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Proactive Strategies to Reduce Risk for Physicians . Solutions to Communication Challenges and Error Prevention. Michael Handler, MD Becky Miller, MHA, CPHQ, FACHE, CPPS. Today’s Presentation. Two components Solutions to communication challenges and the reduction of error
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Proactive Strategies to Reduce Risk for Physicians Solutions to Communication Challenges and Error Prevention Michael Handler, MD Becky Miller, MHA, CPHQ, FACHE, CPPS
Today’s Presentation • Two components • Solutions to communication challenges and the reduction of error • Proactive strategies to reduce risk for physicians
Objectives • Explore new ways of enhancing communication between physicians and healthcare providers • Discuss strategies to resolve differences between physicians and hospital staff as they occur • Identify strategies to reduce risk through a safety culture evaluation, event reporting and collaboration
Proactive Strategies to Reduce Risk • Burning Platform • Institute of Medicine Report, “To Err is Human”, 1999 • Need to keep our patients safe—the right thing to do • Increased demand for transparency, accountability and public reporting • Medical malpractice/Tort reform concerns • Changing structure of healthcare delivery models
Solutions to the Challenges • Evaluation and improvement of the safety culture • Proactive risk reduction strategies • Collaboration and communication • Learning, sharing and prevention!
Enhanced Teamwork & Communication A Solution to Reducing Risk –
Solutions to Communication Challenges • Communication—interaction between any two anythings • Must permeate every single interaction in patient care • Failure to communicate is easily one of the most common root causes in medical errors
Solutions - TeamSTEPPS • Team strategies to enhance performance and patient safety • Program developed in collaboration between the AHRQ and the Department of Defense • Similar to crew resource management from the aviation industry
Solutions - TeamSTEPPS • Based on four teachable learnable skills • Leadership • Situation awareness • Mutual support • Communication All interact to create desired outcomes of team competencies
TeamSTEPPS - Outcomes of Team Competencies • Knowledge • Shared Mental Model • Attitudes • Mutual Trust • Team Orientation • Performance • Adaptability • Accuracy • Productivity • Efficiency • Safety
Solutions - TeamSTEPPS • Designed primarily for high risk units in hospitals • OB • ED • ICU • Surgery or other procedural areas • Skills are be applied in any setting
Solutions - TeamSTEPPS • Lesson learned • Must be multidisciplinary---physicians, nurses, techs, respiratory therapists, pharmacists • Basically anybody involved in core team of patient care • Doesn’t just come • Takes hard work to be successful
Solutions - TeamSTEPPS • Does teamwork work?? • Examples • Hospital in Aurora, CO that handled theatre shootings • United Airlines crisis center on 9/11 • Miracle on the Hudson • Largest study to date— • Veterans Health Administration Medical Team Training study
Evidence it Works! (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine (Sexton, 2006) Johns Hopkins Draycott et al. BJOG(2006); 113: 177-82 Beth Israel Deaconess : 23% reduction in OB adverse events 13% reduction in severity of adverse events Pratt et al. J Comm J Qual Pat Safety(2007); 33: 720-725
VHA Study • Findings showed that the trained OR groups experienced an 18% reduction in annual mortality rate versus the OR groups that had not undergone training • Dose-response relationship for additional quarters of the training program showed an additional reduction of 0.5 deaths per 1000 procedures for each additional quarter
Solutions - Professionalism • Recent study by ISMP (Institute of Safe Medication Practices) 2013 • 70% of practitioners surveyed (physicians, nurses, pharmacists, other staff) experienced some type of disrespectful behavior
Disrespectful Behavior • Most frequent types— • Negative comments about colleagues • Reluctance or refusal to answer questions or return calls • Condescending language or demeaning comments
Disrespectful Behavior • Half of these respondents reported that this behavior adversely altered the way that they practiced • Avoidance • HUGE barrier to communication and HUGE patient safety issue
Disrespectful Behavior • We as physicians MUST police ourselves on this one • There are many others that would like to take this from us—administrators, regulators, lawyers, etc etc etc
Disrespectful Behavior • MUST hold ourselves and our peers accountable to an exceptional professional standard over and above everybody else • Medical societies, MECs, specialty organizations
What’s in it for me? • Increased demand for improved quality and safety of care, transparency and public reporting • 2012—caps for medical malpractice liability were struck down by the Missouri Supreme Court • Solutions needed to enhance patient safety within a culture that supports sharing and collaboration with appropriate legal and confidentiality protections
Understanding the Safety Culture Learning, Sharing, Improvement A Solution to Reducing Risk –
Center for Patient Safety • Founded in 2005 in response to recommendations of the Missouri Commission on Patient Safety • Center’s Founding Members – MSMA, MHA, Primaris • Strategic Initiatives • Federally-designated Patient Safety Organization (PSO) • Facilitate safety improvement activities and projects • Provide safety related education, training & resources • Issue an annual report • One of 79 PSOs in 29 States • One of most active in terms of participating organizations and reports
Patient Safety & Quality Improvement Act of 2005 (PSQIA) • Federal law in response to “To Err is Human” • Establishes Patient Safety Organizations (PSOs) • Provides federal confidentiality and legal protections for “Patient Safety Work Product” • Purpose – • To provide a culture that encourages reporting, analysis, sharing and learning about adverse events • To learn what medical errors occur, why and how to prevent them • To reduce error, costs and patient harm
Protections Available through the PSQIA • Quality and safety documentation defined by the organization as “patient safety work product” • Expands protections available through “peer review” and “attorney-client privilege” protections • Does NOT protect the medical record or billing records • Does NOT circumvent any mandated reporting requirements • Available to any healthcare provider licensed by a state that works with a PSO
Patient Safety Organizations (PSOs) • Must meet defined federal criteria • Varying PSOs models • Provide PSQIA-defined protections • Obtain adverse event, near miss and unsafe condition reports • Uses a Common Data Format (CDF) to collect event data and information • Analyze and report findings • Convene participants to share learning in a protected environment
Solutions - Proactive Risk Reduction Strategies • Safety Culture Assessments • Surveying, Analysis & Reporting • Safety Culture Training and Education • Just Culture • Comprehensive Unit-Based Safety Program (CUSP) • TeamSTEPPS • PSO Services
No BSI = 5 months or more w/ zero No BSI 21% No BSI 44% No BSI 31% Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate
Center PSO Activity - Learning EMS Agencies
Center PSO Activity - Learning There is great learning possible from near misses and unsafe conditions; PSOs are differentiated from regulatory-based and mandatory reporting activities because of the collection of near miss and unsafe conditions to enhance learning and prevention opportunities.
Typical Event Reporting - we only see the “Tip of the Iceberg” Sentinel Events Incident Reports Approx. 4% Adverse Events (GTT) 96% GTT = Global Trigger Tool
Common Causes of Error The CPS The Joint Commission
Majority of Patient Harm in 6 Areas -VTE-Pressure Ulcers-Falls-HAIs, Surgery and Blood Events
Center PSO Activity – Learning - Meds • Potential Causes Identified • Dispensing errors due to incorrect medication retrieval from dispensing systems; pharmacy dispensing the wrong dose • CPOE order entry errors, CPOE systems not transferring to electronic MARs • Auto-stops and auto-substitution features • Look like-sound alike medications (Zyvox vs. Zosyn, Hydrocodone vs. Oxycodone, Trazodone vs. Tramadol)
Center PSO Activity – Learning – Surgery/Anesthesia Include NQF-defined “Never Events” - infrequently occur limiting learning in one facility - broader learning through PSO participation
PSO Learning – Healthcare Acquired Infections • UTIs • 57% classified as asymptomatic, 50% result in harm • 18% are asymptomatic bacteremia, 78% resulting in harm • SSIs • 77% of all SSIs result in harm • Majority are superficial incisional & deep incisional primary infections
PSO Learning – EMS – Missouri National Leader Over 100 EMS agencies participating in the Center PSO