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Perioperative Patient Safety Changing Safety Culture One Step at a Time

Perioperative Patient Safety Changing Safety Culture One Step at a Time. Satya Krishna Ramachandran MD FRCA Department of Anesthesiology University of Michigan. Disclosures. Paid scientific advisory consultant Galleon Pharmaceuticals Merck, Sharp & Dohme Funding PSA with MSD for 2014

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Perioperative Patient Safety Changing Safety Culture One Step at a Time

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  1. Perioperative Patient SafetyChanging Safety CultureOne Step at a Time Satya Krishna Ramachandran MD FRCA Department of Anesthesiology University of Michigan

  2. Disclosures • Paid scientific advisory consultant • Galleon Pharmaceuticals • Merck, Sharp & Dohme • Funding • PSA with MSD for 2014 • MiCHR CTSA PGP UL1TR000433 for 2014 The material of this talk is independent of these disclosures This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  3. How Hazardous Is HealthCare?

  4. Patient safety and human factorsTo err is human

  5. We can't solve problems by using the same kind of thinking we used when we created them Albert Einstein

  6. Where Healthcare Was • Cottage Industry Mentality • Virtually Total Reliance on: • Professional/Individual Responsibility • Individual Perfection • Train and Blame • Little Understanding of Systems Relative to People and Processes • Ignorance vs. Arrogance This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  7. Where Healthcare Is • Cottage Industry Mentality • Virtually Total Reliance on: • Professional/Individual Responsibility • Individual Perfection • Train and Blame • Little Understanding of Systems Relative to People and Processes • Ignorance vs. Arrogance This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  8. Patient Safety Culture This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable A culture of safety can be defined as an integrated pattern of individual and organizational behaviour based upon shared beliefs and values that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999)

  9. Importance of Culture This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable • “Health care organizations must develop a culture of safety such that an organization's care processes and workforce are focused on improving the reliability and safety of care for patients.” (p. 14; IOM, 1999) • “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.” (p. 79; Crossing the Quality Chasm, 2001)

  10. Culture and Patient Safety PatientSafety Patient Safety Culture Norms and Behaviour Enabler/ Barrier Patient Safety Interventions

  11. Typical Approach • New Policies, Regulations, Reporting Systems, Training • Good First Step But….. • Lack of Systems Insight • Superficial Solutions (?Answers) • Inadequate Follow-Up • Lost Opportunity This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  12. Typical Missing Features • Clear Understanding of Goal • Preventive Approach • Field Understanding & Buy-In • Systems Approach • Sustainability • Trust/Culture of Safety This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  13. Patient Safety Culture Elements This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable • Leadership commitment to safety • Organizational resources for patient safety • Priority of safety versus production • Effectiveness and openness of communication • Openness about problems and errors • Near misses • Organizational learning (Singer et al. 2003)

  14. IOM Strategy For Improvement • Education: Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety • Reporting: Identifying and learning from errors by developing a nationwide public mandatoryreporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  15. IOM Strategy For Improvement • Implementing safety systems in health care organizations to ensure safe practices at the delivery level • Professionalism: Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  16. Changing Cultureresident Education

  17. Key points • Patient Safety, Professionalism and Quality Improvement skills are extremely valuable for all career paths • These attributes have renewed emphasis in the NAS • Anesthesiologists are uniquely positioned to lead • We can leverage existing resources to improve teaching/learning of these attributes • The goal is to create physicians who are in tune with growing public demand for accountability and transparency, while upholding the highest standards of clinical care This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  18. Why change the system? The ACGME’s public stakeholders have heightened expectations of physicians • team-oriented care • information-technology literacy • sensitivity to cost-effectiveness • the ability to involve patients in their own care, and • the use of health information technology to improve care for individuals and populations This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  19. CLER This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  20. CLER - QA Areas of Focus • Patient Safety – opportunities for residents to: • report errors, unsafe conditions & near misses • participate in inter-professional teams to promote & enhance safe care. • Quality Improvement – engage residents in using data to: • improve systems of care, • reduce health care disparities & • improve patient outcomes. • Professionalism - • educate for professionalism, • monitor behavior on the part of residents and faculty & • respond to issues concerning: (i) accurate reporting of program information; (ii) integrity in fulfilling educational and professional responsibilities; & (iii) veracity in scholarly pursuits.

  21. So How Can You Make a Difference? • Problem: No Problem This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  22. Non-Punitive Systems Approach • TIVA for acoustic neuroma • Patient coughs = surgeon very upset • In a punitive system – event would go unreported • Root cause contributing factors: • Carrier fluid ran out (without alerting resident) • Antibiotics hung on carrier line • Teaching session ongoing distracting clinical care • Depth of anesthesia unknown • Isoflurane could be used (AEP) This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  23. Changing Culturereporting adverse events

  24. Patient Safety • How to report a clinical event? • hint: search for “QA” in Centricity This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  25. Patient Safety • How to report a confidential QA concern? • hint: search for “QA” in Centricity This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  26. Patient Safety • What happens when you report an event? An anesthesia reviewer (usually faculty member) from the QA Committee conducts a comprehensive incident review… This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  27. Standard Review Process This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  28. Patient Safety • How to identify system issues from adverse event reports? This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  29. This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  30. The Postoperative Patient Care HandoverUH PACU This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable Department of Anesthesiology, University of Michigan Health System

  31. The Postoperative Patient Care Handovera plan for improvement • UMHS Proposal: • Clearly establish & communicate patient care handover expectations to all involved care givers. • Standardize handoff communication by: • developing a comprehensive, succinct conversation guideline for all handovers • leveraging the EHR to provide easily accessible and retrievable electronic documentation • Establish expectations for the required • Timing of and Participants in the care handover • Provide a clearly communicated path for care escalation This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  32. Implementation This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable • New EHR tool • Video handover simulation • Multiple presentations at departmental M&M’s • One-on-one PACU RN training • Signage in PACU • Continuous implementation feedback

  33. Participation and Distraction Rates This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable • Both Surgery and PACU anesthesia attendance rates increased ~ 30%, • surgery distraction rates at the bedside also increased: • Attending/resident conversations - Non-handover conversations • Texting - Responding to pages

  34. Quality of Handover – communication & teamwork This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  35. Handover Time Distribution This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable • Observed handovers differ greatly from re-structured goals. • Brief assessment allowance • Coordinated communication • OR Anesthesia time

  36. Barriers This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable Observed barriers included: • Time pressures, • Non-standard work, • System support issues & • Institutional culture

  37. Barriers - time pressures This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable • OR Turnover • Periods of high workload and competing tasks, such as future cases, negatively impact communication and coordination between care providers. • Initial Post-Operative Assessment • The need for the PACU RN to assess patients immediately upon arrival to the recovery unit establishes a built-in delay to communication efforts. This delay reduces participation in the established communication structure.

  38. RN Assessment Time Median nurse assessment time = 3:43 25% = 2:41 75% = 4:56 Mean = 4:11 This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  39. Changing cultureengage surgeons and nurses

  40. Perioperative Quality Improvement • Medical Team Training: • Provides for a shared mental model of care by enabling clear, concise communication between providers • For better patient care & • Timely identification and resolution of problems • The Debrief Process: • The gateway for improvement of intraopSystems failures WHY IS THIS IMPORTANT??? This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  41. Perioperative Quality Improvement • Problems Addressed: • Even with limited feedback to providers, there has been an >100% increase in participation just since last October: This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  42. Perioperative Quality Improvement • Problems Addressed: • Cases with documented issues with instrumentation have declined by >30% This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  43. Perioperative Quality Improvement • Problems Addressed: • Cases with documented issues with instrumentation have declined by >30% Is this decline actual improvement, …. or “reporting fatigue”? This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

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