Hospital Performance and Best Practice Management: Altering systems of care in the hospital to impro

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Hospital Performance and Best Practice
ManagementAltering systems of care in the
hospital to improve patient safety

• J. Christopher Farmer

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Discussion points

• Overcoming the culture change does not apply to
  me
• Knowing what changes make a positive difference
• Overcoming the impact of human factors
• Making positive changes durable

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The Mom Test

• If your mom becomes an ICU patient..
• Does experience level matter? (intubation,
  central line placement, advanced medical
  decision-making)
• Are your expectations different at 2PM from 2AM?
• What level of communications do you expect?
  Assigned nurse vs. resident vs. attending
  physician? Every day?
• What are your expectations regarding supervision
  of learners caring for your mom?

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Universal laws that we often forget...

• Todays problems come from yesterdays solutions
• Dividing an elephant in half does not produce two
  small elephants
• Cause and effect are not closely related in time
  and space
• Behavior grows better before it grows worse
• The harder you push, the harder the system pushes
  back
• Small changes can produce big results, but the
  areas of highest leverage are often the least
  obvious

From The Fifth Discipline by Peter Senge 1990
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Quality lapses in the hospital...where are the
brakes?

• Systems of care versus individuals
• Communications
• Education
• Failure to recognize
• Failure to rescue
• Non-integration

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What is patient safety?

• The absence of harm
• The presence of quality
• The perception of value

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Quality versus patient safety...

• Clinical acts versus care processes aimed at
  prevention
• Prevention of adverse events
• Compliance with the rules

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Yes, the details are important...

• Protocolized (standardized) management improves
  clinical outcomes (published data)
• Sepsis
• Acute myocardial infarction
• Central line insertion and catheter site
  maintenance
• Ventilator use strategies in ARDS
• Ventilator bundle
• Glucose control
• Sedation and delirium management
• Surgical site wound care
• Daily goals sheet (communications tool)
• Communications tools for assessment and transfer
  to lower levels of care
• Rapid response teams
• Multidisciplinary, team-based rounds
• Use of remote ICU virtual presence monitoring by
  intensivists and critical care nurses
• On-site intensivist program
• On-site hospitalist program
• Adverse drug event prevention program

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Sepsis bundle
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Sepsis putting it all together

• Revised and implemented a Severe Sepsis and
  Septic Shock order set that includes all
  components of the Sepsis Resuscitation and Sepsis
  Management Bundles
• Targeted early sepsis recognition
• Instituted sepsis screening in the ICU, using the
  IHI screening tool, on all new admissions and
  patients with greater than three-day length of
  stay (LOS)
• Incorporated screening into multidisciplinary
  rounds and the Patient Daily Goals/Plan of Care 
• Implemented a Sepsis Alert screening tool in
  the Emergency Department (ED) Posted Sepsis
  Alert Screen in ED rooms and on ED chart backs as
  prompters to staff
• Added sepsis screening to the ED standardized
  T-System documentation for all ED patients
• Implemented screening on Medical Response Team
  (MRT) calls
• Instituted ED chart review of patients admitted
  with a sepsis diagnosis to monitor compliance
  with appropriate screening and initiation of the
  Sepsis Resuscitation Bundle gave feedback to ED
  staff and physicians
• Prioritized ED/ICU collaboration for timely
  transfer of septic patients to ICU ED nurse
  notified the ICU float charge nurse of positive
  sepsis screens 
• Initiated sepsis resuscitation (lactates, blood
  cultures, antibiotics, fluid resuscitation) in
  the ED as indicated
• ED staff and physicians were educated to the
  Sepsis Resuscitation Bundle
• Intensivists assisted the ED as needed
• Focus was on prompt transfer of patients to ICU
  for insertion of central venous oximetry
  catheters 
• Placed prompters in the ED to collect blood
  cultures prior to first dose antibiotic
  administration 
• Implemented components of the Sepsis
  Resuscitation and Sepsis Management Bundles in
  ICU using a systematic, incremental approach
• Began by obtaining orders for lactates for all
  positive sepsis screens
• Tracked the volume of lactates collected in ED
  and ICU 
• Added absolute neutrophils to CBC and CBCI
  reports 
• Added prompters for the Resuscitation Bundle to
  the sepsis screening tools in ED and ICU

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Daily goals sheet
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Which metrics define patient safety?
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Which metrics define patient safety?
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The Six Sigma model has three aspects

• Process Improvement focuses on improving broken
  processes.
• Process Design is aimed at developing something
  from nothing. The new products and services will
  encompass Six Sigma principles.
• Process Management translates Six Sigma in every
  day management decisions through the use of
  measurement systems.

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Living with 99.9...

• 84 unsafe airline landings/day
• 1 major plane crash every three days
• 16,000 items of lost mail/hour
• 37,000 ATM errors/hour

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Hand washing...are we passing the test?

• Average compliance in a U.S. Hospital 50
• 60 of CRBSI are S. aureus Coagulase negative
  staph
• Almost half of S. aureus-related CBRSI are MRSA
• Increasing incidence of C. difficile VRE

Since we cant reliably force compliance with
our current processes, then maybe we should
consider redesigning the processes themselves?
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The ancient approach to human factorsThe Code
of Hammurabi

• If the surgeon has made a deep incision in the
  body of a free man and has caused the mans death
  or has opened the carbuncle in the eye and so
  destroys the mans eye, they shall cut off his
  forehand.

Circa 2000 B.C.
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Re-design systems for...

• Prevention
• Detection
• Mitigation

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The impact of human factors

• Human Factors Engineering (HFE) are activities
  such as
• function task analysis
• workload analysis
• human error modeling
• system ergonomics
• human machine interface design
• usability testing
• workspace layout contribute to an efficient,
  effective, usable and safe product, system or
  environment

These contribute to an efficient, effective,
usable and safe product, system, or environment
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The impact of human factors

• Human Factors Integration (HFI) is
• a philosophy and set of management processes and
  tools that ensure human issues are identified,
  collated, shared and impact minimized
• Actively managing human factors and planning how
  human issues will be shared and acted upon by
  other teams or disciplines (e.g. system
  engineering, logistics, software)

We must accept that human error as inevitable
and design around that fact.Donald Berwick
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And how does inpatient medicine score?
Afessa et al, Crit Care Med, 2008
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Changing processes AND changing the culture!

• This is a leadership challenge!
• Must accomplish systems level changes that
  facilitate success
• Must study the processes with analytical
  discipline in order to make the correct changes
• Management by walking around
• What is the hospital leadership change management
  plan?

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An incremental approach

• Develop a strategic plan for necessary changes in
  the hospital
• Timeline, deliverables, accountable individuals,
  metrics of success
• Begin with a project that will establish a record
  of success
• Pick the correct team members
• Consider the use of an outside consultant to help
  articulate the current state, define
  priorities, techniques, leaders, methods,
  outliers (who will cause problems)
• A credible consultant can say and do things
  without alienating staff, and they will listen!

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By far the most dangerous foe we have to fight
is apathy - indifference from whatever cause, not
from a lack of knowledge, but from carelessness,
from absorption in other pursuits, from a
contempt bred of self satisfaction.Sir William
Osler, 1932