Future Directions, Future Challenges for the Continuing Partnership for Health Care Quality

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Future Directions, Future Challenges for the
Continuing Partnership for Health Care Quality

• Mark R. Chassin, MD, MPP, MPH
• President, The Joint Commission
• North Carolina Hospital Association
• 2008 Summer Meeting
• Hilton Head, SC
• July 18, 2008

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State of Quality and Safety

• 3 kinds of quality problems do harm
• 1. Overuse
• 2. Underuse
• 3. Misuse
• Patient safety misuse
• Public reporting underuse and misuse

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State of Quality and Safety

• Misuse Fewest data
• ? 1.5 million Americans injured annually by
  medication errors (IOM 2007)
• Underuse About 50
• ? 45 fail to get effective care (RAND)
• Overuse About 20
• ? 21 of all ambulatory antibiotics are
  prescribed for colds

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Overuse of Tympanostomy Tubes

• Most frequent surgery in children ? 650,000
• Requires general anesthesia
• Major complications are not common
• Procedure performed most often for fluid
• Evidence is sparse consensus guidelines agree on
  waiting at least 3 months
• Jan 2008 study median 16 days 75 had
  fewer than 42 consecutive days

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How Is Health Care Doing?

• We have made some progress
• ? Improvement on most public measures
• ? Level of attention has never been higher
• Evidence of improvement is poor
• ? Data are old, sparse, and incomplete
• ? Most apply to hospitals, fewer for
  ambulatory care almost none for home health,
  ambulatory surgery, long-term care

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Scarce Resources

• All organizations across the continuum of care
  have scarce QI resources
• Increasing demands for data on quality
• Increasing financial incentives
• Focus on small number of measures
• Joint Commission has an obligation to maximize
  the health benefit of our measures and standards

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This Target is Moving

• Many new tests and treatments
• ? With underuse, we fail to convey their full
  potential benefit
• ? With overuse, we do harm directly
• Increasing risk of harm
• ? With misuse, we inflict the harm of
  avoidable complications
• Burden of harm of poor quality is rising

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The Public-Private Partnership Overseeing Quality
in Health Care

• Government has played a limited role in quality
  oversight up to the present
• Two related forces threaten this relationship
• 1) Bad things still happen at good hospitals
• 2) Routine safety processes break down
• Omens?
• ? MRSA screening laws proposed, passed? Florida
  rescinds peer review protection

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How Often Does This Happen?

• Most common TJC sentinel event
• Since 1995 651 reviewed (13)
• Minnesota requires SE reporting by hospitals and
  publishes results
• 2007 35 wrong site surgical procedures
• Minnesota has 1.7 of US population
• Extrapolating these figures.
• ? 6 wrong site surgical procedures in US
  every day

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How Can We Do Much Better?

• Our goal must be to drive the delivery system to
  achieve major, durable improvement
• A little better is not good enough
• We must document improvement
• Major barriers are
• 1) Lack of capacity to execute and
  disseminate robust process improvement
• 2) Poor understanding of how to greatly
  reduce rates of serious adverse events

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Robust Process Improvement

• Systematic approaches to problem solving proven
  in many other spheres of work
• Lean, six sigma, change acceleration, Toyota
• Different from what came before (CQI, TQM)
• Equally effective when applied to our toughest
  safety and quality problems
• Directly address critical failings of current QI
• Appealing to physicians and other clinicians (if
  jargon is minimized)

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Robust Process Improvement

• Five essential steps ( DMAIC )
• 1) Specify the improvement target
• 2) Measure the size of the problem
• 3) Identify specific causes
• 4) Target interventions to most important,
  modifiable causes
• 5) Embed intervention into routine work

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Improving Pain Management

• Managing patients pain is a crucial component of
  high quality care
• Satisfaction with pain control is an important
  driver of overall satisfaction
• In 2006, a Mount Sinai six sigma team focused on
  improving of patients rating their satisfaction
  with pain management as Excellent on two
  inpatient units (10E, 10W)
• Physicians and nurses had difficulty in seeing
  this problem through the patients eyes

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Satisfaction With Pain Management on 10E and 10W

No Answer
Poor
Fair
Excellent
Good
May 2006
Very Good
Units 78 Defects 49 Opportunities 1 DPMO
628,205 Yield 37 Baseline Sigma 1.1
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Drivers of Excellent Pain Management

• Team interviewed, then surveyed patients on 10E
  and 10W
• 3 primary concerns arose consistently
• 1) Care and concern attitude
• 2) Attentiveness after asking for
  nursing assistance not clock time
• 3) Ask did all caregivers ask about
  pain at every opportunity?
• Only excellence matters

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Pain Management by Care and Concern
Pain Management Excellence ()
Care and Concern Rating
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Pain Management by Attentiveness
Pain Management Excellence ()
Attentiveness Rating
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Pain Management by Asking About Pain
Pain Management Excellence ()
Asking About Pain
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Overall Excellence Requires Consistency

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• Scale sums excellent responses to 3 drivers
• Care concern
• Attentiveness
• Asking about pain

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Summary of Interventions

• Interdisciplinary meetings with unit staff,
  facilitated by team to develop scripts,
  educational material, reminder cards
• Pain management bill of rights
• Posters in staff conference rooms
• Patient discharge survey card
• Feedback of data on unit performance on drivers
  and overall pain satisfaction
• Recognition program to reward individuals cited
  for excellence by patients

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Overall Satisfaction with Pain Management
Percent Excellent Increases by 46
No Answer
Poor
Fair
Excellent
Good
Very Good
Sigma 1.1
Sigma 1.6
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Recurring Lessons

• Must understand specific causes of the problem
  youre trying to fix
• Target interventions to those causes
• Solutions developed elsewhere may not work for
  you
• Sustaining improvement is difficult requires
  monitoring and feedback

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Robust Process Improvement

• Essential to producing durable health care
  excellence consistently
• Capacity for such process improvement in the
  delivery system is limited
• The Joint Commission will lead an effort to
  facilitate more rapid and widespread development
  and adoption of generalizable, proven solutions
• The Joint Commission is adopting these tools for
  internal improvement

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Joint Commission Initiative

• Enterprise-wide adoption of lean, six sigma,
  change acceleration process
• Training began 2 months ago
• We will use these strategies and tools to drive
  all our process improvement
• Systematic attention to customer needs, improving
  efficiency, simplifying our processes, and
  improving value

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Adverse Events are Different

• Adverse events in hospitals usually represent
  unique sequences of events
• Errors challenge defenses (hiring, training,
  supervision, teamwork, protocols, communication,
  etc.)
• When defenses fail, patients suffer
• Same weak defenses permit many different error
  sequences to do harm
• Reasons Swiss-Cheese model

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A Familiar Adverse Event Pathway

• I made a mistake
• ?
• A patient suffered

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Characteristic Pattern

• Many individuals made errors
• Many errors occurred
• No single error caused the event
• All errors had to occur to do harm
• Many opportunities for individuals to intervene
  and prevent harm

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The Swiss Cheese Model
Errors
Defenses with Weaknesses
Harm
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Defenses

• Leadership
• Hiring
• Training
• Personnel evaluation
• Policies, protocols
• Computer systems
• Communication
• Supervision of trainees

• Teamwork
• Coordination (among teams)
• Staffing (levels, availability, mix)
• Equipment
• Environment
• Individuals (knowledge, skills, stress)

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Traditional Approach Needs Improvement

• Root cause analysis often superficial
• Nomenclature is misleading
• Relationship to errors and discipline is unclear
• Does not assemble information about event or why
  it happened to best inform improvement
• Focus is on a single event
• Turn to Reasons model for more clarity

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Getting to Solutions

• Fixing all the weaknesses in all the defenses is
  difficult and expensive
• Which ones do we fix first?
• We lack a systematic method for learning across
  many adverse events
• That learning holds the key to understanding
  which weaknesses are most problematic
• Vital role of the close call

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Close Calls Free Lessons

• Critical barometer of safety culture
• Punitive organizational culture
• ? never finds out
• Bureaucratic culture
• ? celebrates
• High reliability organization
• ? reacts as if it were an adverse event

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What Do Organizations Need?

• Clear, actionable information about the
  weaknesses that are most commonly involved in
  their adverse events
• Communication failure is too vague
• Between staff nurses and supervisors? Trainees
  and attendings? MDs and RNs?
• Must be collected and analyzed at the service
  level for accountability
• Interventions that work

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The Joint Commissions Role

• Uniquely positioned with long history of sentinel
  event policy and data base
• We will invest in producing next generation of
  knowledge and tools for more effective
  investigation and analysis of adverse events
• ? How to decide which errors warrant
  discipline---equitably across professions
• ? Systematic assessment of defenses
• ? Compiling learning across cases
• ? Incorporating assessment of close calls

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Recent Joint Commission Initiatives

• Major improvements to standards and survey
  process in past 5 years
• Changes focus accreditation much more sharply on
  safety and quality
• 1) National patient safety goals
• 2) Tracer methodology for surveys
• 3) Unannounced visits

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The Present Joint Commission

• Continue to aggressively improve standards and
  survey process (for example, the Standards
  Improvement Initiative)
• Lead effort to harmonize measures and focus
  improvement on highest priorities
• ? Recognize scarce QI resources
• ? Must have high confidence that improving on
  measures and complying with standards will
  improve health outcomes
• New programs to drive improvement

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The Next Generation Joint Commission

• Remarkable world-wide convergence on health care
  quality and safety issues
• Harness global investment to produce
  generalizable, durable solutions
• Training initiative to embed improvement capacity
  throughout delivery system
• Next generation of accreditation standards will
  assess institutions on their capacity for robust
  process improvement

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The Big Challenge

• Can we rise to the challenge of transforming
  health care into a high-reliability
  industry---with rates of adverse events and
  safety process breakdowns comparable to air
  travel?