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Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar: Creating Transparency, Openness, and Impr

Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar: Creating Transparency, Openness, and Improved Safety (Safe Practices 5-8) Hosted by NQF and TMIT. Attendee dial-in instructions: Toll-free Call-in number (US/Canada): 1- 866-764-6260

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Welcome to the NQF Safe Practices for Better Healthcare 2009 Update Webinar: Creating Transparency, Openness, and Impr

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  1. Welcome to the • NQF Safe Practices for Better Healthcare • 2009 Update Webinar: • Creating Transparency, Openness, • and Improved Safety • (Safe Practices 5-8) • Hosted by NQF and TMIT Attendee dial-in instructions: Toll-free Call-in number (US/Canada): 1-866-764-6260 (direct number, no code needed) To join the online webinar, go to: www.safetyleaders.org Online Access Password: Webinar1 (case-sensitive)

  2. Welcome and Safe Practice Overview Charles Denham, MD Chairman, TMIT; Co-chairman, NQF Safe Practices Consensus Committee; Chairman, Leapfrog Safe Practices Program Safe Practices Webinar October 22, 2009 Toll-free Call-in number: 1-866-764-6260

  3. Panelists Timothy McDonald Lucian Leape Peter Angood Charles Denham Charles Denham: Welcome and Safe Practice Overview Timothy McDonald: Looking Forward: Principles Applied Lucian Leape: Looking Back: Lessons Learned Peter Angood: The National Quality Forum Perspective Rebecca Martins: Opportunities for Patient and Family Involvement Rebecca Martins Toll-free Call-in number: 1-866-764-6260

  4. Changes of 2006 Version to 2009 Update Final Report: • Format Structure Preserved • Lightly Edited Text of Most Practices • New Practices • Updated References • Corrections and Clarification • Care Setting Clarification Using CMS Classification • Measures To Be Considered (in formulation) • Soft Copy Document Hyperlinks • Crosswalk Tables • Glossary Practice Line-Up Changes: • From 30 to 34 Practices • Culture Practice Elements Broken Up into 4 Practices • 2 Practices Discontinued • 4 Medication Management Practices Combined into 1 • 2 Communication Practices Combined into 1 • 8 New Practices Added • CMS Care Settings Defined • Patient and Family Involvement Section Added

  5. Toll-free Call-in number: 1-866-764-6260

  6. Harmonization – The Quality Choir 11 Toll-free Call-in number: 1-866-764-6260

  7. Culture Consent & Disclosure Consent and Disclosure Workforce Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices 12 Toll-free Call-in number: 1-866-764-6260

  8. Culture CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices] • Leadership Structures and Systems • Culture Measurement, Feedback, and Interventions • Teamwork Training and Team Interventions • Identification and Mitigation of Risks and Hazards Structures and Systems Culture Meas., FB., and Interv. Team Training and Team Interv. ID and Mitigation Risk and Hazards Consent & Disclosure Consent and Disclosure CHAPTER 3: Informed Consent and Disclosure • Informed Consent • Life-Sustaining Treatment • Disclosure • Care of the Caregiver Informed Consent Life-Sustaining Treatment Disclosure Care of Caregiver Workforce CHAPTER 4: Workforce • Nursing Workforce • Direct Caregivers • ICU Care 2009 NQF Report Nursing Workforce Direct Caregivers ICU Care Legend: CHAPTER 5: Information Management and Continuity of Care • Patient Care Information • Order Read-Back and Abbreviations • Labeling Studies • Discharge Systems • Safe Adoption of Integrated Clinical Systems including CPOE Information Management and Continuity of Care No Material Changes Patient Care Info. Read-Back & Abbrev. Material Changes Labeling Studies Discharge System CPOE New Medication Management CHAPTER 6: Medication Management • Medication Reconciliation • Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging Med. Recon. Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose CHAPTER 7: Hospital-Associated Infections • Hand Hygiene • Influenza Prevention • Central Venous Catheter-Related Blood Stream Infection Prevention • Surgical-Site Infection Prevention • Care of the Ventilated Patient and VAP • MDRO Prevention • UTI Prevention Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention VAP Prevention MDRO Prevention UTI Prevention CHAPTER 8: • Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention • Pressure Ulcer Prevention • DVT/VTE Prevention • Anticoagulation Therapy • Contrast Media-Induced Renal Failure Prevention • Organ Donation • Glycemic Control • Falls Prevention • Pediatric Imaging Condition-, Site-, and Risk-Specific Practices Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy Contrast Media Use Organ Donation Glycemic Control Falls Prevention Pediatric Imaging 13

  9. Values Systems Structures Behaviors Outcomes LEADERSHIP STRUCTURES and SYSTEMS Patients and Community Leadership Structures and Systems Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Identification and Mitigation of Risks and Hazards NQF 34 Safe Practices

  10. Looking Forward: Principles Applied Timothy McDonald, MD, JD Chief Safety and Risk Officer for Health Affairs; Professor, Anesthesiology and Pediatrics, University of Illinois Safe Practices Webinar October 22, 2009 15 Toll-free Call-in number: 1-866-764-6260

  11. National Quality Forum Safe Practices #5 Informed Consent #6 Life-Sustaining Treatment #7 Disclosure #8 Care of the Caregiver Toll-free Call-in number: 1-866-764-6260

  12. NQF SP #5 #5 Informed Consent Toll-free Call-in number: 1-866-764-6260

  13. Arch Surg 2000; 135:26-33 Background to Current Problem Only 24% of consent forms contained the four elements considered essential for informed consent. Designed more to protect institution than inform patient. Toll-free Call-in number: 1-866-764-6260

  14. The gap between patient reading comprehension and the readability of patient education materials. Davis, Crouch et al. J Fam Pract 1990; 31(5):533-8 Background to Current Problem Average reading comprehension was 6th grade; Educational materials – 11th to 14th grade; Informed consent written materials – written at college-level Toll-free Call-in number: 1-866-764-6260

  15. NQF SP #5 • Informed Consent:Safe Practice Statement • Ask each patient or legal surrogate to “teach back,” in his or her own words, key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent. Toll-free Call-in number: 1-866-764-6260

  16. NQF SP #5 • Informed Consent:Additional Specifications - Informed consent documents for use with the patient should be written at or below the 5th-grade level. - Shared decision-making: the patient and the family should be engaged in a dialogue about the nature and scope of the procedure. - A qualified medical interpreter or reader should be provided to assist patients with limited English proficiency, limited health literacy, and visual or hearing impairments. - The risk that is associated with high-risk elective cardiac procedures and high-risk procedures with the strongest volume-outcomes relationship should be conveyed. Toll-free Call-in number: 1-866-764-6260

  17. Informed Consent: Looking Forward • Full disclosure begins with the first visit to the caregiver’s office or with obtaining an informed consent • Consider a random selection of patients for follow-up and assess degree of “recall” related to the informed consent process and “teach back” • Future with computerized, internet-linked adult learning methodologies to engage patients and their families Toll-free Call-in number: 1-866-764-6260

  18. NQF SP #6 #6 Life-Sustaining Treatment Toll-free Call-in number: 1-866-764-6260

  19. NQF SP #6 • Life-Sustaining Treatment: The Problem • The provision of unwanted end-of-life care is an adverse event that can be avoided by effective patient/provider collaboration • In one study, 48% of patients with advance directives received mechanical ventilation against their wishes Fins JJ, Miller FG, Acres CA, et al. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage 1999 Jan;17(1):6-15. Toll-free Call-in number: 1-866-764-6260

  20. NQF SP #6 • Life-Sustaining Treatment: Safe Practice Statement • Ensure that written documentation of the patient’s preferences for life-sustaining treatments is prominently displayed in his or her chart. • Additional specification: Organization policies, consistent with applicable law and regulation, should be in place that address patient preferences. Toll-free Call-in number: 1-866-764-6260

  21. A Not-Uncommon Ethical Dilemma • Elderly patient, with DNR order - GI suite for peg • Peg for nutrition and pain management • Is alert and conversant • In error, patient over-sedated • Patient becomes apneic • Code called • DNR form recognized • Caregivers panic Toll-free Call-in number: 1-866-764-6260

  22. Ethical Principles • Beneficence • Non-maleficence • Patient autonomy • Truth telling • Ethical dilemmas – when principles conflict Toll-free Call-in number: 1-866-764-6260

  23. The Dilemma • Beneficence – put the tube in/give reversal • Non-maleficence – put the tube in/give reversal • Patient autonomy – do not resuscitate! • Truth telling - ? Toll-free Call-in number: 1-866-764-6260

  24. Life-Sustaining Treatment: Looking Forward • Should advance in parallel with informed consent • Involves shared decision-making • Can “force function” with documentation requirements • Electronic medical record solutions Toll-free Call-in number: 1-866-764-6260

  25. NQF SP #7 #7 Disclosure Toll-free Call-in number: 1-866-764-6260

  26. NQF SP #7 • Disclosure: The Problem • We “deny and defend” • We “shame and blame” • We hide behind a “wall of silence” • We fail to learn from our mistakes • Patients and their insurers pay for our mistakes Toll-free Call-in number: 1-866-764-6260

  27. NQF SP #7 • Disclosure: Safe Practice Statement • Following serious unanticipated outcomes, including those that are clearly caused by systems failures, the patient and, as appropriate, the family should receive timely, transparent, and clear communication concerning what is known about the event • Disclosure: Additional Specifications - Support system, reporting, communication, apology, performance improvement, remedy Toll-free Call-in number: 1-866-764-6260

  28. Hard-wiring NQF SP #7A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service Yes Consider “Care for Caregiver” Error Investigation hold bills? Process Improvement Activation of Crisis Management Team No Inappropriate care? Yes Full Disclosure with Rapid Apology and Remedy

  29. Disclosure: Looking Forward • Full engagement of stakeholders - Patients and families - Caregivers - Administrators - Malpractice insurers - Health insurers - Legal community - A cultural transformation – the “Trojan horse” Toll-free Call-in number: 1-866-764-6260

  30. NQF SP #8 #8 Care of the Caregiver Toll-free Call-in number: 1-866-764-6260

  31. NQF SP #8 • Care of Caregiver: The Problem • Caregivers are also hurt by medical error • Can develop psychological impairment • Impairment can lead to future errors • Vicious cycle West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA 2006 Sep 6;296(9):1071-8. Toll-free Call-in number: 1-866-764-6260

  32. NQF SP #8 • Care of the Caregiver: Safe Practice Statement • Following serious unintentional harm due to systems failures and/or errors that resulted from human performance failures - the involved caregivers should receive timely and systematic care: treatment that is just, respect, compassion, supportive medical care, and the opportunity to fully participate in event investigation and risk identification and mitigation activities that will prevent future events. Toll-free Call-in number: 1-866-764-6260

  33. Hard-wiring NQF SP #8A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service Yes Consider “Care for Caregiver” Error Investigation hold bills? Process Improvement Activation of Crisis Management Team No Inappropriate care? Yes Full Disclosure with Rapid Apology and Remedy

  34. Care of Caregiver: Looking Forward • Rapid response teams for patients, caregivers • Psychological support for all • Ongoing support and assessment • Implementation of “just culture” concepts Toll-free Call-in number: 1-866-764-6260

  35. Looking Back: Lessons Learned Lucian Leape, MD Chair, Lucian Leape Institute; Adjunct Professor of Health Policy, Harvard School of Public Health Safe Practices Webinar October 22, 2009 41 Toll-free Call-in number: 1-866-764-6260

  36. Making Disclosure Happen:What Do Patients Want? 1. Know what happened 2. Receive an apology 3. Be assured the hospital is doing all it can to prevent a recurrence Toll-free Call-in number: 1-866-764-6260

  37. Why Are Disclosure and ApologySo Difficult? 1. It is very difficult for anyone to apologize - No one likes to admit guilt and apologize - It’s even harder in the medical encounter 2. Medical injury is very different from the other reasons people apologize 3. Many of us lack the skills for delivering bad news Toll-free Call-in number: 1-866-764-6260

  38. Why Are Disclosure and ApologySo Difficult? It is very difficult for doctors to accept failure The sense of shame and guilt can be overpowering Fear of consequences: - Loss of patient’s trust, respect - Loss of colleagues’ respect - Risk of being sued Toll-free Call-in number: 1-866-764-6260

  39. We Have Serious Hang-ups About Being Open and Apologizing Our fear of being sued overpowers our sense of responsibility to the patient and our recognition of the patient’s need for full, open, honest disclosure. Toll-free Call-in number: 1-866-764-6260

  40. Bad Advice from Lawyers • Framing apology as a liability issue sabotages the needs of both the patient and the doctor for healing • Withholding information and not apologizing for our mistakes makes a difficult situation infinitely worse Toll-free Call-in number: 1-866-764-6260

  41. The Malpractice Myth Myth: If you tell the patient what happened or apologize, he is more likely to sue, and it will be used against you in court Reality: Patients are much less likely to sue if you level with them - Plaintiff lawyer experience - Evidence: VA, U. Mich, COPIC Toll-free Call-in number: 1-866-764-6260

  42. The Malpractice Myth • 1999: 136 2003: 81 • 2000: 122 2004: 91 • 2001: 121 2005: 85 • 2002: 88 2006: 61 • 2008: 14 Toll-free Call-in number: 1-866-764-6260

  43. University of Michigan Toll-free Call-in number: 1-866-764-6260

  44. The Experience with Transparency • University of Michigan Hospitals • University of Illinois Medical Center at Chicago • Kaiser Permanente (CA) • Children’s Hospital & Clinics of Minnesota • Johns Hopkins Hospital • Catholic Healthcare West • Physicians Reimbursement Fund (CA) • COPIC (CO) Toll-free Call-in number: 1-866-764-6260

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