Lisa Lubomski, PhD November 11 and 13, 2013

1. The Science of Improving Patient Safety and Identifying Defects Lisa Lubomski, PhD November 11 and 13, 2013 DRAFT – final pending AHRQ approval

2. Where are we now? • Give your frontline staff the vision to see system-level defects, and the voice to create a local SSI prevention bundle they can own.

3. Learning Objectives After this session, you will be able to: • Apply Science of Safety into your work • Educate your team and executive partners on the Science of Safety • Identify defects within your OR by administering the Perioperative Safety Staff Assessment (PSSA) • Distribute and share PSSA results with your SUSP team • Locate SUSP resources on the project website to help complete the above tasks DRAFT – final pending AHRQ approval

4. Comprehensive Unit-based Safety Program (CUSP)1 CUSP for Surgery We are here Educate staff on science of safety Identify defects Recruit executive to adopt unit Learn from one defect per quarter Implement teamwork tools Adaptive Work

5. Advances in Medicine: Lingering Contradictions Advances in medicine have led to positive outcomes: • Most childhood cancers are curable • AIDS is now a chronic disease • Life expectancy has increased 10 years since the 1950s However, sponges are still found inside patients’ bodies after operations. Postoperative X-Ray Reveals Unwanted Situations2

6. Why is your SUSP work important?10 • 1 in 25 people will undergo surgery • 7 million (25%) in-patient surgeries followed by complication • 1 million (0.5 – 5%) deaths following surgery • 50% of all hospital adverse events are linked to surgery AND are avoidable

7. How Can These Errors Happen? • People are fallible • Medicine is still treated as an art, not a science • Systems do not catch mistakes before they reach the patient

8. Educate staff on the Science of Safety12, 13 • Understand that the system determines performance and safety is the property of the system • Majority of errors don’t belong to individual doctors or nurses • Use strategies to improve system performance • Standardize • Create independent checks for key processes • Learn from mistakes • Recognize that teams make wise decisions with diverse and independent input

9. System Factors Impact Safety14 Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics

10. Safety is a Property of the System

11. Educate staff on the Science of Safety12, 13 • Understand that the system determines performance and safety is the property of the system • Majority of errors don’t belong to individual doctors or nurses • Use strategies to improve system performance • Standardize • Create independent checks for key processes • Learn from mistakes • Recognize that teams make wise decisions with diverse and independent input

12. Standardize When You Can

13. Create Independent Checks

14. Educate staff on the Science of Safety12, 13 • Understand that the system determines performance and safety is the property of the system • Majority of errors don’t belong to individual doctors or nurses • Use strategies to improve system performance • Standardize • Create independent checks for key processes • Learn from mistakes • Recognize that teams make wise decisions with diverse and independent input

15. Communication Breakdowns

16. Basic Components and Process of Communication21

17. Comprehensive Unit-based Safety Program (CUSP)1 CUSP for Surgery Educate staff on science of safety Identify defects Recruit executive to adopt unit Learn from one defect per quarter Implement teamwork tools We are here Adaptive Work

18. What is a defect? Anything that happens that you do not want to happen again.

19. Examples of Defects That Affect Patient Safety

20. How can your team identify defects? • Event reporting systems, liability claims, sentinel events, M&M conference • Perioperative Staff Safety Assessment (PSSA) – completed by all staff members (not just medical) in the clinical area

21. PSSA taps into the wisdom of frontline providers • Frontline providers: • Understand the patient safety risks in their clinical areas • Have insight into potential solutions to these problems • We need to tap into this knowledge and use it to guide safety improvement efforts

22. What is the Perioperative Staff Safety Assessment (PSSA)? Asks providers to complete 4 questions: • Please describe how you think the next patient in your unit/clinical area will be harmed • Please describe what you think can be done to prevent or minimize this harm • Please describe how you think the next patient in the OR will get a Surgical Site Infection • Please describe what you think can be done to prevent this Surgical Site Infection

23. When and Who administers the PSSA? • Who: SUSP project lead or a designee • Recommendation: Administer PSSA following training on the Science of Safety – providers will have lenses to see system problems • To encourage staff to report safety concerns, establish a collection box or envelope in an accessible location where completed forms can be dropped off • Staff should complete the PSSA at least every 6 months

24. What do you do with the PSSA results? Prioritize identified defects using the following criteria: • Likelihood of the defect harming the patient • Severity of harm the defect causes • How commonly the defect occurs • Likelihood that the defect can be prevented in daily work

25. How will the next patient be harmed? (SSI Specific)22 Percentage of Responses (%)

26. PSSA follow-up • It is crucial that physician and nurse leaders respond to staff patient concerns • The SUSP team and other leaders must be ready to follow-up on the defects identified on the PSSA • You will use PSSA data to create your local surgical care improvement bundle

27. Next steps **Present the SOS video and administer PSSA during these ideal times: Medical staff Grand Rounds New staff orientation Regularly scheduled staff meetings (for nurses, surgeons, anesthesiologists, etc) Lunch and learn sessions Special educator sessions Make video available in break room Hang up SOS factsheet in break room, restroom, etc. Annual recertification requirements Hospital Intranet

28. Next StepsEngage staff who’ve watched the video • Discuss safety events in the clinical area • What systems may have led to these events? • How can the principles of safe design be applied to prevent future events? • How can staff and others in the clinical area improve communication? • How can these concepts be applied in the SUSP project?

29. Next stepsUse these tools to educate staff on the Science of Safety

30. References • Pronovost P, Cardo D, Goeschel C, et al. A Research Framework for Reducing Patient Harm. Oxford Journals. 2011; 52(4): 507-513. • http://home.earthlink.net/~radiologist/tf/050800.htm • Bates DW, Cullen DJ, Laird N, et al. Incidence of Adverse Drug Events and Potential Adverse Drug Events. ADE Prevention Study Group. JAMA. 1995; 274(1): 29–34. • Donchin Y, Gopher D, Olin M, et al. A Look Into the Nature and Causes of Human Errors in the Intensive Care Unit. Crit Care Med. 1995; 23(2):294-300. • Andrews LB, Stocking C, Krizek T, et al. An Alternative Strategy for Studying Adverse Events in Medical Care. Lancet. 1997; 349(9048): 309-313.

31. References • Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999. • Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March 2009. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf • KlevensM, Edwards J, Richards C, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR. 2007;122:160–166. • 8. Ending health care-associated infections, AHRQ, Rockville, MD; 2009. http://www.ahrq.gov/qual/haicusp.htm.

32. References • World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. http://www.who.int/patientsafety/challenge/safe.surgery/en/. Accessed August 7, 2013. • Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. Published March 2012. Accessed August 7, 2013. • Baker DP, Day R, Salas E. (2006), Teamwork as an Essential Component of High-Reliability Organizations. Health Services Research. 41:1576–1598. • Pronovost P, Goeschel C, MarstellarJ,et al. Framework for Patient Safety Research and Improvement. Circulation Journal of the American Heart Association. 2009; 119:330-337.

33. References • Vincent C, Taylor-Adams S, Stanhope N. Framework for Analysing Risk and Safety in Clinical Medicine. BMJ. 1998;316:1154. • Healthcare-Associated Infection: A Preventable Epidemic. Committee on Oversight and Government Reform. http://democrats.oversight.house.gov/index.php?option=com_content&task=view&id=3649&Itemid=2. Accessed August14, 2013. • Center for Disease Control. Appendix B: Summary of Recommended Frequency of Replacements for Catheters, Dressing, Administration Set and Fluids. MMWR. 2002;51:RR-10. • Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating Catheter-related Bloodstream Infections in the Intensive Care Unit. Crit Care Med. 2004; 32(10):2014-2020.

34. References • Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med. 2006; 355:2725-2732. • Pronovost P, Goeschel C, Needham D. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ 2010;340:c309 • Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. http://www.onthecuspstophai.org/. Accessed August 7, 2013. • Dayton E, Henrikson K. Teamwork and Communication: Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. JtComm J Qual Patient Saf. 2007; 31(1):34-47. • Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am CollSurg. 2012;215(2):193-200.