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Best Practices: Teaching Resident Patient Safety and Quality Improvement Skills

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.

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Best Practices: Teaching Resident Patient Safety and Quality Improvement Skills

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  1. 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

  2. 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

  3. 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

  4. Safety and Quality of Care Are Central Dimensions of Health Care • Both could be better • Increasingly measured • Public demands accountability • Pay for Performance

  5. 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

  6. 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

  7. 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

  8. Teaching Patient Safety & Quality Improvement Skills Should be Part of a Broad Initiative • Curriculum Design • Competency Assessment • Experiential Learning • Hidden Curriculum • Role modeling

  9. Human Errors • Person Approach • Longstanding widespread approach • Focus on unsafe act of person • System Approach • Humans are fallible • Errors as consequence rather than causes

  10. Person Approach To Human Errors Unsafe Act Arises From • Aberrant mental processes • Forgetfulness • Inattention • Poor Motivation • Carelessness • Negligence • Recklessness

  11. 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

  12. 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

  13. 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

  14. Frequency of Adverse Events in Health Care Settings • Inpatient • Nursing Home • Outpatient

  15. 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)

  16. 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

  17. 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

  18. 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)

  19. Measuring Safety • Difficult • Expensive • Data Mining • Nosocomial infections • Falls • Self Reporting • 1 of 20 ADEs reported

  20. 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

  21. 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

  22. 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

  23. 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

  24. Measuring Quality Percent of Patients Receiving Recommended Care • Overall 55% • Preventive Care 55% • Acute Care 54% • Chronic Conditions 56% • Dartmouth Atlas on geographic variations

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. Summary • Understanding of Scope and Magnitude • Lifelong Commitment • Active participation • Integrated Education • Varied Modalities • Location Specific

  34. Thank You amejia@uic.edu mejia.alfonso@gmail.com

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