Keystone Surgery: Science of Safety

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Keystone Surgery Science of Safety

• Johns Hopkins University
• Quality and Safety Research Group
• February 2008

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Case Is this death preventable

• 65 yo male admitted for elective colon surgery
• Multiple comorbid diseases DM, CHF, Afib
• Received ancef prophylaxis on call to OR
• 120 min prior to incision
• On admission to ICU
• Glucose 210 mg/dl
• Temp 35.0
• Developed fistula, renal failure, and SSI
• Died POD 64

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RAND Study Confirms Continued Quality Gap
McGlynn et al, NEJM 2003 348(26)2635-2645
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More than 5 years after IOM report

• No significant improvements
• -40 say quality of care is worse than 5
  years ago
• - 38 feel it is the same
• - Only 10 feel it has improved
• How do we know patients are safer?

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How can this happen?

• Need to view the delivery of healthcare as a
  science

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Sources ACP-ASIM Observer, 2001,
http//www.acponline.org/journals/news/feb01/clinr
esearch.htm Federal Funding and
Priorities for Health Services Research,
AcademyHealth, March 10, 2003.
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How can we improve

• System is a set of parts interacting to achieve a
  goal
• Every system is perfectly designed to achieve
  the results it gets

Caregivers are not to blame
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System Failures
Communication between resident and nurse
Inadequate training and supervision
Catheter pulled with Patient sitting
Lack of protocol For catheter removal
Patient suffers Venous air embolism
Reason
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• Rather than being the main instigators of an
  accident, operators tend to be the inheritors of
  system defects.. Their part is that of adding
  the final garnish to a lethal brew that has been
  long in the cooking.
• James Reason, Human Error,
  1990

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To Improve Reliability

• Standardize what is done, when it is done
• Reduce complexity
• Create independent checks for key processes
• How often do we do what we should
• Learn from defects
• How often do we learn from defects

Health Services Research 2006 Circulation (in
press)
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Catheter- Related Blood Stream Infections
(CR-BSIs)

• gt 2 million central venous catheters placed in
  U.S. ICUs annually
• 16,000 CR-BSI in U.S. ICUs annually
• Mortality 18 (0-35)
• Annual deaths 500 - 4,000
• Cost per episode 28,690-56,000
• Annual cost 60 - 460 million
• CDC. MMWR 2002 Heiselman JAMA 1994 Dimick Arch
  Surg 2001

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Eliminating CR-BSIs

• Apply 5 best practices
• Remove Unnecessary Lines
• Hand Hygiene
• Maximal Barrier Precautions
• Chlorhexidine for Skin Antisepsis
• Avoid Femoral Lines
• Decrease complexity
• Create redundancy (checklist)

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CR-BSI Rate
VAD Policy
Checklist
Line Cart
Daily goals
Empower Nursing
Crit Care Med 200432(10) 2014-2020
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Michigan Keystone ICU
N Engl J Med 20063552725-32
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Lessons Learned

• Harm is preventable
• Need to overcome prior beliefs that constrain
• Collaborative social network
• Ohana
• Hard to learn within single institution
• Learning network
• Culture is important
• Couple with clinical focus
• Can be improved

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Familiarity with others is a critical component
of effective teamwork

• 74 of all commercial aviation accidents happen
  on the first day of a crew flying together
• Familiarity trumps fatigue
• Highlights the importance of predictable patterns
  of behavior

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of respondents reporting above adequate teamwork
LD RN/MD ICU RN/MD OR RN/Surg
CRNA/Anesth
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Teamwork Disconnect

• RN Good teamwork means I am asked for my input
• MD Good teamwork means the nurse does what I say

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Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
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SAQ climate domains are linked to clinical and
operational outcomes in healthcare

• Wrong Site Surgeries
• Decubitus Ulcers
• Delays
• Bloodstream Infections
• Post-Op Sepsis
• Post-Op Infections

• Post-Op Bleeding
• PE/DVT
• RN Turnover
• Absenteeism
• VAP

Data provided by Bryan Sexton
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Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
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Teamwork Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
teamwork climate
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The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)

• Evaluate culture of safety
• Educate staff on science of safety
• Identify defects
• Assign executive to adopt unit
• 5. Implement teamwork tools Learn from one
  defect per month
• 6. Evaluate culture of safety

J Patient Safety 2005 Jt Comm J Qual Saf.
200430(2)59-68. http//www.jhsph.edu/ctlt/traini
ng/patient_safety.html
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Science of Safety Summary

• Accept that we will make mistakes
• Focus on systems rather than blame
• Standardize, create independent checks, and learn
  from mistakes
• CUSP is a structured approach to learn from
  mistakes and improve safety culture

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Breaking the 4-minute-mile

• Roger Bannister

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Who are we?

• 75 participating hospitals
• 48 hospitals completed readiness survey
• 27 urban, 21 rural (including 10 critical access)
• 45 community, 16 w/ residents, 3 academic
• Median bed size 172 (14 - 1000)
• Median annual surgical volume
• In-patient 2148 (34 21,500)
• Out-patient 4442 (469 15,269)

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Keystone SurgeryCollaborative Goals

• Develop a safety scorecard
• Eliminate surgical site infections, by ensuring
  that 90 of patients receive evidence-based
  interventions for preventing surgical site
  infections
• Eliminate mislabeled specimens
• Learn from our mistakes, in particular focusing
  on the National Quality Forums Never events
  (wrong site surgery and retained foreign bodies)
• Have 80 of your staff reporting positive safety
  and teamwork climate using a measurement
  instrument that is psychometrically sound.

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How will be get there?

• Use collaborative model to learn together
• Central support from MHA for technical work
  (evidence and measures)
• Local leadership to execute
• Ohana

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Perioperative Safety Scorecard

• How often do we harm patients?
• Eliminate surgical site infections
• How often do we do what we should?
• gt 90 compliance with SSI prevention process
  measures
• How often do we learn from defects?
• Learn from one per month- NQF never events
• How well do we improve culture?
• CUSP with quantitative assessment of culture

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Draft Timeline

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Next Steps

• Complete the readiness survey
• Discuss project with OR and hospital leaders
• Decide what OR teams to start with
• Consider initial focus on 2 specialties
• Create project team (surgeon, anesthesiologists,
  nurses, administrator) and meet to develop
  infrastructure select project manager
• Register for April workshop
• Educate staff on science of safety

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Dial-In Number 877-591-4958 Call Title
Keystone Surgery Confirmation 9014941
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Discussion