J. Christopher Farmer

1. Hospital Performance and Best Practice Management:Altering systems of care in the hospital to improve patient safety J. Christopher Farmer

2. Discussion points • Overcoming the culture: “change does not apply to me” • Knowing what changes make a positive difference • Overcoming the impact of human factors • Making positive changes durable

3. The “Mom” Test If your mom becomes an ICU patient.. • Does experience level matter? (intubation, central line placement, advanced medical decision-making) • Are your expectations different at 2PM from 2AM? • What level of communications do you expect? Assigned nurse vs. resident vs. attending physician? Every day? • What are your expectations regarding supervision of “learners” caring for your mom?

4. Universal laws that we often forget... • Today’s problems come from yesterday’s solutions • Dividing an elephant in half does not produce two small elephants • Cause and effect are not closely related in time and space • Behavior grows better before it grows worse • The harder you push, the harder the system pushes back • Small changes can produce big results, but the areas of highest leverage are often the least obvious From The Fifth Discipline by Peter Senge 1990

5. Quality lapses in the hospital...where are the brakes? • Systems of care versus individuals • Communications • Education • Failure to recognize • Failure to rescue • Non-integration

6. T 38 C, increased rsspiratory secretions, chest Xray + urine analysis ordered, no antibiotics Dobhoff inserted, ongoing dysarthria, transferred to ward 72 year old man admitted for elective neurosurgery DAY 2 Extubated, no gag reflex, npo, tube feediings ordered DAY 4 DAY 6 DAY 7 T 39.2 C, HR 120, RR 30, chest Xray - pneumonia, all cultures (+), antibiotics ordered T 39.7 C, HR 140, RR 40, returned to MICU, broad spectrum antibiotics administered Persistent ARDS, sepsis, family conference convened DAY 8 Antibiotics adjusted, reintubated, ARDS develops DAY 9 DAY 10 DAY 12 ARDS and sepsis not improving, now in renal failure Decision: no dialysis, no tracheostomy, no PEG DAY 14 DAY 16 DAY 18 Decision not to pursue further ICU care DEATH

7. What is patient safety? • The absence of harm • The presence of quality • The perception of value

8. Quality versus patient safety... • Clinical acts versus care processes aimed at prevention • Prevention of adverse events • Compliance with “the rules”

9. Yes, the details are important... Protocolized (standardized) management improves clinical outcomes (published data) • Sepsis • Acute myocardial infarction • Central line insertion and catheter site maintenance • Ventilator use strategies in ARDS • Ventilator bundle • Glucose control • Sedation and delirium management • Surgical site wound care • Daily goals sheet (communications tool) • Communications tools for assessment and transfer to lower levels of care • Rapid response teams • Multidisciplinary, team-based rounds • Use of remote ICU virtual presence monitoring by intensivists and critical care nurses • On-site intensivist program • On-site hospitalist program • Adverse drug event prevention program

10. Sepsis bundle

11. Sepsis: putting it all together • Revised and implemented a Severe Sepsis and Septic Shock order set that includes all components of the Sepsis Resuscitation and Sepsis Management Bundles • Targeted early sepsis recognition • Instituted sepsis screening in the ICU, using the IHI screening tool, on all new admissions and patients with greater than three-day length of stay (LOS) • Incorporated screening into multidisciplinary rounds and the Patient Daily Goals/Plan of Care  • Implemented a “Sepsis Alert” screening tool in the Emergency Department (ED): Posted Sepsis Alert Screen in ED rooms and on ED chart backs as prompters to staff • Added sepsis screening to the ED standardized T-System documentation for all ED patients • Implemented screening on Medical Response Team (MRT) calls • Instituted ED chart review of patients admitted with a sepsis diagnosis to monitor compliance with appropriate screening and initiation of the Sepsis Resuscitation Bundle; gave feedback to ED staff and physicians • Prioritized ED/ICU collaboration for timely transfer of septic patients to ICU; ED nurse notified the ICU float charge nurse of positive sepsis screens  • Initiated sepsis resuscitation (lactates, blood cultures, antibiotics, fluid resuscitation) in the ED as indicated • ED staff and physicians were educated to the Sepsis Resuscitation Bundle • Intensivists assisted the ED as needed • Focus was on prompt transfer of patients to ICU for insertion of central venous oximetry catheters  • Placed prompters in the ED to collect blood cultures prior to first dose antibiotic administration  • Implemented components of the Sepsis Resuscitation and Sepsis Management Bundles in ICU using a systematic, incremental approach • Began by obtaining orders for lactates for all positive sepsis screens • Tracked the volume of lactates collected in ED and ICU  • Added absolute neutrophils to CBC and CBCI reports  • Added prompters for the Resuscitation Bundle to the sepsis screening tools in ED and ICU • Promoted utilization of central venous oximetry catheters by setting out the catheter for intensivists to use instead of a triple lumen catheter • Educated physicians to the purpose and benefits of using the central venous oximetry catheter  • Established a sepsis resuscitation box (lab tubes, type and cross-match supplies, catheters, fluids, etc.) • Revised the Pre-extubation Worksheet for lower tidal volumes and inspiratory plateau pressures — Respiratory Care monitored and followed up on compliance • Posted criteria for steroids in ICU and added steroid order to the sepsis pre-printed order set • Implemented Clinical Pharmacy review of cases for drotrecogin alfa based on established criteria  • Implemented a standing order process for nurse to automatically initiate the Insulin Drip Protocol for ICU patients with two blood glucose (BG) levels >150 mg/dL  • Addressed glycemic control in all rounds  • Consulted Clinical Pharmacy for insulin protocol patients with BG >150 mg/dL — also, the Pathology Department emailed a daily list of uncontrolled patients to Nursing and Clinical Pharmacy.  • Implemented Clinical Pharmacy screening of all new total parenteral nutrition (TPN) orders for appropriateness and ongoing screening for early switching to enteral feedings  • Implemented a process for Infection Control Practitioner to call a huddle meeting with Nursing and the ICU Medical Director for initial positive blood isolates of ICU patients — the purpose was to determine the source of infection, discontinue lines as indicated, initiate antibiotics, etc.  • Installed the Surviving Sepsis database to concurrently enter and track data from ICU patient charts on sepsis bundle compliance and mortality — feedback to staff and physicians

12. Daily goals sheet

13. Which metrics define patient safety?

14. Which metrics define patient safety?

15. The Six Sigma model has three aspects • Process Improvement focuses on improving broken processes. • Process Design is aimed at developing “something from nothing.” The new products and services will encompass Six Sigma principles. • Process Management translates Six Sigma in every day management decisions through the use of measurement systems.

16. Living with 99.9%... • 84 unsafe airline landings/day • 1 major plane crash every three days • 16,000 items of lost mail/hour • 37,000 ATM errors/hour

17. Hand washing...are we passing the test? • Average compliance in a U.S. Hospital = 50% • 60% of CRBSI are S. aureus + Coagulase negative staph • Almost half of S. aureus-related CBRSI are MRSA • Increasing incidence of C. difficile + VRE Since we can’t reliably “force” compliance with our current processes, then maybe we should consider redesigning the processes themselves?

18. The ancient approach to human factors:The Code of Hammurabi “If the surgeon has made a deep incision in the body of a free man and has caused the man’s death or has opened the carbuncle in the eye and so destroys the man’s eye, they shall cut off his forehand.” Circa 2000 B.C.

19. Re-design systems for... • Prevention • Detection • Mitigation

20. The impact of human factors Human Factors Engineering (HFE) are activities such as: • function & task analysis • workload analysis • human error modeling • system ergonomics • human machine interface design • usability testing • workspace layout contribute to an efficient, effective, usable and safe product, system or environment These contribute to an efficient, effective, usable and safe product, system, or environment

21. The impact of human factors Human Factors Integration (HFI) is: • a philosophy and set of management processes and tools that ensure human issues are identified, collated, shared and impact minimized • Actively managing human factors and planning how human issues will be shared and acted upon by other teams or disciplines (e.g. system engineering, logistics, software) “We must accept that human error as inevitable – and design around that fact.”Donald Berwick

22. And how does inpatient medicine score? Afessa et al, Crit Care Med, 2008

23. Changing processes AND changing the culture! • This is a leadership challenge! • Must accomplish systems level changes that facilitate success • Must study the processes with analytical discipline in order to make the correct changes • Management by walking around • What is the hospital leadership change management plan?

24. An incremental approach • Develop a strategic plan for necessary changes in the hospital • Timeline, deliverables, accountable individuals, metrics of success • Begin with a project that will establish a record of success • Pick the correct team members • Consider the use of an outside consultant to help articulate the “current state,” define priorities, techniques, leaders, methods, “outliers” (who will cause problems) • A credible consultant can say and do things without alienating staff, and they will listen!

25. “By far the most dangerous foe we have to fight is apathy - indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction.”Sir William Osler, 1932