Overview of AHRQ Resources to Improve Patient Safety

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Overview of AHRQ Resources to Improve Patient
Safety

• September 15, 2009

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Agenda

• Overview Introduction
• Jeff Brady, M.D., AHRQ, CQuIPS
• Speakers
• Erin Hartman, M.S., University of California, San
  Francisco
• Jim Battles, Ph.D., AHRQ, CQuIPS
• Greg Maynard, M.D., University of California, San
  Diego
• Kerm Henriksen, Ph.D., AHRQ, CQuIPS
• Farah Englert, AHRQ, OCKT

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To Err is Human Building a Safer Health System

• 44,000 98,000 deaths/yr
• 8th leading cause of death in US
• National Costs 17 to 29 billion
• 2 billion Adverse Rx event costs alone
• 2 hospital admissions (preventable)
• Add 4,700 in costs to each hospitalization

Institute of Medicine, 1999
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Personal Experience with Medical Errors
The percentage who said they have been personally
involved in a situation where a preventable
medical error was made in their own medical care
or that of a family member?
(Source Kaiser Family Foundation surveys)
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AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
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Patient Safety Portfolio

• To improve the quality of care delivered to
  patients by decreasing or eliminating health care
  risks and harms.
• Increased emphasis on implementation
• Continued investment in research

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AHRQ Core Business Areas

• Creation of Knowledge
• Synthesis and Dissemination
• Implementation and Use

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AHRQ Patient Safety Budget
Projected
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Patient Safety Portfolio Broad Areas of
Emphasis

• Create new knowledge about safe practices and
  optimal structure for care.
• Build research capacity by stabilizing upstream
  investment to keep the research pipeline flowing.
  
• Address methodological and core scientific
  questions e.g., Evidence Report on Patient
  Safety Practices.
• Disseminate patient safety products effectively
  for implementation.
• Continue to engage in field-based partnerships
  (HAI ACTION)
• Seize opportunities for national implementation
  of safe practices

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AHRQ Patient Safety Resources

• AHRQ PSNet
• AHRQ WebMM
• TeamSTEPPS Creating a safety Net for Healthcare
  Organization
• TeamSTEPPS Rapid Response System Module
• Hospital Survey on Patient Safety Culture
• Hospital Survey on Patient Safety Culture 2009
  Comparative Database Report
• Nursing Home Survey on Patient Safety Culture
• Medical Office Survey on Patient Safety Culture
• Preventing Hospital-Acquired Venous
  Thromboembolism A Guide for Effective Quality
  Improvement
• 
  Continued..
  

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AHRQ Patient Safety Resources

• Transforming Hospitals Designing for Safety and
  Quality
• Advances in Patient Safety From Research to
  Implementation
• Advances in Patient Safety New Directions and
  Alternative Approaches
• Patient Safety and Quality An Evidence-Based
  Handbook for Nurses
• Patient Safety Improvement Corps Tools, Methods,
  and Techniques for Improving Patient Safety
• 10 Patient Safety Tips for Hospitals
• Guide for Developing Patient Safety Councils
• Your Guide to Preventing and Treating Blood Clots
• Blood Thinner Pills Your Guide to Using Them
  Safely

http//www.ahrq.gov/qual/errorsix.htm
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A world of patient safety information at your
fingertips

• AHRQ Patient Safety Network (PSNet) and WebMM

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AHRQ Patient Safety Network (PSNet)

• A national one-stop portal featuring a
  collection of resources and content about
  improving patient safety and preventing medical
  errors
• Offers weekly updates of patient safety
  literature, news, tools, conferences, as well as
  wide variety of information on patient safety
• Diverse users can customize the site around their
  unique interests by creating a My PSNet page
• Web site http//psnet.ahrq.gov

psnet.ahrq.gov
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Search
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Patient Safety Primers
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AHRQ WebMM Morbidity Mortality Rounds on the
Web

• Online journal featuring expert analysis of real
  medical error cases, perspectives on patient
  safety, and interviews with experts
• Users submit cases of errors anonymously
• Continuing education credit (CME/CEU) available
• Web site http//webmm.ahrq.gov

webmm.ahrq.gov
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Evidence-based Team Training and Implementation
Toolkit

• Set of ready-to-use materials and training
  curricula to integrate teamwork principles
• More than 900 people have been trained as
  TeamSTEPPS trainers as of July 2009
• Collaboration between AHRQ and Department of
  Defenses military health system

http//teamstepps.ahrq.gov/
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TeamSTEPPS Rapid Response Module

• Rapid Response Systems ? composed of teams of
  clinicians who bring critical care expertise to
  patients requiring immediate treatment while
  under hospital care
• Discusses how communication and teamwork
  strategies taught via TeamSTEPPStools can work
  for Rapid Response Systems
• CD includes
• PowerPoint presentations
• Teaching modules
• Video vignettes

AHRQ Publication No. 08(09)-0074-CD.
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AHRQ Suite of Patient Safety Culture Survey Tools

• Suite of tools that measure patient safety
  culture in
• Hospitals
• Medical offices
• Nursing homes
• Tools include survey instruments and report
  templates
• User's Guide provides information on
• Getting started
• Selecting a sample
• Determining data collection methods
• Establishing data collection procedures
• Conducting a Web-based survey
• Preparing and analyzing data
• Producing reports

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Hospital Survey on Patient Safety Culture

• Helps hospitals and health systems evaluate
  employee attitudes about patient safety in their
  facilities or within specific units
• Includes survey guide, survey, and feedback
  report template to customize reports
• AHRQ partnership with Premier, Inc., Department
  of Defense, and American Hospital Association
• http//www.ahrq.gov/qual/hospculture/ or e-mail
  to ahrqpubs_at_ahrq.gov

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Hospital Culture Survey Comparative Database

• Provides results hospitals can use as benchmarks
  in establishing a patient safety culture.
• Features a narrative description of the survey
  findings, with results by hospital and respondent
  characteristics, as well as trending results for
  98 hospitals that submitted data from previous
  and most recent safety culture surveys.
• Appendixes provide data tables and show trends
  over time.

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Nursing Home Survey on Patient Safety Culture

• Pilot tested in 40 nursing homes
• Survey materials and technical assistance for
  survey administration are free  
• Use the survey to
• Capture opinions of staff at all
  levels
• Assess 12 domains of patient
  safety culture
• Benchmark and evaluate
  patient safety efforts
• Track changes in patient
  safety culture over time

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Medical Office Survey On Patient Safety Culture

• Pilot tested in 200 offices
• Free survey materials and technical assistance
  for survey administration
• Designed for providers and staff in
  medical offices
• Includes about 50 items in 12 areas
  (e.g.Teamwork, Staff Training)
• Tracks changes in patient safety and
  evaluate interventions over time

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Guide Available for Deep Vein Thrombosis

• Developed from Partnerships in Implementing
  Patient Safety program toolkit
• Based on quality improvement initiatives
  undertaken at the University of California, San
  Diego Medical Center and Emory University
  Hospitals
• Assists quality improvement practitioners in
  preventing one of the most important problems
  facing hospitalized patients - DVT / PE (VTE)

http//www.ahrq.gov/qual/vtguide/
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Why build a toolkit for VTE Prevention?

• VTE is a common source of inpatient MM
• Jumbo jet crash / day- gt Breast CA, HIV, MVA
  combined
• May be 1 preventable source of hospital death
• Effective and safe methods of prevention exist
• Large implementation gap - best practice ?
  current practice
• These methods are grossly underutilized
• Awareness, difficulty implementing, no validated
  risk assessment
• P4P, public reporting, and core measures

Geerts WH, et al. Chest. 2008133381S-453S. Cohen
, Tapson, Bergmann, et al. ENDORSE study Lancet
2008 371 38794. Surgeon Generals Call to
Action to Prevent DVT and PE 2008 DHHS
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To Achieve Improvement

• Real institutional support / prioritization
• Will to standardize
• Physician leadership
• Measurement of process / outcomes
• Protocol, integrated into order sets
• Education
• Continued refinement / tweaking- PDSA

SHM and AHRQ Guides on VTE Prevention
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Hierarchy of Reliability
Predicted Prophylaxis rate
Level

• No protocol (State of Nature)
• Decision support exists but not linked to order
  writing, or prompts within orders but no decision
  support
• Protocol well-integrated
• (into orders at point-of-care)
• Protocol enhanced
• (by other QI / high reliability strategies)
• Oversights identified and addressed in real time

1
40
50
2
3
65-85
4
90
5
95
Protocol standardized decision support,
nested within an order set, i.e. what/when
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The Essential First Intervention
VTE Protocol

• 1) a standardized VTE risk assessment, linked to
• 2) a menu of appropriate prophylaxis options,
  plus
• 3) a list of contraindications to pharmacologic
  VTE prophylaxis
• Challenges
• Make it easy to use (automatic)
• Make sure it captures almost all patients
• Trade-off between guidance and ease of use /
  efficiency

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Low Medium
High
Example from UCSD Keep it Simple A 3 bucket
model
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IPC needed if contraindication to AC exists
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Map to Reach Level 3Implementing an Effective
VTE Prevention Protocol

• Examine existing admit, transfer, periop order
  sets with reference to VTE prophylaxis.
• Design a protocol-driven DVT prophylaxis order
  set (w/ integrated risk assessment)
• Vette / Pilot PDSA
• Educate / consensus building
• Place new standardized DVT order set module
  into all pertinent admit, transfer, periop order
  sets.
• Monitor, tweak - PDSA

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N 2,944 mean 82 audits / month
In press, JHM 2009
In press, Maynard, Morris et al, J Hosp Med
Real time ID intervention
Order Set Implementation Adjustment
Consensus building
Baseline
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Hierarchy of Reliability
Predicted Prophylaxis rate
Level

• No protocol (State of Nature)
• Decision support exists but not linked to order
  writing, or prompts within orders but no decision
  support
• Protocol well-integrated
• (into orders at point-of-care)
• Protocol enhanced
• (by other QI / high reliability strategies)
• Oversights identified and addressed in real time

1
40
50
2
3
65-85
4
90
5
95
Protocol standardized decision support,
nested within an order set, i.e. what/when
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Map to Reach Level 595 prophylaxis

• Use MAR or Automated Reports to Classify all
  patients on the Unit as being in one of three
  zones
• GREEN ZONE - on anticoagulation
• YELLOW ZONE - on mechanical prophylaxis only
• RED ZONE on no prophylaxis
• Act to move patients out of the RED!

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Situational Awareness and Measure-vention
Getting to Level 5

• Identify patients on no anticoagulation
• Empower nurses to place SCDs in patients on no
  prophylaxis as standing order (if no
  contraindications)
• Contact MD if no anticoagulant in place and no
  obvious contraindication
• Templated note, text page, etc
• Need Administration to back up these
  interventions and make it clear that docs can not
  shoot the messenger

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Collaborative Efforts and Kudos

• SHM VTE Prevention Collaborative I - 25 sites
• SHM / VA Pilot Group - 6 sites
• SHM / Cerner Pilot Group 6 sites
• AHRQ / QIO (NY, IL, IA) - 60 sites
• IHI Expedition to Prevent VTE 60 sites
• SHM Team Improvement Award
• NAPH Safety Net Award
• Venous Disease Coalition

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AHRQ Simulation Grants

• For research in 2007/2008 AHRQ sponsored 19
  simulation grants for more than 10 million
• 2-year cooperative agreements
• Focused on practitioners and teams in a variety
  of clinical settings using a diverse range of
  simulation techniques
• Intent was to inform researchers, providers,
  health educators, patients, policy makers,
  payers, and the public

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AHRQs Grants - A Diverse Range of Simulated
Clinical Applications

• Central venous catheter insertion
• High volume ambulatory surgical procedures
• Diagnosis of melanoma
• Obstetric emergency response drills in rural
  hospitals
• Disclosure of medical error
• Improving teamwork culture of safety
• Patient-tracking systems in the emergency
  department
• Acute coronary syndrome management in rural
  setting
• Medication administration
• Rapid response emergency team training

• Management of acute care events by graduate
  physicians
• Airway management in the pediatric intensive care
  unit
• Training rapid response teams
• Emergent cesarean deliveries
• Three-dimensional virtual reality team training
• Patient care hand-offs
• Postanesthesia care unit communication
• Pediatric emergency care
• Resuscitation team response in small rural
  hospitals

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Evidence Based Design

• Build Private Rooms
• Reduce Noise
• Incorporate Nature
• Improve Air Quality
• Encourage Hand Hygiene
• Improve Wayfinding
• Reduce Walking Distance

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Transforming Hospitals Designing for Safety and
Quality

• A DVD that demonstrates how evidence-based design
  can improve the quality and safety of hospital
  services while improving staff satisfaction and
  retention
• Case studies of three hospitals illustrate the
  benefit of incorporating evidence-based design
  principles into new construction or renovation
  projects

AHRQ Publication No. 07-0076-DVD
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Advances in Patient Safety From Research to
Implementation

• Four-volume set of 140 peer-reviewed articles
  representing an overview of patient safety studies

AHRQ Publication No. 05-0021-CD
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Advances in Patient Safety New Directions and
Alternative Approaches

• Describes new patient safety findings,
  investigative approaches, process analyses,
  lessons learned, and practical tools to prevent
  harming patients
• 4-volume set or 1 CD of 115 articles on reporting
  systems, risk assessment, safety culture, medical
  simulation, patient safety tools and practices,
  health information technology, medication safety,
  and more

AHRQ Publication No. 08-0034 (print copy) or
08-0034-CD (Searchable CD-ROM)
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Handbook for Nurses

• Comprehensive, 1400-page handbook for nurses on
  patient safety and quality.
• Experts in the field reviewed the literature, and
  their contributions are grouped into sections
  that address
• Patient safety and quality
• Evidence-based practice
• Patient-centered care
• Working conditionswork environment
• Critical opportunities for patient safety and
  quality
• Tools

AHRQ Publication No. 08-0043 (print copy) or
08-0043-CD (CD-ROM)
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Patient Safety Improvement Corps

• DVD features a self-paced, modular approach to
  training individuals involved in patient safety
  activities at the institutional level.
• Modules address
• Investigation of medical errors and their root
  causes.
• Identification, implementation, and evaluation of
  system-level interventions to address patient
  safety concerns.
• Steps necessary to promote a culture of safety
  within a hospital or other health care facility.

AHRQ Publication No. 07-0035-DVD
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10 Patient Safety Tips for Hospitals

• Evidence-based tips help hospitals promote
  patient safety
• Go to http//www.ahrq.gov/qual/10tips.pdf

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Guide for Developing Patient Safety Councils

• Provides information and guidance to empower
  individuals and organizations to develop a
  community-based advisory council
• Councils involve patients, consumers, and a
  variety of practitioners and professionals from
  health care and community organizations
• Councils drive change for patient safety through
  education, collaboration, and consumer engagement

http//www.ahrq.gov/qual/advisorycouncil/
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Blood Clot Prevention

• Deep vein thrombosis is a potentially deadly
  medical problem that affects at least 350,000 and
  possibly as many as 600,000 Americans each year
• 24-page easy-to-read booklet in English and
  Spanish that helps both patients and their
  families
• Identify the causes and symptoms of dangerous
  blood clots.
• Learn tips on how to prevent them.
• Know what to expect during treatment.
• Created by experts funded through AHRQ's
  Partnerships in Implementing Patient Safety grant
  program

http//www.ahrq.gov/consumer/bloodclots.htm
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Blood Thinner Pills Your Guide to Using Them
Safely

• Consumer publication and DVD explain what to
  expect and watch out for while taking blood
  thinner pills
• Based on research originally conducted by one of
  AHRQs Partnership for Implementing Patient
  Safety grant projects
• Educates patients about
• Medication therapy and potential side
  effects
• How to communicate effectively with their health
  care providers
• Tips for lifestyle modifications

http//www.ahrq.gov/consumer/btpills.htm
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How to Order?

• Ordering information for AHRQ Publications
  Products available at
• http//www.ahrq.gov/news/pubsix.htm

Call the AHRQ Publication Clearinghouse at
1-800-358-9295 Send an email to
AHRQPubs_at_ahrq.hhs.gov