340 likes | 490 Views
Best Practices: Teaching Resident Patient Safety and Quality Improvement Skills. Alfonso Mejia, MD-MPH Program Director, Orthopedic Surgery Residency Program Vice Head, Department of Orthopedic Surgery University of Illinois at Chicago CORD Conference Saturday June 15, 2013. Disclosures.
E N D
Best Practices: Teaching Resident Patient Safety and Quality Improvement Skills Alfonso Mejia, MD-MPH Program Director, Orthopedic Surgery Residency Program Vice Head, Department of Orthopedic Surgery University of Illinois at Chicago CORD Conference Saturday June 15, 2013
Disclosures None Relevant to this Topic • Acumed • Arthrex • Biomet • BloxR • C-Spine • Depuy • Medtronic • Medartis • Orthologic • Smith-Nephew Richards • Synthes • Trimed • Zymmer No personal financial disclosures AAOS Council on Advocacy Liaison to DAB _________________________ Educational and Research Grants For Orthopedic Residency Program and Orthopedic Department
Goals and Objectives • Understand nature and extent of medical errors • Discuss Patient Safety Analysis • List Methods of Quality Improvement • Explain methods of Safety and Quality Improvement Education
Safety and Quality of Care Are Central Dimensions of Health Care • Both could be better • Increasingly measured • Public demands accountability • Pay for Performance
Safety and Quality • Closely related but not identical • Safety is first part of quality • Health care must guarantee safe care • Greater gains can be obtained from improving quality • Safety more tangible to public
Background on Reports Leading to Focus on Patient Safety and Quality Improvement • IOM Report 1999: To Err is Human: Building a Safer Health System • 44, 000 to 98, 000 people die each year from preventable medical errors • IOM Report 2001: Crossing the Quality Chasm • 6 Aims for Improvement • 10 Rules for redesign • Goal of 50% reduction in five years • Leading Causes of Death in US (2011) • 1) Heart Disease: 597,689 • 2) Cancer: 574,743 • 3) Chronic Respiratory Diseases: 138,080 • 4) Stroke: 129,476 • 5) Accidents: 120,859 • 6) Alzheimer’s Disease: 83,494 • 7) Diabetes: 69,071 • 8) Renal Disease: 50,476 • 9) Influenza & Pneumonia: 50,097 • 10) Preventable Medical Errors: 44,000 • 11) Suicide: 38,364
Background on Reports Leading to Focus on Patient Safety and Quality Improvement • IOM Report 1999: To Err is Human: Building a Safer Health System • 44, 000 to 98, 000 people die each year from preventable medical errors • IOM Report 2001: Crossing the Quality Chasm • 6 Aims for Improvement • 10 Rules for redesign • Goal of 50% reduction in five years • Leading Causes of Death in US (2011) • 1) Heart Disease: 597,689 • 2) Cancer: 574,743 • 3) Chronic Respiratory Diseases: 138,080 • 4) Stroke: 129,476 • 5) Accidents: 120,859 • 6) Preventable Medical Errors: 98,000 • 7) Alzheimer’s Disease: 83,494
Teaching Patient Safety & Quality Improvement Skills Should be Part of a Broad Initiative • Curriculum Design • Competency Assessment • Experiential Learning • Hidden Curriculum • Role modeling
Human Errors • Person Approach • Longstanding widespread approach • Focus on unsafe act of person • System Approach • Humans are fallible • Errors as consequence rather than causes
Person Approach To Human Errors Unsafe Act Arises From • Aberrant mental processes • Forgetfulness • Inattention • Poor Motivation • Carelessness • Negligence • Recklessness
Safety Theory • Individuals make errors all the time • Slip • Error in semiautomatic behavior • Forgot to write order • Error • Occur in new or non stereotypic situation (decision) • Dosing error • Implant selection
System Theory • Most accidents due to series of small failures that line upso accident can occur • Does not excuse negligent individual • Appropriate system design is key • Should make errors less likely • Should identify errors that do occur
Factors That Increase Errors • Fatigue • Decreased extended duty shifts • Stress • Use of protocols • Interruptions • Interruption free zones • Complexity • Breaking tasks into component parts • Transitions • Structured hand offs
Frequency of Adverse Events in Health Care Settings • Inpatient • Nursing Home • Outpatient
Adverse Health Event Data Harvard Medical Practice Study 19% adverse drug events 14% wound infections 13% technical complications ~50% associated with surgical procedures Other studies 6-10% of patients admitted in USA have ADE • Injury Caused by Medical Management Rather than Underlying Disease • Death • Disability • Increased stay by 2 days or more • 3.7% of pts (58% preventable)
Discharge Errors A Risky Time • 19% of discharged patient have adverse event • 1/3 preventable • 1/3 could have been less severe • ADE leading cause
Prevention Strategies • Nosocomial Infections • Use of checklist • Decrease in ICU • Ventilator associated pneumonia • Catheter associated sepsis • ADEs • Computerized physician order entry • Suggest default dose • Ensure order complete • Check for allergies • Check for drug-drug interaction • Check for drug-laboratory issue • linked with clinical decision support • Doubles appropriate renal dosing to 2/3rds • Bar coding medication administration
Organizations Involved in Safety and Quality Improvement • National Quality Forum (NQF) • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • Institute of Medicine (IOM) • Agency for Health Care Research and Quality (AHCRQ) • Centers for Medicaid and Medicare Services (CMS)
Measuring Safety • Difficult • Expensive • Data Mining • Nosocomial infections • Falls • Self Reporting • 1 of 20 ADEs reported
Improving Safety • Identify systemic problems • Identify risky behaviors • Transitions • Build Checklists • Use technology • Take into account human factors • Train the team • Build a culture of safety
Components of Quality • Structure • Presence of characteristic • EMR • Process • Manner Care Given • Was protocol adhered to • Outcome • Good structure and process do not guarantee good outcome
Quality Theory • Raising the level of all providers • Rather than finding few poor performers • Continuous quality improvement • Requires ongoing monitoring and assessing • Plan-Do-Check-Act cycle
Factors Relating to Quality • Stress • Providers may omit steps • High levels of production pressure • A form of stress • Low levels of production • Providers may be unfamiliar with steps • Poor systems • Great adverse effect • Extremely dedicated providers cannot achieve high levels of performance
Measuring Quality Percent of Patients Receiving Recommended Care • Overall 55% • Preventive Care 55% • Acute Care 54% • Chronic Conditions 56% • Dartmouth Atlas on geographic variations
Improving Quality • Rationing • Use of formulary • Doctors resist • Education • Changes opinions • Effects diminish over time • Feedback • Better when given in proximity to event • Incentives • Pay for performance • Penalties • resented
Changing System of Care • Injury specific checklists • Based on practice guidelines • Bundles of Care • Ventilator associated pneumonia • Multimodal System Change • Self-management support • Delivery system design • Decision support • Information systems • Practice team
Education As to Safety and Quality Must Encompass A Broad Spectrum • Education • Medical Students • AAMC • Faculties in Medicine • Residents • ACGME • Practiced Based Learning and Improvement • Systems Based Practice • CanMEDS • Manager • Attending Surgeons
Educational Modalities on Patient Safety and Quality Improvement • Didactic Curriculum (foundation 5-10hrs) • Effectively improves learner knowledge of patient basic safety and quality of care principles • Less effective in behavior modification • Educational Activities • Specific know high risk areas can be targeted • Web based curriculum • Can disseminate to large number of learners on their time • Costly and time consuming to set up • QI Initiatives • Chart audit • Root cause analysis
Specific Safety and Quality Improvement Educational Activities • Patient Handover Training • Disclosure of Medical Errors • Teamwork training • Surgical Skills Training • Safe Medication Prescribing Training • Discharge Summary Improvement Programs
Resident Participation In Quality Improvement Initiatives • Initiatives may change models of care • Supervision • Rapid response teams • Experiential learning more likely to change behavior • Resident(s) may sequentially take over a quality improvement project • Carried over longer time frame • May decrease resident autonomy
Active versus Passive Engagement in Quality Improvement • Passive • Exposes learner to principles • Limited usefulness • Active • Disease based • Efficiency based • Address resultant shift in resident education
Faculty Development for Patient Safety and Quality Improvement Education • Train the trainer faculty development • Skills based training • Faculty requirement • Masters or Certification Programs in Safety and Quality Improvement
Summary • Understanding of Scope and Magnitude • Lifelong Commitment • Active participation • Integrated Education • Varied Modalities • Location Specific
Thank You amejia@uic.edu mejia.alfonso@gmail.com