Improving Quality & Patient Safety

1. Improving Quality & Patient Safety Evidence Based Order Sets An effective solution to the complex challenge of improving patient care and safety

2. Experimental Design, Data Collection, AnalysisChris O’Connor MD, Neill KJ Adhikari MD CM MSc, Katharine DeCaire RN MN ACNP, Jan O Friedrich MD DPhil Order Set Committee Chris O’Connor, Katharine DeCaire, Zelia Campos, Bruce Tugwood, Pam Johnson, Allan Mills, Vera Jovanovic, Catherine Scaletta

3. Outline • Current Context: The Need for Order Sets • Order Sets A Clinical Decision Support Tool • Order Sets Improving Care at Trillium • Order Set Advantages • Order Set Challenges • Trillium’s Order Set Innovation • Open Source Order Set Project

4. Current Context: The Need for Order Sets

5. Modern Case Presentation • 67 year old female • Past Medical History: • High Blood Pressure, Diabetes • History of Present illness: Presents to Emergency Room with severe pneumonia. • Patient is unable to breathe on her own and is intubated. • She is transferred to the Intensive Care Unit for her medical care

6. Antibiotic treatment- fast Activated Protein C Early goal directed fluid therapy DVT prophylaxis Early feeding Low tidal volume ventilation Steroids Pepcid to prevent GI bleeding Strict glycemic control Communicate with and support patient family Proper sedation/pain relief Correct electrolytes Elevate the head of the bed Bowel routine Mouth care Ongoing investigations Modern Case Treatments

11. Context:Massive Gap Between the Possible and the Actual • Quality • Misuse, under use, overuse on a massive scale: Crossing the Quality Chasm 2001 • Safety • Medical error is common: Institute Of Medicine Report on Error 2000 • Variation in Care • Variability in care not explained by patient preferences or different disease patterns: British Medical Journal 2002; 325: 961-964

12. Context:The Canadian Adverse Events Study G. Ross Baker et al, CMAJ May 25 2004 170(11) • The adverse event (AE) rate due to health care management was 7.5% • The AE rate of preventable events was 2.8% • The rate of deaths from preventable AEs was 0.66% • This would mean between 9200 and 23750 deaths/yr in Canada

13. Context: Gaps in the Care of Patients Admitted to Hospital with an Exacerbation of Chronic Obstructive Pulmonary Disease Edward Etchells et al, CMAJ April 27, 2004; 170 (9) • 84% had at least 1 inpatient gap in care • 15% patients with 3 or more gaps in their care, • 15% an inpatient adverse event • 2 of the 16 pts with adverse events died • longer stays 16.4 v. 8.6 days if a pt had an adverse event • Patients who had an inpatient adverse event had more gaps in their care 2.0 v. 1.3 gaps

14. Where do we go from here? • Traditional Methods to Change Clinician Behavior • Written Materials/guidelines • Audit and Feedback • Academic Detailing • Local Opinion Leaders • Zero to moderate effectiveness at best • Not scaleable • Limited Scope • Not durable

15. Solution: Order Sets a Clinical Decision Support Tool • A group of orders with a common functional purpose used by the physician to create orders. • Integrates knowledge into the care delivery process “knowledge where the clinician needs it most” • Organizes clinical knowledge so it is easy to remember, easy to use and has maximum benefit to the patient • Contain evidence-based best practices • Source of education • Can be used in paper or computerized ordering systems

16. Trillium Health Centre 2006

17. Trillium Health Centre 2006

18. Trillium Health Centre 2006

19. Order Sets: Key Benefits • Safety • Reduced transcription errors • Reduced errors of omission • Reduced errors in medication dosing • Quality • Improved compliance with evidence-based best practices • Standardization of care • Efficiency • Decreased time to write and process orders • Reduction in physician call-backs • Reduction in missed orders • Critical enabler for computerized practitioner order entry

20. Order Sets: Improving Care

22. Data Collection • Primary outcome DVT Prophylaxis Rates: • Random Chart audit from three time periods • October-November 2003 • April – December 2004 • February – March 2005 • DVT prophylaxis rates in the Department of Medicine • April 2003 to March 2005 • Secondary Outcomes: Assess in second chart period • Multiple Quality metrics assessed.

23. DVT:The Preventable Epidemic • DVT is the formation of blood clots in the legs • DVT is very common in hospitalized patients • DVT can cause death or serious disability • There is excellent treatment to prevent DVT if patients get it • Many studies have shown that many patients do not get this treatment which can save their lives “The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis” - S. GoldHaber, Associate Professor Harvard Medical School, 2003 • The order sets contained a section with treatment to prevent DVT

34. The Order Set Advantage Addresses the challenges facing medicine today: • Scalable • Durable • Broad Scope • No significant process redesign to implement • No significant education • Work in line with ordering process augmentingphysician knowledge • Preserve autonomy

35. The Order Set Challenge

36. The Order Set Challenge Order Sets Must Be: • Current • Evidence Based and Best Practice • Authoritative • Easy to Use • Comprehensive • Reliable and safe • Clinically Intelligent

37. The Order Set Challenge Order Sets are Complex! • Typical medical admission order set has 130 order elements in the set • Interdisciplinary • Multiproccess • Integration with other care documents and activities • Over 400 different order sets for a typical hospital • Standardization, integration across systems is critical

38. Current Status of Order Sets

39. Current Status of Order Sets • Lack of Recognition of Order Set Importance • Order Set Design • Often no standardized structure • Structure is not modular • Lack of integration with other processes/documents • Order set life cycle not well established • No dedicated Order Set Committee at most hospitals • Most often P+T/MAC based process, occasionally process is distributed to the level of the health systems • Best practices often not scaled across departments • Lack of version control • No measurement of metrics • Each hospital has its own structure and approach to order sets

40. Current Status of Order Sets • No good library of content • No standardization of format, content or processes between organizations • Limited ability to share order set content between organizations • Each Organization must create its own order set project • Duplication of effort • Reduced quality • Slow implementation of best practices • Consumption of limited hospital resources • Organization may lack content expertise in all the subject areas need for order sets • Organization may lack knowledge of order set best practices in design and order set lifecycle • External resources for order sets currently are very limited

41. Order Set Innovation

42. Trillium’s Order Set Project • 2001: Order set development begins in ICU • Rapid Cycle improvement of order set design • 2002: Order set development in other departments • 2003: Standardized order set format established • 2004: Current Order Set Committee established • 2006: Standardized order sets in use in every Health System • Over 250 order sets currently in use • Admission order set use > 90% in most health systems

43. Trillium Order Set Project • Winner of the first Ministry of Health award for Innovation in Patient Safety and Quality • Expanded Commitment to Order Set Development and Implementation • Order Set Project now has six dedicated FTEs • Goal of expanding content by over 400 order sets in the next year • Preparation for CPOE. Order sets developed for use in current paper ordering environment and in CPOE system

44. Trillium Order Set Innovation • Excellence in Order Set Design • 5 years of iterative improvement in order set design • Integration of real world feedback • Intelligent knowledge representation to increase usability and clinical impact • Order Set Process • Real time integration of authoritative content expertise into order sets • Dedicated Interdisciplinary Order Set Committee • 9 member committee that meets weekly • Clearly established processes for all aspects of the order set lifecycle – initiation, development, approval implementation and maintenance • Integration of order sets with other processes and documents

45. Trillium Order Set Innovation • Order Set Content • Over 250 order sets developed • Order sets used in every health system • Content is interdisciplinary addressing all aspects of a patient’s care • Web enabled searchable data base of all clinical decision support tools • Interdisciplinary development teams • Content experts own the content • Order set committee provide process knowledge

46. Open Source Order Sets • Based on Trilliums award winning Order Set Project • Dedicated to improving healthcare in Canada by facilitating the use of high quality, standardized evidence based order sets • Partnering with other Health Care Organizations to standardize and improve the quality and safety of patient care • Niagara Health System • Open Source Order Sets • Provide a complete order set solution • Save organizations time, money and reduce demand on limited organizational resources • Improve quality • Local ownership and adaptation of tools

47. Open Source Order Sets • Standardized Order Set Design • Standardized structure to order set content based on DAVID • Rules of correct formatting at all levels of order set content • Clear syntax of order set content • Designed to anticipate CPOE • Modular Format • Best practices are contained in functional groups • Facilitates the spreading of best practices across different order sets and across health systems • Over 300 modules including many high value best practice modules such as deep vein thrombosis prophylaxis, bowel care, pain control, electrolyte management • Order Set Lifecycle • Order Set Committee • Interdisciplinary membership • Robust methodology for development, approval, implementation and maintenance

48. Open Source Order Sets • Large Library of Developed Content • Over 250 order sets and clinical protocols • Comprehensive interdisciplinary content • Incorporation of real world experience • Will grow to over 600 order sets in the next year • Order Set Web Page • Web accessible data base to store library of order set content • Order sets clearly organized, searchable by many different criteria and relationships between order sets and clinical protocols clearly established • Order Set Project Support • On-site and remote support including physician, nursing, pharmacy • Goal is rapid knowledge transfer

49. Order Set Project Outline • Establish an Order Set Committee • Best practices around order set lifecycle • Catalogue and upgrade legacy order set content • Convert to standardized modular format • Integrate new best practice content as appropriate • Standardization of best practices across the organization • Approval of new and upgraded order sets by the Order Set Committee • Develop and Implement Order Sets • Utilization of library of best practice content • Adapt Open Source Order Sets to local health system needs • New sets developed by content experts at Grey Bruce • Comprehensive communication plan to facilitate adoption

50. Order Set Project Outline • Store order sets on an intranet accessible database • Collection of data for metrics • The measurement of improved outcomes is an important part of an order set project • Order sets can have a dramatic impact on easily measured quality metrics in a very short time period • Open Source Order Sets will work with you to select the key metrics that can be used to evaluate your project • Number of order sets in use • Order set adoption • Adherence to best practices • Before/after, cross-sectional analysis