH Critical Incident Policy & Procedure

Department/Function QI Internal Process

Data Warehouse AE Analysis

Safety Rounds M&M Rounds

Patient Safety Learning System

Department & Division Front Line Staff

System Improvement

Ongoing Surveillance

Disclosure Disclosure is a professional, ethical, moral and legislative requirement

“Disclosure” refers to the communication of information regarding anadverse event, adverse outcome or critical incident.

Public Hospitals Act directs that the disclosure conversation must include:

(a) the material facts of what occurred with respect to the critical incident;(b) the consequences for the patient of the critical incident, as they become known; and(c) the actions taken and recommended to be taken to address the consequences to the patient of the critical incident, including any health care or treatment that is advisable.

Documentation of the disclosure discussion is also a legislative requirement. TOH Disclosure Toolkit available

Goals of Root Cause Analysis (RCA)

To find out:• What happened• Why it happened• What can be done to reduce the likelihood of a

recurrence?

Resources: CPSI RCA Toolkit & TOH RCA Lite Toolkit

Steps of a RCA1. Determine the team2. Organize the meeting 3. Gather information and the facts of the incident

Who, What, Where, When but not the Why4. At the meeting

Review the information gathered and determine what did happen compared with what should have happened

5. Determine contributing factors and root causes Keep asking “why” until the contributing factors and root

causes are found6. Develop actions and determine performance measurements 7. Implement the actions 8. Measure and evaluate the effectiveness of the actions

Common Root Causes

Rules, Policies, Procedures, Protocols and Processes: Lack of awareness of what protocols, policies and procedures are available Lack of standardization of processes

Communication Issues: Breakdown in communication primarily at the point of transition, both

internally and externally Lack of information in the patient health record

Equipment Issues: Lack of available equipment (department specific requirements)

Staff Factors (Knowledge, skill) Incomplete & inaccurate documentation across all disciplines Lack of ongoing education related to policies, procedures and protocols

CPSI/TOH Patient Safety Culture Project

Questions?

Documents

Quality & Patient Safety TOH