QA Reviews: Lessons from the Sharp End

1. QA Reviews: Lessons from the Sharp End 3rd Annual Emergency Medicine Symposium, SJRMC David J. Adinaro MD, MAEd, FACEP Chief, Adult Emergency Department, EM Residency Research Director

2. Disclosures

3. Disclosures • I have nothing to report in terms of financial disclosures. However…. My biases

4. Biases I have been both a Practitioner and Consumer of emergency medicine

6. Biases I believe • That I have the best job in the world • That I work with the best people in the best profession • That we do noble work

7. Biases • That I have the best job in the world • That I work with the best people in the best profession • That we do noble work • That we can do better I believe

8. Those who do not learn from history…. • “No plan survives contact with the enemy.” Moltke the Elder (1800-1891) • No captain can do wrong placing his ship besides that of the enemy. Admiral Lord Nelson (1758-1805)

9. Objectives • Understand ways to improve patient safety • Understand the concepts of the sharp end, the blunt end, and HROs • Review the working of EDQA committee

10. Definitions • The Sharp End • The Blunt End • High Reliability Organizations • EDQA

11. The Sharp End

12. The Sharp End • Where the work is done and errors are made\discovered • Real time decisions based on available information • Last line of defense in error prevention • In healthcare made up of doctors, nurses, techs

13. The Blunt End • Distal to the sharp (work end) • Often remote from real time decisions but contribute to the care given and errors made • ED Exec, Hospital Administration, State regulations, National Policies

14. Sharp and Blunt Ends in Errors

15. HRO A High Reliability Organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity

16. HRO • Hypercomplexity- HROs exist in complex environments that depend on multi-team systems that must coordinate for safety • Tight coupling - HROs consist of tightly coupled teams in which the members depend on tasks performed across their team • Extreme hierarchical differentiation - In HROs, roles are clearly differentiated and defined. Intensive coordination efforts are needed to keep members of the teams working cohesively • Multiple decision makers in a complex communication network - HROs consist of many decision makers working to make important, interconnected decisions • High degree of accountability - HROs have a high degree of accountability when an error occurs that has severe consequences • Need for frequent, immediate feedback - HROs exist in industries where team members must receive frequent feedback at all times • Compressed time constraints - Time constraints are common to many industries, including health care

17. HRO • Aircraft carrier flight deck operations • Nuclear Power Plants • Fireground Operations (especially wildfire)

18. HRO Commitment to resilience Deference to expertise • Preoccupation with failure • Reluctance to simplify interpretations • Sensitivity to operations

19. Flight Deck Operations • So you want to understand an aircraft carrier? Well, just imagine that it's a busy day, and you shrink San Francisco Airport to only one short runway and one ramp and gate.

21. Flight Deck Operations • Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side, and require that everyone who leaves in the morning returns that same day.

23. Flight Deck Operations • Then turn off the radar to avoid detection, impose strict controls on radios, fuel the aircraft in place with their engines running, put an enemy in the air, and scatter live bombs and rockets around.

25. Flight Deck Operations • Now wet the whole thing down with salt water and oil, and man it with 20-year-olds, half of whom have never seen an airplane close up.

26. Flight Deck Operations Oh, and by the way, try not to kill anyone.

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28. HRO • Aircraft carrier flight deck operations • Nuclear Power Plants • Fireground Operations (especially wildfire) • Emergency Departments!

29. ED Operations

30. ED Operations PICTURE

31. ED Operations PICTURE

32. HRO • Hypercomplexity • Tight coupling • Extreme hierarchical differentiation • Multiple decision makers in a complex communication network • High degree of accountability • Need for frequent, immediate feedback • Compressed time constraints

33. SJRMC ED Operations • Embraces many aspects of HRO • 2009 Survey of Staff • Feedback related to validated, national Patient Safety Survey • Don’t Drop the Ball Program • Residents, Medical Students, Staff • Yellow Cards • Operations and safety issues • Anonymous

34. SJRMC ED Operations • Emergency Department Quality Assurance Committee • Physician and Nursing Leaders • ED Exec • Case management, nursing educator • Physician\nursing representatives • Quality Assurance representative • Review of identified cases and evaluates them for concerns\problems related to certain aspects of care • Grade care given and also identify SHARP and BLUNT END issues to be resolved.

35. Everyone raise their Hands!

36. EDQA • Started in the Fall of 2009 • Initially met once a month, then twice a month, now weekly for two hours • In 2010 SJRMC saw 126,000 patients • EDQA reviewed 115

37. EDQA • Some acceleration in 2011 • 56 reviewed to date • 25,000 ED visits • Between 1 and 2 of every 1,000 charts submitted for review

38. EDQA • Peds not well represented • 30% of patients, < 10% of charts • Good mix of admitted and discharged patients • Physicians average 4-8 charts a year reviewed

39. EDQA • A major tool for physician review, early warning, and blunt end decision making • Recently Wayne ED has joined process • Has become a model for other departments in hospital

40. EDQA Where do the charts come from? • Most are identified\referred from our own department • Leadership becomes aware of patient issue • Referrals by those on the sharp end • Sharon Pineda (pinedas@sjhmc.org) • Automatic screens (Admit after RTC < 72 hours, mortality) • A significant number come from other departments • Trauma, STEMI committee, Risk management

42. To date approximately 200 charts have been reviewed during EDQA The information collected on these sheets form the basis of the information that follows Limitations • Specific to St. Joe’s • Small proportion of Peds cases

43. EDQA Review • Adverse Outcome? • Area of Concern • Who Referred • Documentaton Issue? • Care Issue? • System Issue? • Reccomendations • Outcome\EDQA Referral

44. Example #1 • 70 year old female. Hypotensive, signs of sepsis, no IV access • Screen (Sepsis care) • Delay in ABX tx • NO adverse outcome • NO documentation issues • State Trooper • Design of car and malfunction of handguns

45. Example #1 • YES Care Issue • Clinical judgment • Communication\responsiveness • Delay in Abx and IV access • YES System Issue • Awareness of sepsis and tx • SCORE • 2 (physician) • RECC: • Phys to ED Chair

46. Adverse Outcomes • Still not well defined • Generally taken to mean did anunexpected event cause increase in the anticipated care of the patient. • Not found in most of the reviewed charts • However, need for unanticipated life sustaining tx found in about 10% of all charts reviewed.

47. Adverse Outcomes

48. Adverse Outcomes Breakdown

49. Area of Concern

50. Documentation Issues