Proactive Strategies to Reduce Risk for Physicians

1. Proactive Strategies to Reduce Risk for Physicians Solutions to Communication Challenges and Error Prevention Michael Handler, MD Becky Miller, MHA, CPHQ, FACHE, CPPS

2. Today’s Presentation • Two components • Solutions to communication challenges and the reduction of error • Proactive strategies to reduce risk for physicians

3. Objectives • Explore new ways of enhancing communication between physicians and healthcare providers • Discuss strategies to resolve differences between physicians and hospital staff as they occur • Identify strategies to reduce risk through a safety culture evaluation, event reporting and collaboration

4. Proactive Strategies to Reduce Risk • Burning Platform • Institute of Medicine Report, “To Err is Human”, 1999 • Need to keep our patients safe—the right thing to do • Increased demand for transparency, accountability and public reporting • Medical malpractice/Tort reform concerns • Changing structure of healthcare delivery models

5. Solutions to the Challenges • Evaluation and improvement of the safety culture • Proactive risk reduction strategies • Collaboration and communication • Learning, sharing and prevention!

6. Enhanced Teamwork & Communication A Solution to Reducing Risk –

7. Solutions to Communication Challenges • Communication—interaction between any two anythings • Must permeate every single interaction in patient care • Failure to communicate is easily one of the most common root causes in medical errors

8. Solutions - TeamSTEPPS • Team strategies to enhance performance and patient safety • Program developed in collaboration between the AHRQ and the Department of Defense • Similar to crew resource management from the aviation industry

9. Solutions - TeamSTEPPS • Based on four teachable learnable skills • Leadership • Situation awareness • Mutual support • Communication All interact to create desired outcomes of team competencies

10. TeamSTEPPS - Outcomes of Team Competencies • Knowledge • Shared Mental Model • Attitudes • Mutual Trust • Team Orientation • Performance • Adaptability • Accuracy • Productivity • Efficiency • Safety

11. Solutions - TeamSTEPPS • Designed primarily for high risk units in hospitals • OB • ED • ICU • Surgery or other procedural areas • Skills are be applied in any setting

12. Solutions - TeamSTEPPS • Lesson learned • Must be multidisciplinary---physicians, nurses, techs, respiratory therapists, pharmacists • Basically anybody involved in core team of patient care • Doesn’t just come • Takes hard work to be successful

13. Solutions - TeamSTEPPS • Does teamwork work?? • Examples • Hospital in Aurora, CO that handled theatre shootings • United Airlines crisis center on 9/11 • Miracle on the Hudson • Largest study to date— • Veterans Health Administration Medical Team Training study

14. Evidence it Works! (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine (Sexton, 2006) Johns Hopkins Draycott et al. BJOG(2006); 113: 177-82 Beth Israel Deaconess : 23% reduction in OB adverse events 13% reduction in severity of adverse events Pratt et al. J Comm J Qual Pat Safety(2007); 33: 720-725

15. VHA Study • Findings showed that the trained OR groups experienced an 18% reduction in annual mortality rate versus the OR groups that had not undergone training • Dose-response relationship for additional quarters of the training program showed an additional reduction of 0.5 deaths per 1000 procedures for each additional quarter

17. Solutions - Professionalism • Recent study by ISMP (Institute of Safe Medication Practices) 2013 • 70% of practitioners surveyed (physicians, nurses, pharmacists, other staff) experienced some type of disrespectful behavior

18. Disrespectful Behavior • Most frequent types— • Negative comments about colleagues • Reluctance or refusal to answer questions or return calls • Condescending language or demeaning comments

19. Disrespectful Behavior • Half of these respondents reported that this behavior adversely altered the way that they practiced • Avoidance • HUGE barrier to communication and HUGE patient safety issue

20. Disrespectful Behavior • We as physicians MUST police ourselves on this one • There are many others that would like to take this from us—administrators, regulators, lawyers, etc etc etc

21. Disrespectful Behavior • MUST hold ourselves and our peers accountable to an exceptional professional standard over and above everybody else • Medical societies, MECs, specialty organizations

22. What’s in it for me? • Increased demand for improved quality and safety of care, transparency and public reporting • 2012—caps for medical malpractice liability were struck down by the Missouri Supreme Court • Solutions needed to enhance patient safety within a culture that supports sharing and collaboration with appropriate legal and confidentiality protections

23. Understanding the Safety Culture Learning, Sharing, Improvement A Solution to Reducing Risk –

24. Center for Patient Safety • Founded in 2005 in response to recommendations of the Missouri Commission on Patient Safety • Center’s Founding Members – MSMA, MHA, Primaris • Strategic Initiatives • Federally-designated Patient Safety Organization (PSO) • Facilitate safety improvement activities and projects • Provide safety related education, training & resources • Issue an annual report • One of 79 PSOs in 29 States • One of most active in terms of participating organizations and reports

25. Patient Safety & Quality Improvement Act of 2005 (PSQIA) • Federal law in response to “To Err is Human” • Establishes Patient Safety Organizations (PSOs) • Provides federal confidentiality and legal protections for “Patient Safety Work Product” • Purpose – • To provide a culture that encourages reporting, analysis, sharing and learning about adverse events • To learn what medical errors occur, why and how to prevent them • To reduce error, costs and patient harm

26. Protections Available through the PSQIA • Quality and safety documentation defined by the organization as “patient safety work product” • Expands protections available through “peer review” and “attorney-client privilege” protections • Does NOT protect the medical record or billing records • Does NOT circumvent any mandated reporting requirements • Available to any healthcare provider licensed by a state that works with a PSO

27. Patient Safety Organizations (PSOs) • Must meet defined federal criteria • Varying PSOs models • Provide PSQIA-defined protections • Obtain adverse event, near miss and unsafe condition reports • Uses a Common Data Format (CDF) to collect event data and information • Analyze and report findings • Convene participants to share learning in a protected environment

28. Solutions - Proactive Risk Reduction Strategies • Safety Culture Assessments • Surveying, Analysis & Reporting • Safety Culture Training and Education • Just Culture • Comprehensive Unit-Based Safety Program (CUSP) • TeamSTEPPS • PSO Services

29. Safety Culture Assessment - Dimensions

30. Safety Culture Assessment - Dimensions

31. A Just Culture

32. No BSI = 5 months or more w/ zero No BSI 21% No BSI 44% No BSI 31% 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

33. Center PSO Activity - Learning EMS Agencies

34. Center PSO Activity - Learning There is great learning possible from near misses and unsafe conditions; PSOs are differentiated from regulatory-based and mandatory reporting activities because of the collection of near miss and unsafe conditions to enhance learning and prevention opportunities.

35. Typical Event Reporting - we only see the “Tip of the Iceberg” Sentinel Events Incident Reports Approx. 4% Adverse Events (GTT) 96% GTT = Global Trigger Tool

36. Center PSO Activity - Learning

37. Common Causes of Error The CPS The Joint Commission

38. Center PSO Activity - Learning

39. Majority of Patient Harm in 6 Areas -VTE-Pressure Ulcers-Falls-HAIs, Surgery and Blood Events

40. Center PSO Activity – Learning - Falls

41. Center PSO Activity – Learning - Falls

42. Center PSO Activity – Learning - Meds • Potential Causes Identified • Dispensing errors due to incorrect medication retrieval from dispensing systems; pharmacy dispensing the wrong dose • CPOE order entry errors, CPOE systems not transferring to electronic MARs • Auto-stops and auto-substitution features • Look like-sound alike medications (Zyvox vs. Zosyn, Hydrocodone vs. Oxycodone, Trazodone vs. Tramadol)

43. Center PSO Activity – Learning - Meds

44. Center PSO Activity – Learning – Surgery/Anesthesia

45. Center PSO Activity – Learning – Surgery/Anesthesia Include NQF-defined “Never Events” - infrequently occur limiting learning in one facility - broader learning through PSO participation

46. Center PSO Activity – Learning - HIT

47. Center PSO Activity – Learning - HIT

48. PSO Learning – Healthcare Acquired Infections • UTIs • 57% classified as asymptomatic, 50% result in harm • 18% are asymptomatic bacteremia, 78% resulting in harm • SSIs • 77% of all SSIs result in harm • Majority are superficial incisional & deep incisional primary infections

49. Center PSO Activity – Learning – “Other” Events

50. PSO Learning – EMS – Missouri National Leader Over 100 EMS agencies participating in the Center PSO