Improving Quality

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Improving Quality Patient Safety

• Evidence Based Order Sets
• An effective solution to the complex challenge
  of improving patient care and safety

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Experimental Design, Data Collection,
AnalysisChris OConnor MD, Neill KJ Adhikari MD
CM MSc, Katharine DeCaire RN MN ACNP, Jan O
Friedrich MD DPhil

• Order Set Committee
• Chris OConnor, Katharine DeCaire, Zelia Campos,
  Bruce Tugwood, Pam Johnson, Allan Mills, Vera
  Jovanovic, Catherine Scaletta

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Outline

• Current Context The Need for Order Sets
• Order Sets A Clinical Decision Support Tool
• Order Sets Improving Care at Trillium
• Order Set Advantages
• Order Set Challenges
• Trilliums Order Set Innovation
• Open Source Order Set Project

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Current Context The Need for Order Sets
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Modern Case Presentation

• 67 year old female
• Past Medical History
• High Blood Pressure, Diabetes
• History of Present illness Presents to
  Emergency Room with severe pneumonia.
• Patient is unable to breathe on her own and is
  intubated.
• She is transferred to the Intensive Care Unit
  for her medical care

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Modern Case Treatments

• Antibiotic treatment- fast
• Activated Protein C
• Early goal directed fluid therapy
• DVT prophylaxis
• Early feeding
• Low tidal volume ventilation
• Steroids
• Pepcid to prevent GI bleeding

• Strict glycemic control
• Communicate with and support patient family
• Proper sedation/pain relief
• Correct electrolytes
• Elevate the head of the bed
• Bowel routine
• Mouth care
• Ongoing investigations

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ContextMassive Gap Between the Possible and the
Actual

• Quality
• Misuse, under use, overuse on a massive scale
• Crossing the Quality Chasm 2001
• Safety
• Medical error is common
• Institute Of Medicine Report on
  Error 2000
• Variation in Care
• Variability in care not explained by patient
  preferences or different disease patterns
• British Medical Journal 2002 325
  961-964

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ContextThe Canadian Adverse Events Study

• G. Ross Baker et al, CMAJ May 25 2004 170(11)
• The adverse event (AE) rate due to health care
  management was 7.5
• The AE rate of preventable events was 2.8
• The rate of deaths from preventable AEs was 0.66
  
• This would mean between 9200 and 23750 deaths/yr
  in Canada

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Context Gaps in the Care of Patients Admitted to
Hospital with an Exacerbation of Chronic
Obstructive Pulmonary Disease

• Edward Etchells et al, CMAJ April 27, 2004 170
  (9)
• 84 had at least 1 inpatient gap in care
• 15 patients with 3 or more gaps in their care,
• 15 an inpatient adverse event
• 2 of the 16 pts with adverse events died
• longer stays 16.4 v. 8.6 days if a pt had an
  adverse event
• Patients who had an inpatient adverse event had
  more gaps in their care 2.0 v. 1.3 gaps

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Where do we go from here?

• Traditional Methods to Change Clinician Behavior
• Written Materials/guidelines
• Audit and Feedback
• Academic Detailing
• Local Opinion Leaders
• Zero to moderate effectiveness at best
• Not scaleable
• Limited Scope
• Not durable

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Solution Order Sets a Clinical Decision Support
Tool

• A group of orders with a common functional
  purpose used by the physician to create orders.
• Integrates knowledge into the care delivery
  process knowledge where the clinician needs it
  most
• Organizes clinical knowledge so it is easy to
  remember, easy to use and has maximum benefit to
  the patient
• Contain evidence-based best practices
• Source of education
• Can be used in paper or computerized ordering
  systems

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• Trillium Health Centre 2006

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• Trillium Health Centre 2006

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• Trillium Health Centre 2006

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Order Sets Key Benefits

• Safety
• Reduced transcription errors
• Reduced errors of omission
• Reduced errors in medication dosing
• Quality
• Improved compliance with evidence-based best
  practices
• Standardization of care
• Efficiency
• Decreased time to write and process orders
• Reduction in physician call-backs
• Reduction in missed orders
• Critical enabler for computerized practitioner
  order entry

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Order Sets Improving Care
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Data Collection

• Primary outcome DVT Prophylaxis Rates
• Random Chart audit from three time periods
• October-November 2003
• April December 2004
• February March 2005
• DVT prophylaxis rates in the Department of
  Medicine
• April 2003 to March 2005
• Secondary Outcomes Assess in second chart
  period
• Multiple Quality metrics assessed.

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DVT The Preventable Epidemic

• DVT is the formation of blood clots in the legs
• DVT is very common in hospitalized patients
• DVT can cause death or serious disability
• There is excellent treatment to prevent DVT if
  patients get it
• Many studies have shown that many patients do not
  get this treatment which can save their lives
• The disconnect between evidence and execution
  as it relates to DVT prevention amounts to a
  public health crisis
• - S. GoldHaber, Associate Professor Harvard
  Medical School, 2003
• The order sets contained a section with treatment
  to prevent DVT

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The Order Set Advantage

• Addresses the challenges facing medicine today
• Scalable
• Durable
• Broad Scope
• No significant process redesign to implement
• No significant education
• Work in line with ordering process
  augmentingphysician knowledge
• Preserve autonomy

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The Order Set Challenge
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The Order Set Challenge

• Order Sets Must Be
• Current
• Evidence Based and Best Practice
• Authoritative
• Easy to Use
• Comprehensive
• Reliable and safe
• Clinically Intelligent

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The Order Set Challenge

• Order Sets are Complex!
• Typical medical admission order set has 130
  order elements in the set
• Interdisciplinary
• Multiproccess
• Integration with other care documents and
  activities
• Over 400 different order sets for a typical
  hospital
• Standardization, integration across systems is
  critical

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Current Status of Order Sets
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Current Status of Order Sets

• Lack of Recognition of Order Set Importance
• Order Set Design
• Often no standardized structure
• Structure is not modular
• Lack of integration with other processes/documents
  
• Order set life cycle not well established
• No dedicated Order Set Committee at most
  hospitals
• Most often PT/MAC based process, occasionally
  process is distributed to the level of the
  health systems
• Best practices often not scaled across
  departments
• Lack of version control
• No measurement of metrics
• Each hospital has its own structure and approach
  to order sets

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Current Status of Order Sets

• No good library of content
• No standardization of format, content or
  processes between organizations
• Limited ability to share order set content
  between organizations
• Each Organization must create its own order set
  project
• Duplication of effort
• Reduced quality
• Slow implementation of best practices
• Consumption of limited hospital resources
• Organization may lack content expertise in all
  the subject areas need for order sets
• Organization may lack knowledge of order set best
  practices in design and order set lifecycle
• External resources for order sets currently are
  very limited

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Order Set Innovation
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Trilliums Order Set Project

• 2001 Order set development begins in ICU
• Rapid Cycle improvement of order set design
• 2002 Order set development in other departments
• 2003 Standardized order set format established
• 2004 Current Order Set Committee established
• 2006 Standardized order sets in use in every
  Health System
• Over 250 order sets currently in use
• Admission order set use gt 90 in most health
  systems

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Trillium Order Set Project

• Winner of the first Ministry of Health award for
  Innovation in Patient Safety and Quality
• Expanded Commitment to Order Set Development and
  Implementation
• Order Set Project now has six dedicated FTEs
• Goal of expanding content by over 400 order sets
  in the next year
• Preparation for CPOE. Order sets developed for
  use in current paper ordering environment and in
  CPOE system

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Trillium Order Set Innovation

• Excellence in Order Set Design
• 5 years of iterative improvement in order set
  design
• Integration of real world feedback
• Intelligent knowledge representation to increase
  usability and clinical impact
• Order Set Process
• Real time integration of authoritative content
  expertise into order sets
• Dedicated Interdisciplinary Order Set Committee
• 9 member committee that meets weekly
• Clearly established processes for all aspects of
  the order set lifecycle initiation,
  development, approval implementation and
  maintenance
• Integration of order sets with other processes
  and documents

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Trillium Order Set Innovation

• Order Set Content
• Over 250 order sets developed
• Order sets used in every health system
• Content is interdisciplinary addressing all
  aspects of a patients care
• Web enabled searchable data base of all clinical
  decision support tools
• Interdisciplinary development teams
• Content experts own the content
• Order set committee provide process knowledge

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Open Source Order Sets

• Based on Trilliums award winning Order Set
  Project
• Dedicated to improving healthcare in Canada by
  facilitating the use of high quality,
  standardized evidence based order sets
• Partnering with other Health Care Organizations
  to standardize and improve the quality and safety
  of patient care
• Niagara Health System
• Open Source Order Sets
• Provide a complete order set solution
• Save organizations time, money and reduce demand
  on limited organizational resources
• Improve quality
• Local ownership and adaptation of tools

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Open Source Order Sets

• Standardized Order Set Design
• Standardized structure to order set content based
  on DAVID
• Rules of correct formatting at all levels of
  order set content
• Clear syntax of order set content
• Designed to anticipate CPOE
• Modular Format
• Best practices are contained in functional groups
• Facilitates the spreading of best practices
  across different order sets and across health
  systems
• Over 300 modules including many high value best
  practice modules such as deep vein thrombosis
  prophylaxis, bowel care, pain control,
  electrolyte management
• Order Set Lifecycle
• Order Set Committee
• Interdisciplinary membership
• Robust methodology for development, approval,
  implementation and maintenance

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Open Source Order Sets

• Large Library of Developed Content
• Over 250 order sets and clinical protocols
• Comprehensive interdisciplinary content
• Incorporation of real world experience
• Will grow to over 600 order sets in the next year
• Order Set Web Page
• Web accessible data base to store library of
  order set content
• Order sets clearly organized, searchable by many
  different criteria and relationships between
  order sets and clinical protocols clearly
  established
• Order Set Project Support
• On-site and remote support including physician,
  nursing, pharmacy
• Goal is rapid knowledge transfer

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Order Set Project Outline

• Establish an Order Set Committee
• Best practices around order set lifecycle
• Catalogue and upgrade legacy order set content
• Convert to standardized modular format
• Integrate new best practice content as
  appropriate
• Standardization of best practices across the
  organization
• Approval of new and upgraded order sets by the
  Order Set Committee
• Develop and Implement Order Sets
• Utilization of library of best practice content
• Adapt Open Source Order Sets to local health
  system needs
• New sets developed by content experts at Grey
  Bruce
• Comprehensive communication plan to facilitate
  adoption

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Order Set Project Outline

• Store order sets on an intranet accessible
  database
• Collection of data for metrics
• The measurement of improved outcomes is an
  important part of an order set project
• Order sets can have a dramatic impact on easily
  measured quality metrics in a very short time
  period
• Open Source Order Sets will work with you to
  select the key metrics that can be used to
  evaluate your project
• Number of order sets in use
• Order set adoption
• Adherence to best practices
• Before/after, cross-sectional analysis

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Benefits

• Save time
• Save money
• Improve the quality and safety of patient care
• Large improvements of easily measured metrics in
  short periods of time
• Improve order set design
• Increase order set use by physicians
• Increase the clinical impact of order set use
• Increase the standardization of best practices
  across the healthcare system
• Increase the knowledge base that can be used for
  order set development
• Hospitals are no longer developing order set
  content in isolation
• Improve the coordination of order sets with other
  order sets, documents and processes
• Improved coordination of health care delivery in
  Ontario

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Future

• The forces driving the need for order sets are
  accelerating
• Medical knowledge is increasing
• Complexity of treatments is increasing
• Effectiveness of treatments is increasing
• Care is delivered by large interdisciplinary
  teams
• Computerized Physician Order Entry requires order
  sets
• Recognition that effective orders must achieve
  many objectives simultaneously

• Quality
• Safety

• Workflow
• Resource utilization

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Why We Are Doing This?
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Why We Are Doing This?

• Share our award winning project with others
• Collaborate with other healthcare organizations
• Build a community of shared knowledge
• Potential to transform healthcare
• To standardize best practices across
  organizations
• To facilitate clinicians practice
• To improve the quality and safety of patient care
  we provide to all patients
• Save Lives

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Why We Are Doing This?

• Order Sets Save Lives
• Order Sets Deliver Better Care
• Order Sets Improve Efficiency

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• Standardize and automate that which is routine
  about a patients care so the clinician can
  focus on what is unique about each patient

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Thank You!

• Chris OConnor M.D. FRCPC
• Katharine De Caire ACNP