Patient Safety in Times of Limited Resources

1. Patient Safety in Times of Limited Resources Don Parsons, MD Exempla Ethics Symposium September 16, 2011

2. Theme Improved patient outcomes do not require increased resources, in fact, smarter allocation may result in better outcomes. We promote ethical and rational deployment, not “rationing”.

3. Take this home with you!

4. IHI Triple Aim • Better care for individuals • Better health for populations • Lower per capita costs • www.IHI.org

5. Institute of Medicine 1999 Dr. Mark Chassin Current Chair of The Joint Commission National Quality Goals

6. What is the Problem? • Shrinking resources (politics) • Increasing demand (population and technology growth) • Doing too much • 50 million operations per year for 300 million people • 150,000 post operative deaths per year (30 days) • Half are deemed avoidable! • Exorbitant care at the end of life • Doing too little • 50 million uninsured + underinsured • Primary care provider shortage

7. The Problem? • Overtreatment • Undertreatment • Mistreatment

8. “Savior of mothers” Dr. Ignaz Semmelweis 1860 Age 42

9. Florence Nightingale “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm” 1859-Crimean War

10. Dr. Ernest Amory Codman-Surgeon Boston, 1915 "We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians."

11. Quality improvement pioneers-1950’s Dr. Joseph Juran- LEAN, 6 Sigma W. Edwards Deming

12. Don Berwick, MD, MPP Administrator CMS Founder, Institute for Healthcare Improvement www.ihi.org Professor of Pediatrics and Health Policy, Harvard Medical School and School of Public Health

13. Medical Ethics • Do Good (beneficence) • Do no harm (non-maleficence) • Autonomy (respect for the patient’s preferences) • Justice (Equitable distribution of resources) • Truth telling • Integrity—alignment of principles and behavior • Compassion

14. Framework: What should we do? • Dr. Mark Chassin: Three kinds of treatments • Those we know are beneficial • Those we know (or should know) are not beneficial • Those where we lack effectiveness information • Apply beneficial treatments • Withhold non-beneficial treatments • Study those lacking in information

15. Cost of Adverse Events Event Cost • Health Care Acquired Infections • Intensive Care/Cardiac Care adverse events • Medicare Readmissions within 30 days (AMI, CHF, Pneumonia) = 25% • 1.7 million per year* • 99,000 deaths • $3961/$3857 = $1.5 mm/yr • Large tertiary care urban hospital 108 patients (20%) • $26 bb/yr *estimated, no reporting requirement in most states, except total knees and hips

16. Never (Ever) Events (1) • Category 1 – Health Care-Acquired Conditions (For Any Inpatient Hospitals Settings in Medicaid) • Foreign Object Retained After Surgery • Air Embolism • Blood Incompatibility • Stage III and IV Pressure Ulcers • Falls and Trauma; including Fractures, Dislocations, Intracranial Injuries , Crushing Injuries, Burns, Electric Shock

17. Never (Ever) Events (2) • Catheter-Associated Urinary Tract Infection (UTI) • Vascular Catheter-Associated Infection • Manifestations of Poor Glycemic Control; including:Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary  Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity

18. Never (Ever) Events (3) • Surgical Site Infection Following: • Coronary Artery Bypass Graft (CABG) - Mediastinitis • Bariatric Surgery; including Laparoscopic Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery • Orthopedic Procedures; including Spine, Neck, Shoulder, Elbow • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Total Knee Replacement or Hip Replacement

19. Never (Ever) Events (4) • Category 2 – Other Provider Preventable Conditions (For Any Health Care Setting) • Wrong Surgical or other invasive procedure performed on a patient • Surgical or other invasive procedure performed on the wrong body part • Surgical or other invasive procedure performed on the wrong patient

20. Colorado Foundation for Medical Care CMS Initiative August 30, 2011 • Healthcare Acquired Infections (a top 10 leading cause of death in the US)-100,000 deaths/year • HHS National Quality Strategy-Partnership for Patients • Better health care for individuals • Better health for people and communities • Affordable care through lowering costs by improvement • Statewide Learning and Action Network • Voluntary participation by hospitals

21. CFMC Initiative • Catheter Associated Urinary Tract Infections • Surgical Site Infections • Clostridium Difficile Infections “Commitment to support and actively participate in identifying and implementing system changes that will lead to significant and sustainable improvement in your hospital”

22. Dr. Atul Gawande Surgeon at Brigham and Women’s, Boston WHO Surgical Checklist—average reduction in deaths: 46%, could save $25bb/year!! The Checklist Manifesto: How to Get Things Right, 2009

23. Success Stories • Denver Health—visited 2 months ago by Kathleen Sebelius (HHS) and Don Berwick (CMS) • Large public hospital system • Applied the LEAN training and techniques for system improvement • Saved many millions of $$ and many hundreds of lives • If a public hospital can do it, why not all?

24. Success Stories (2) • Michigan intensive care units average ZERO catheter-related infections per quarter since implementing the Johns Hopkins 5-step checklist in 2009; the worst in the state has had a 90% reduction in CLABSI • Shift in power—nurse (patient/family) questions doctor: team medicine = Culture Change

25. Call to Action • Hand Hygiene (and clean other things, too) • Checklists • Less talk about tort reform and more about prevention of bad outcomes! • Do what we know works; don’t do what we know is harmful; study all the rest

26. Call to Action Patient and Family empowerment • Informed Consent • Patient and Family voices on key health care committees • Patients and family are members of the team • Advocates for policy (e.g. The Michael Skolnick Act)

27. Call to Action Communicate • Aviation Crew Resource Management • Electronic Health Records/health information exchange (CORHIO) • Decision Support (Watson) • Collect data/ empower front line/improve performance • Transitions of Care (10% of all admissions) • Teams (including patients/significant others)

28. Call to Action • Ethical behavior at all times (compassion) • Hold all parties accountable • Providers for building safer and better systems • Patients for investing in healthy behavior • www. 3four50.org • Become informed • Educators for training primary care providers • Insurers for improving care, lowering costs • All of us for hand hygiene; make Ignaz and Florence happy!

29. Call to Action • Finally, lets do lots of Comparative Effectiveness Research as mandated in PPACA (Health Reform) so we will someday know what works and what does not • Intracranial artery stents do not work (new study) • Add to that Comparative Benefit Analysis , so we know who derives benefit from what we do • Are we always better with high tech or expensive technology? How do we change the culture? • Reallocation • Selective use

30. Primum Non Nocere • Challenge status quo values • More is better • High tech is better than low tech • The hospital is where care should be delivered • Fault based error reporting (blame/shame) as opposed to errors as opportunities for improvement of systems • “Problems are opportunities in work clothes”—Henry J. Kaiser • Learn from others’ best practices

31. Questions? Comments?