Title: Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation
1Patient 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
2 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
3Patient 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
4Logistics
- 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
5Safety 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
6Objectives
- 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.
7Instructions
- 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.
8Health 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
9Errors 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.
10IOM 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
11Definition 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?
12Definition 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?
13Key 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
14Quality Health Care
- Freedom from errors
- Consistent best practice
- Great service
? a safe system
? a reliable system
? a great service system
15An 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.
16An 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.
17A Clinical Practice as a System
- Components of interdependence and interaction
between individuals include - Workflow
- Team work
18Reframing Safety Moving to System Reliability
- Error prevention safety are components of
system reliability
19Reliability 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.
20 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.
21An 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
22Some 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?
23More 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?
24System 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.
25System 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
26What 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
27Reliability 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.
28Reliability 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.
29Reliability Registries
- Registry The ability to track all of a
practices patients, and to identify those with a
particular condition.
30Decision 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
31Summary
- 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
32Patient Safety Interactive Learning Community
(PSILC)
- Program Information Updates
- All Seven Modules
- Refresher Exercises
- Email Discussion Groups
- http//www.acponline.org/ptsafety
33Refresher Exercises
- http//www.acponline.org/ptsafety