Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation

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Patient Safety CME Curriculum Patient Safety
The Other Side of the Quality Equation

• Under a Grant from
• The Agency for Healthcare Research and Quality
• Principal Investigator
• Christel Mottur-Pilson, PhD
• Director, Scientific Policy
• ACP-ASIM

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Patient Safety The Other Side of the Quality
Equation Seven Modules in Ambulatory Care

• Systems
• The influence of systems on the practice of
  medicine
• Cognitive Capacity
• Coping mechanisms under information overload and
  time pressures
• Communication
• Communication barriers, lack, and unclear
  communication
• Medication Errors
• Uniform dosing, look- and sound-alikes, forcing
  functions

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Patient Safety The Other Side of the Quality
EquationSeven Modules in Ambulatory Care

• The Role of Patients
• Patients as allies in patient safety
• The Role of Electronics
• Supportive products and processes
• Idealized Office Design
• Medical practice design to support patient safety

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Logistics

• CME To receive your CME, please fill out the
  usual forms
• Evaluation form
• CME form
• Research Grant Surveys
• Pre-CME assessment of knowledge level
• Post-CME assessment of knowledge level
• Six-month follow up to CME
• Virtual Patient Safety Electronic Community

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Safety as a Component of Medical Practice Design

• This module was developed by Charles M. Kilo, MD,
  MPH for the American College of
  Physicians-American Society of Internal Medicine.
  
• Charles M. Kilo, MD, MPH
• Fellow, Institute for Healthcare Improvement
• President, GreenField Health System
• 9427 SW Barnes Road, Suite 590
• Portland, OR 97225
• Chuck.Kilo_at_GreenFieldHealth.com
• 503-292-9560

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Objectives

• By the end of this module, the learner will be
  able to
• Define a system, list key tenets of system
  theory, and describe the medical practice as a
  system of care.
• Describe the connection between the concepts of
  safety and system reliability.
• Provide examples of system components that can
  help improve safety and reliability in medical
  practices.

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Instructions

• This module is interactive wed like you to be
  actively involved in the discussion and to
  contribute your critical thoughts and questions.
• The symbol will be used throughout this
  presentation as a reminder when specific
  discussion is desired.

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Health Care Quality in the US

• IOM National Roundtable on Quality, convened in
  96
• National Roundtable on Quality, The Urgent Need
  to Improve Health Care Quality (JAMA, Sept.
  1998)
• National Cancer Policy Board, Ensuring Quality
  Cancer Care, 1999
• Presidents Advisory Commission on Consumer
  Protection and Quality in the Health Care
  Industry
• Quality First Better Health Care for All
  Americans
• IOM Committee on Quality of Health Care in
  America
• To Err Is Human Building A Safer Health System
• Crossing the Quality Chasm A New Health System
  for the 21st Century

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Errors are a Serious Problem

• Account for as many as 44,000 to 98,000 deaths
  per year in the U.S. (primarily hospital data)
• More people die from medical errors than from
  breast cancer, AIDS, or motor vehicle accidents.

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IOM Committee on Quality of Health Care in
America Conclusions

• There are serious problems in quality
• Between the health care we have and the health
  care we could have lies not just a gap but a
  chasm.
• The problems come from POOR SYSTEMS not bad
  people
• In its current form, habits, and environment,
  American health care is incapable of providing
  the public with the quality health care it
  expects and deserves.
• We can fix it but it will require change

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Definition of a System

• A system is a set of interdependent parts that
  share a common aim.
• Discussion points
• Interdependent parts What does it mean to have
  interdependent parts? What are the implications
  for a medical practice?

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Definition of a System

• Discussion points
• Common aim What does it mean to share a common
  aim? What is the common aim in a medical
  practice?

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Key Rules of Systems Theory

• All systems are perfectly designed to produce the
  results they produce.
• The results of a system depend on both
• The quality of the interdependent parts
• The quality of the interaction between the parts

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Quality Health Care

• Freedom from errors
• Consistent best practice
• Great service

? a safe system
? a reliable system
? a great service system
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An Example Prescription Refills

• The prescription refill process is error prone.
  There are multiple individuals involved, and many
  steps in the process. Within an individual
  practice, there tends to be variation in how
  refills are handled.

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An Example Prescription Refills

• Consider your prescription refill process.
• Write down each of the individuals involved in
  that process, and note the number of interactions
  involved in the process.
• Write down where the process is subject to error
  note why those particular spots are error
  prone.
• You want to improve your prescription refill
  process, to make it less error prone write down
  a specific aim for your practice.
• List particular ideas that might help you
  accomplish the aim.

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A Clinical Practice as a System

• Components of interdependence and interaction
  between individuals include
• Workflow
• Team work

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Reframing Safety Moving to System Reliability

• Error prevention safety are components of
  system reliability

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Reliability A Definition

• Reliability is the ability of the delivery
  system to do the right thing at the right time
  for the right patient - all the time.

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An Illustrative Case

• A 22 yo man with asthma has been treated with
  inhaled albuterol as needed. He has been using
  the inhaler fewer than 3 times/wk until the past
  6 wks when he found that he needed the inhaler
  three or four times each day. He is taking no
  other meds.
• On PE RR16, no distress. Chest mild wheezing
  on forced expiration. FEV1 3.1 L (77
  predicted), FVC 4.8 L (96 predicted), CXR nl.

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An Illustrative Case

• The most appropriate therapy at this time is
• A. Cont albuterol as a single agent, used as
  needed
• B. Regular albuterol q 4 hrs, used as a single
  agent
• C. Addition of inhaled ipratropium qid
• D. Addition of oral albuterol
• E. Addition of an inhaled corticosteroid

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Some Nagging Questions

• 1. How many asthmatics do you have in your
  practice? Diabetics? Patients with Breast Cancer
  or a family history of breast cancer?
• 2. What of your asthmatics are inhaled
  steroids?
• 3. If the FDA approved a new miracle drug for
  asthma, how would you go about instituting that
  medication in your asthmatic population?

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More Nagging Questions

• What does it mean for each asthmatic to receive
  the best possible care all of the time?
• How does a practice assure that all patients with
  asthma, for example, receive absolutely the best
  possible care all of the time?
• How does a practice keep up on its knowledge of
  the best possible care?

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System Reliability

• Why focus on system reliability?
• Expanding complexity of knowledge base
• In the 1960s, about 100 RCTs were published each
  year
• In the 1990s, over 10,000 RCTs were published
  each year

Chassin M. Is Health Care Ready for Six Sigma
Quality? Milbank Quarterly, 1998.
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System Reliability

• Expanding complexity An example
• Parenteral Anticoagulant Agents
• 1990 Unfractionated heparin
• 2001
• Unfractionated heparin
• Enoxaprin
• Dalteparin
• Tinzaparin
• Ardeparin
• Lepirudin
• Argatroban
• Danaparoid
• Bivalirudin
• Fondaparinux

Diuguid DL. Choosing a parenteral anticoagulant
agent. NEJM 20013451340-41
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What Does a System for Reliable Care Look Like?
What are the system components to assure that the
individual receives highly reliable care for a
single visit and into the future?
Patient with condition
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Reliability 2 System Components

• Proactive population management and registries
  
• I can accurately and rapidly identify all of my
  patients with a particular condition and assess
  how we (our care team) are performing against
  that condition.
• Decision Support
• I can very efficiently find the best available
  information right when I am seeing a patient to
  assist me in caring for that individual.

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Reliability Population Management

• Proactive Population Management is NOT about
  managing the population, but rather it is about
  improving the care of individuals in our practice
  by proactively understanding and tracking our
  practices performance for various clinical
  populations. Understanding how we are doing
  against a whole population of diabetics, for
  example, helps us to improve the care of
  INDIVIDUAL diabetics.

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Reliability Registries

• Registry The ability to track all of a
  practices patients, and to identify those with a
  particular condition.

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Decision Support

• Decision support is about systems that provide
  the best scientific knowledge and information at
  the time of care. Such systems often use
  information technology. Examples
• Epocrates loaded on a Palm Pilot to allow very
  rapid pharmaceutical information
• Sanford Guide on Antimicrobial Therapy to provide
  guidance on antibiotic choices
• Computerized order-entry to reduced adverse drug
  events
• Reminder systems to improve the consistent
  application of best practices

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Summary

• During this session, I have attempted to provide
• A deeper understanding of systems and the
  implications for medical practices
• An imperative to think hard about safety as one
  aspect of overall system reliability
• Some examples of system components to improve
  safety and reliability

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Patient Safety Interactive Learning Community
(PSILC)

• Program Information Updates
• All Seven Modules
• Refresher Exercises
• Email Discussion Groups

• http//www.acponline.org/ptsafety

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Refresher Exercises

• http//www.acponline.org/ptsafety