High Reliability Healthcare: What’s Holding Us Back?
High Reliability Healthcare: What’s Holding Us Back? Mark R. Chassin, MD, FACP, MPP, MPH President, The Joint Commission 5th International High Reliability Organizing Workshop Oakbrook Terrace, IL May 21, 2012 Current State of Quality Routine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of care Uncommon, preventable adverse events • Surgery on wrong patient or body part • Fires in ORs, retained foreign objects • Infant abductions, inpatient suicides “Joan Morris” “Joan Morris” is a 67 year old woman, admitted to telemetry unit for angiography and possible Rx of cerebral aneurysms Unexplained fall led to MRI, which showed two cerebral aneurysms She is a fluent English speaker and a high school graduate Her daughter is a physician Hospital Stay Cerebral angiography confirmed 2 aneurysms; one treated successfully Plan to discharge the next day After angio, she was “boarded” on oncology The next day, instead of being discharged, she was taken to the cardiac EP lab and an invasive procedure was performed More than two hours into the procedure, the team discovered they had the wrong patient Ann Int Med 2002;136:826 Wrong Patient: The Sequel www.webmm.ahrq.gov The “Right” Patient “Jane Morrison” had been transferred from an outside hospital (also to the telemetry unit) for an EP study. Ms. Morrison’s procedure had been delayed and was scheduled as the first case of the morning of Joan Morris’ discharge. Events in detail: 6:15-6:30am EP nurse (RN1) reviews EP schedule, calls telemetry, asks for “Morrison,” told (in error) that the patient was moved to the oncology floor RN1 calls oncology and is told (in error) that patient is there Joan Morris’ nurse (RN2), unaware of plan for procedure, checks with charge nurse, agrees to bring her to EP lab Events in detail: 6:30-6:45am Ms. Morris objects--says she is unaware of plan for procedure. RN2 says she can refuse when she gets to the EP lab RN2 brings patient down to EP lab with her chart Patient repeats reluctance to undergo procedure, says she is nauseated Events in detail: 6:45-7:00am RN1 pages EP attending MD; patient tells attending on phone that she does not want procedure and is nauseated EP attending had met the “right patient” the night before but does not recognize difference in voices Attending tells RN1 patients agrees to proceed and to give drug for nausea Events in detail: 7:00-7:15am RN1 reviews chart, notices no consent form, pages EP fellow (the physician who will perform the procedure) EP fellow reviews chart, is surprised at lack of pertinent information He discusses procedure with patient She signs the consent form To What Did Ms. Morris Consent? Cardiac electrophysiology study AND possible surgery for... Cardiac defibrillator implant Pacemaker implant “Informed” Consent Properly conducted, it should protect patients from errors like this In practice, the process often fails to achieve its theoretical benefits In 2 different studies, 60+% of patients agreed that: “Consent forms are designed to protect physicians’ rights” Events in detail: 7:15-7:30am Neurosurgery resident had gone to see Ms. Morris prior to discharge, found her room empty He goes down to EP lab, demands to know why “his patient” is there RN1 says patient had been bumped from schedule previously He leaves, assuming his attending ordered the study without telling him Events in detail: 7:30-8:00am RN3 administers IV sedation EP attending MD and RN4 arrive Fellow begins procedure, inserts large tube into femoral artery, threads EP catheter up the aorta into the heart EP attending MD, who had met Ms. Morrison the previous evening, takes his position at computer outside room Events in detail: 8:30-8:45am Jane Morrison’s nurse (RN5) calls EP lab, asks why no one has called for her RN3 consults with nurse scrubbed in on the case (RN4), advises RN5 to send Ms. Morrison down at 10am EP charge nurse notices stickers she made for Joan Morris do not match any of the names on the EP schedule Events in detail: 8:30-8:45 EP charge nurse comes into lab, questions fellow about the names Fellow says: “This is our patient!” Charge nurse leaves She assumes Ms. Morris (the wrong patient) was a late addition to the printed schedule Events in detail: 9:00-9:15am Radiology attending MD comes to see Joan Morris, finds her room empty, and is told she was sent to EP lab Calls EP lab to ask why she is there EP attending speaks to Radiology attending, who asks about Joan Morris. EP attending tells nurse that the call concerns patient named Morris, while Jane Morrison is on the table Events in detail: 9:15-9:30am The EP charge nurse says that Joan Morris is on the table EP attending asks to see the chart and recognizes the error The study is halted. Ms. Morris returns to her room. Both physicians explain error to the patient and her physician daughter Summary Many people made many errors Most (but not all) errors were small No single error caused the event Many chances to avoid this event • How many failed to speak up? • How many failed to recognize the unsafe conditions and practices? These conditions are very common Defenses That Failed Communication (at multiple levels) Protocols for patient identification Teamwork within services Coordination between services Supervision of trainees Informed consent process Safety culture that assures staff recognize unsafe conditions and speak up The Swiss Cheese Model Defenses with Weaknesses The Swiss Cheese Model Errors Defenses with Weaknesses Harm High Reliability Science Research has defined how HROs produce sustained excellence over time No health care organizations function at this high level of sustained safety No guidance on how to transform organizations from low to high reliability How do we create blueprints for health care to build high reliability? Leadership High Reliability Trust RPI Improve Report Health Care Safety Culture From Health Affairs Health Affairs 2011;30:559-68 High Reliability Self-Assessment Leadership • Board, CEO, physicians • Quality strategy, quality measures, IT Safety culture • Trust and accountability • Identifying unsafe conditions or practices • Strengthening systems, measurement Robust process improvement • Methods, training, spread Stages of Maturity High Reliability Self Assessment Tool (HRST) • Series of questions, branching logic • All 14 components are assessed Four stages of maturity for each component • Beginning • Developing • Advancing • Approaching Robust Process Improvement Systematic approach to problem solving: (RPI = lean, six sigma, change management) The Joint Commission is adopting RPI • Improve processes and transform culture • Focus on our customers, increase value The Joint Commission is adopting all components of safety culture We measure RPI and safety culture and report on strategic metrics to Board Center for Transforming Healthcare www.centerfortransforminghealthcare.org Center for Transforming Healthcare Customers asking us for solutions Delivering products at no added cost • TJC: $20M; 9 other major donors • AHA, BCBSA, BD, Cardinal Health Ecolab, GE, GSK, J&J, Medline 2009: hand hygiene, wrong site surgery and hand-off communications 2010: colorectal surgery SSIs 2011: safety culture, preventable HF hospitalizations, and falls with injury Participating Hospitals Atlantic Health Barnes-Jewish Baylor Cedars-Sinai Cleveland Clinic Exempla Fairview Froedtert Intermountain Johns Hopkins Kaiser-Permanente Mayo Clinic Memorial Hermann NY-Presbyterian North Shore-LIJ Northwestern OSF Partners HealthCare Stanford Hospital Trinity Health Virtua Wake Forest Baptist Wentworth-Douglass Current State of Quality Routine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of care Uncommon, preventable adverse events • Surgery on wrong patient or body part • Fires in ORs, retained foreign objects • Infant abductions, inpatient suicides Current State of Improvement Usual approaches: best practices, toolkits, protocols, checklists, “bundles” • Describe a specific set of process steps that must be followed to solve a problem • ICU central line protocol, VAP bundle They produce consistent results only in limited circumstances • Process varies little from place to place • Causes of failure are few and common A New Approach is Promising Best practices often fail to achieve consistently excellent results, because: • Complex processes require more sophisticated problem solving methods • Many causes for the same problem • Each cause requires a different strategy • Key causes differ from place to place Next generation of best practices will use RPI to produce solutions---customized to an organization’s most important causes Wrong Site Surgery Best estimate = 40 per week in US Joint Commission Universal Protocol has not solved the problem High rates of risks introduced in 3 areas: • Scheduling: 39% of cases had risks • Pre-op area: 52% of cases had risks; 25% with multiple risks • OR: 59% of cases had risks; 32% with multiple risks Risks of Wrong Site Surgery Scheduling: incomplete data, verbal requests, lack of standardization Pre-op area: missing documents, inadequate patient ID, time pressures lead to rushing, non-surgeon marks site, marking inconsistent, use of non-approved markers OR: mark covered by drapes, distractions, time out performed without full participation, staff are not empowered to speak up, verification omitted with multiple procedures The Swiss Cheese Model Defenses with Weaknesses Reducing the Risks Hospitals and ASCs targeted specific interventions to the risks they uncovered Relative Risk Reduction Scheduling: 46% Pre-op: 63% multiple risk cases 72% OR: 51% multiple risk cases 75% 1. 2. 3. 4. 5. Some Important Causes of Hand Hygiene Failures Faulty data on performance Inconvenient location of sinks or hand gel dispensers Hands full Ineffective education of caregivers Lack of accountability Each requires a very different strategy to eliminate Causes Differ by Hospital Each letter = one hospital Results are Consistent More sophisticated improvement methods (RPI) required for complex problems • Measure and discover specific causes • Identify how causes vary among different organizations and settings • Target interventions to specific causes to maximize effectiveness • Avoid wasting resources by targeting This is the Center’s unique capability Targeted Solutions Tool (TST) Uses secure, established extranet channels • No added cost, voluntary, confidential • Can assess performance across system Educational, no jargon, no special training Guides users to customized, proven solutions Targeting only your causes means you don’t use resources where they aren’t needed Hand hygiene and WSS available now; will add hand-off communication later this year Results Through April 2012 666 projects are using interventions • Baseline = 52.4% (n = 75,451)* • Improve = 75.5% (n = 204,982)* Results Through April 2012 666 projects are using interventions • Baseline = 52.4% (n = 75,451)* *p<0.0001 • Improve = 75.5% (n = 204,982)* Results Through April 2012 666 projects are using interventions • Baseline = 52.4% (n = 75,451)* *p<0.0001 • Improve = 75.5% (n = 204,982)* Unit Baseline Improve • Adult critical care 52% 71% • Emergency dept. 46% 74% • Adult med-surg 46% 75% • Pediatric critical care 62% 81% • Long term care 55% 73% C. Difficile Rate Declines as Hand Hygiene Improves Hand Hygiene Compliance (%) 1.3 1.2 90 1.1 80 1 HH 0.9 C diff 0.8 70 60 0.7 0.6 50 0.5 40 0.4 2007 2008 2009 2010 2011 C. difficile Cases (per 1000 patient days) 100 MRSA Rate Decreases as Hand Hygiene Improves Hand Hygiene Compliance (%) 2.5 90 2.0 80 HH 1.5 70 MRSA 60 1.0 50 0.5 40 0.0 30 2008 2009 2010 MRSA Cases (per 1000 patient days) 100 The Joint Commission and High Reliability Consistent excellence is the vision Leadership + safety culture + RPI All Joint Commission programs and activities are aligning around this aim: • Accreditation, performance measurement • JCR education, publication, consulting • Center-developed improvement solutions Help customers improve no matter where they are on the journey to high reliability
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