Surgical Unit-Based Safety Program

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Surgical Unit-Based Safety Program

• Proposed Resources for Partnership for Patients

Terri Conner, Ph.D. Nybeck Analytics Partnership
for Patients
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HOSPITALIZATIONS ARE RISKY

• In the U.S.
• 7 of patients suffer a medication error
• On average, every patient admitted to the ICU
  suffers an adverse event
• 44,000 98,000 people die in hospitals each year
  as the result of medical errors
• An additional 100,000 deaths from health-care
  associated infections
• Cost of HAI is 28-33 billion

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SURGERY IS RISKY

• 25 of in-patient surgeries are followed by a
  complication, many leading to
• Prolonged LOS
• Re-admission
• Death
• 50 of all hospital adverse events are linked to
  surgery
• At least 50 of adverse surgical events are
  preventable

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PROJECT GOALS

• To achieve significant reductions in surgical
  site infection and surgical complication rates
• Reducing complications reduces readmissions
• To achieve significant improvements in safety
  culture

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IMPORTANT POINTS

• Harm is preventable
• Many HAIs and complications are preventable, and
  should be viewed as defects
• Technical and adaptive work
• Focus on systems not on individuals
• Engage frontline staff to identify and fix local
  opportunities to improve

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SUSPNot Just a Checklist Program

• Informed by science
• Medical best evidence
• Social science
• Led by clinicians and supported by management
• Guided by measures

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SUSP INTERVENTIONS

• No single SSI prevention bundle
• Dive deeply into SCIP measures to identify local
  defects
• Emerging evidence
• Bowel prep
• Antibiotic redosing
• Chlorhexidine skin prep
• Capitalize on frontline wisdom to identify local
  opportunities to improve

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HOW WILL WE GET THERE?

• SUSP
• Technical component
• TRIP Translating Evidence into Practice
• Adaptive component
• CUSP Comprehensive Unit-based Safety Program

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SUCCESSFUL EFFORTS

• Michigan Keystone ICU program
• Reduction in central line-associated blood stream
  infections
• Reduction in ventilator-associated pneumonias

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TRIP Translating Evidence Into Practice

• Summarize the evidence
• Identify local barriers to implementation
• Measure performance
• Ensure all patients get the evidence
• 4 Es Model

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4 ES MODEL TO HELP IMPLEMENT PATIENT SAFETY
INTERVENTIONS

• Engage
• How does this make the world a better place?
• Educate
• What do we need to know?
• Execute
• What do we need to do?
• What keeps me from doing it?
• How can we do it with our resources and culture?
• Evaluate
• How do we know we improved safety?

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CUSP

• Comprehensive Unit-based Safety Program
• An intervention to learn from mistakes and
  improve safety culture
• A good approach whenever there is a gap between
  evidence-based practice and current practice on
  your unit.

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CUSP EMPHASIS ON CULTURE

• Shared attitudes, values, goals, practices,
  behaviors
• Culture influences behavior
• Participation in quality improvement efforts
• Communication
• Breakdown in communication contributes to nearly
  all adverse events.

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CUSP COMPREHENSIVE UNIT-BASED SAFETY PROGRAM

• Safety practices part of daily work
• Implemented at the unit level
• Led by clinicians
• Structured program, yet flexible

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PRE-CUSP STEPS

• Assemble Safety Team
• Multidisciplinary
• Different levels of experience
• Encourage joining team at any phase of the program

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PRE-CUSP STEPS

• Team Members frontline staff
• Project Leader (Unit Champion)
• Nurse Manager
• Physician Champion
• Senior Hospital Executive
• Patient Safety Coordinator
• Epidemiology / Infection Control
• Coach

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PRE-CUSP STEPS

• Measure Safety Culture
• Before CUSP implementation, and then every 12-18
  months
• Use AHRQs The Hospital Survey on Patient Safety
  Culture (HSOPS)
• All clinical and non-clinical providers
• Report results to the unit and senior hospital
  executive

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CUSP STEPS

1. Science of safety training
2. Identify defects
3. Assign executive to adopt unit
4. Learn from defects
5. Implement teamwork tools

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STEP 1 SCIENCE OF SAFETY TRAINING

• Goals
• Magnitude of patient safety problem
• Foundation for investigating safety defects
• Providers involvement significantly affects
  patient safety

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STEP 1 SCIENCE OF SAFETY TRAINING

• Learning Objectives
• Safety is a property of the system
• Use strategies to improve system performance
• Standardize work
• Create independent checks for key processes
• Learn from mistakes
• Apply strategies to both technical work and team
  work
• Teams make wise decisions with diverse and
  independent input

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STEP 1 SCIENCE OF SAFETY TRAINING

• Training Session
• 3-part Improving Safety presentation by Dr.
  Peter Pronovost
• Part 1 http//www.youtube.com/watch?vGOJJHHm7ln
  M
• Part 2 - http//www.youtube.com/watch?vwpzb7nM6oF
  Qfeaturerelated
• Part 3 - http//www.youtube.com/watch?v6BnXs4KtER
  8featurerelated
• Instruct staff on reporting of safety concerns
• Describe executive safety rounds

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STEP 2 IDENTIFY DEFECTS

• Eyes and ears of patient safety
• Ongoing process
• Disseminate Staff Safety Assessment Form
• Combine results and prioritize defects

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WHAT IS A DEFECT?

• Anything you do not want to have happen again.
• Many HAIs are preventable. They should be viewed
  as defects.

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STEP 2 IDENTIFY DEFECTS

• Staff Safety Assessment Form
• Purpose Tap into your knowledge and experiences
  at the frontlines of patient care to find out
  what risks are present on your unit that do or
  could jeopardize patient safety.
• All health care providers in the unit complete
  this form.
• 2-item questionnaire

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STEP 2 IDENTIFY DEFECTS

• Staff Safety Assessment Form
• Please describe how you think the next patient in
  your unit/clinical area will be harmed.
• Please describe what you think can be done to
  prevent or minimize this harm.

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STEP 2 IDENTIFY DEFECTS

• Combine Results
• Group into common types of defects
• Communication
• Medication process
• Patient falls
• Supplies
• Frequency distributions
• Example communication, 57

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STEP 2 IDENTIFY DEFECTS

• Prioritize safety concerns
• Obtain input from CUSP team senior executive
• Prioritize based on
• Likelihood of causing patient harm
• Severity of harm
• How common is the problem
• Likelihood it can be solved by implementing a
  daily work process

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STEP 4 LEARN FROM DEFECTS

• Four Key Questions
• What happened?
• Why did it happen?
• What will you do to reduce the chance it will
  recur?
• How do you know that you reduced the risk that it
  will happen again?

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WHAT HAPPENED?

• Reconstruct the timeline and explain what
  happened
• Put yourself in the place of those involved, in
  the middle of the event as it was unfolding
• Try to understand what they were thinking and the
  reasoning behind their actions/decisions
• Try to view the world as they did when the event
  occurred

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WHY DID IT HAPPEN?SYSTEM FAILURES

• Arise from managerial and organizational
  decisions that shape working conditions
• Often results from production pressures
• Damaging consequences may not be evident until a
  triggering event occurs
• Develop lenses to see the system factors that
  lead to the event

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WHAT WILL YOU DO TO REDUCE THE RISK OF IT
HAPPENING AGAIN?

• Prioritize most important contributing factors
• Prioritize most beneficial interventions
• Safe design principles
• Standardize what we do
• Create independent check
• Make it visible
• Safe design applies to technical and team work

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WHAT WILL YOU DO TO REDUCE THE RISK OF IT
HAPPENING AGAIN?

• Develop list of interventions
• For each intervention
• Rate how well the intervention solves the problem
  or mitigates the contributing factors for the
  accident
• Rate the team belief that the intervention will
  be implemented and executed as intended
• Select top interventions (2 to 5) and develop
  intervention plan
• Assign person, task follow-up date

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HOW DO YOU KNOW RISKS WERE REDUCED?

• Did you create a policy or procedure?
• Do staff know about policy or procedure?
• Are staff using the procedure as intended?
• Behavior observations, audits
• Do staff believe risks were reduced?

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STEP 4 LEARN FROM DEFECTS

• Summarize and Share Findings
• Learning from Defects Tool
• Detailed form for each incident or identified
  defect
• Case Summary Form
• Summarize the case
• Identify system failures
• Identify opportunities for improvement
• List actions taken to prevent future harm
• Share your findings

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STEP 4 LEARNING FROM DEFECTS

• Key Points
• Focus on systems, not people
• Prioritize
• Go mile deep and inch wide, rather than mile wise
  and inch deep
• Pilot test
• Learn from 1 defect a quarter
• Answer the four questions

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STEP 5 TEAM WORK TOOLS

• Staff Safety Assessment
• Safety Issues Worksheet
• Status of Safety Issues
• Learning from Defects Tool
• Case Summary Form
• Briefings/Debriefings
• SSI Investigation
• Audits

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STAFF SAFETY ASSESSMENT

• Used to identify defects in the unit
• Please describe how you think the next patient in
  your unit/clinical area will be harmed.
• Please describe what you think can be done to
  prevent or minimize this harm.

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SAFETY ISSUES WORKSHEET
Identified Issue Potential/ Recommended Solution Resources Needed Resources Not Needed
1.
2.
3.
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STATUS OF SAFETY ISSUES
New and Ongoing New and Ongoing New and Ongoing New and Ongoing New and Ongoing
Date Safety Issue Contact Status Goal
         
         
         
         
         
         
         
         
         
New and Ongoing New and Ongoing New and Ongoing New and Ongoing New and Ongoing
Date Safety Issue Contact Status Goal
         
         
         
         
         
         
         
         
         
Completed Completed Completed Completed Completed
Date Safety Issue Contact Status Goal
         
         
         
         
         
         
         
         
         
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LEARNING FROM DEFECTS

• Explain what happened.
• Check off the factors that negatively or
  positively contributed to the incident.
• Describe how you will reduce the likelihood of
  this defect happening again by completing the
  tables.
• Develop interventions, and choose 2-5 to
  implement.
• What will be done?
• Who will lead the intervention?
• When is follow-up?
• Describe how you know you have reduced the risk.
• Summarize your findings using the Case Summary
  Form.

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CASE SUMMARY FORM

• Form Sections
• Safety tips
• Case summary
• System failures
• Opportunities for improvement
• Actions taken to prevent harm

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BRIEFINGS / DEBRIEFINGS

• Dominant tool for SUSP
• Growing evidence
• Better team performance
• Better safety culture
• Reduction in delays
• Adapted to local hospital and OR
• Adapted to surgery type

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SSI INVESTIGATION TOOL

• Look into factors that may be systematically
  contributing to SSIs

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AUDITS

• Skin prep audits
• Antibiotic audits

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OTHER TOOLS

• Mislabeled specimens
• Wrong sided surgery
• Retained foreign objects

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SUSP IS A CONTINUOUS JOURNEY!!