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Safety and Quality in Dermatology

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  • True story Patient attended a local dermatology department with a changing pigmented lesion Had incisional biopsy Agency nurse – didn’t put sticker in biopsy book Path report was misplaced Never reviewed by dermatologist Patient assumed no news is good news and did not f/u Returned 6 months later Path tracked down – thin melanoma Received definitive treatment
  • Transition to big picture…   In 1999 the IOM report ‘To err is human’ grabbed the public’s attention and galvanized the patient safety movement Stated that a million Americans were injured and 98.000 died each year as the result of medical errors
  • How can this be the case? Doctors and Nurses are smart people who care about doing the right thing for patients Take pride in helping people How can we be harming so many people? Well – there are a number of ways in which we can respond to this data.
  • There are certain stages to facing the reality of the issues with the care our system delivers The data are wrong The data are right, but it is not a problem This is where derm has been It is about the ICU, ER, life and death – just not relevant to us I will present data today to show you that this is a big issue in derm The data are right, it is a problem; but it is not my problem Not my job to fix the system My job to be a good clinician We know the system is broken (analogy to steering a ship through obstacles but not removing the obstacles – to busy or too tired) I accept the burden of improvement I wouldn’t choose the word burden – more like challenge This does require thought and effort but it is also empowering – you can actually shape the solution What I would love to do in the next 45 minutes is move you from wherever you are now on this topic to the final point and help you understand what you can do right away in your practice to address this issue
  • Firstly medical care has become incredibly complex Take something simple that most of you do every day – the biopsy pathway Over 20 steps, many hand-offs between individual and departments Only as strong as our weakest link Say you get things right 90% of the time but you have 20 steps to get right then your overall reliability is only X%. Even if you think all the steps are 99% reliable that only gets you to Z% Point is even if you are a great clinician and a great surgeon, if you don’t track your biopsies or don’t ensure appropriate f/u is in place the outcome is just the same as if you missed the melanoma in the first place  
  • We inherently understand that so we have systems that create layers of protection to guard against errors One model that is frequently used is the swiss cheese model Problem is that each layer of protection fails and if the holes line up, as they frequently do, harm to the patient can result Let’s think back to the initial story – you can see how a series of events each affecting a different slice of cheese led to the delay in treatment that occurred Consider the holes to be opportunities for a process to fail, and each of the slices as “defensive layers” in the process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a defense against potential error impacting the outcome. For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error. If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more defenses you put up, the better. Also the fewer the holes and the smaller the holes, the more likely you are to catch/stop errors that may occur.
  • The second thing is that we actually need a different approach and a new set of skills to be able to perform in today’s system Myths around safety and improvement Perfection myth – if I just try harder, I will not make any mistakes Punishment myth – if we punish people when they make mistakes they will make fewer of them Performance myth – I will measure success according to my actions not the ultimate outcomes (more of a mindset than a myth) Need to remove the idea of separation between individual s and the system Need to learn to be proactive not reactive about dealing with these topics   ***Need to say somewhere it is not all about the system – just culture / individual accountability***  
  • To answer the first of these questions I worked with members of the Q+S committee of the AAD to survey dermatologists and ask them to report errors that have occurred in their practice Very simple, no investigative work, we just asked people ***May need to define adverse events, errors, near misses
  • Use Bob’s slides to outline our findings Might want to show an iceberg slide to illustrate we don’t know what we don’t know Bottom line – we all make mistakes, some are serious, some are frequent, some are both
  • What about quality of care? Well there are things that make this difficult Dermatology is different to other conditions that have objective markers of quality e.g. BP, A1c How could we assess quality of care for a patient with psoriasis – PASI, pt satisfaction..? How do we risk adjust to account for the fact some providers care for sicker patients Regardless we need to lead this conversation otherwise measures will be developed for us that may not be in line with our beliefs   AAD does have a performance measures taskforce led by Dirk Elston from Geisinger Initial measures have focused on melanoma management and they are now starting to look at bone protection for patients on steroids
  • So now let’s move onto the important stuff – what can you do in your practice right now to improve the quality and safety of the care you deliver  
  • Put this on the agenda at your next practice meeting or send an email out to people and ask for their suggestions on what could be better Set up a box where people (staff and patients) can post comments View feedback constructively Show people you listen and that things can change Opportunity to be a leader – executive support and positive role-modeling are powerful agents of change
  • 2. Implement a checklist to improve practice safety AG book Power of the checklist in ICU setting It might be prior to biopsy, laser safety, prior to prescription refills for certain drugs e.g. accutane It might only be very simple

Safety and Quality in Dermatology Presentation Transcript

  • 1. Safety and Quality in Dermatology Alice Watson MD MPH April 14 th 2010
  • 2. I have no relevant disclosures
  • 3.
    • Putting safety in context…a story
  • 4.
    • Does this story surprise you?
    • Could this ever happen again?
    • Could this happen in your practice?
  • 5. To err is human
    • 1999 report by IOM
    • Widespread media and political attention
    • The scale of medical errors
      • 1 000 000 Americans injured each year
      • 98 000 Americans die each year
  • 6.  
  • 7. Swallowing a bitter pill
    • Care providers are smart people who take pride in doing the right thing for patients
    • … ..so how can we be harming so many people?
  • 8. Stages of acceptance
    • The data are wrong
    • The data are right, but it is not a problem
    • The data are right, it is a problem; but it is not my problem
    • I accept the burden of improvement
  • 9. Why do we have a problem?
    • Medical care is incredibly complex
      • Over 20 steps in the biopsy pathway
      • Handoffs between individuals and departments
      • Each has an inherent failure rate
    • How reliable do we need to be?
      • 90%
      • 99%
  • 10. No. of Steps Probability of Success of each step 1 25 50 100 0.95 0.990 0.999 0.999999 0.95 0.990 0.999 0.9999 0.28 0.78 0.98 0.998 0.08 0.61 0.95 0.995 0.006 0.37 0.90 0.99
  • 11. The Swiss Cheese Model
    • More layers of protection
    • Smaller holes
  • 12.
    • It is not enough to be a great clinician or surgeon….
    • We are accountable for the outcome not just our step in the process
  • 13. Why do we have a problem?
    • Our current mindset and skill set are not compatible with optimal performance
      • Individual vs. system
      • Reactive not proactive
  • 14. Myths around safety
    • Perfection myth
      • ‘ If I just try harder, I will not make any mistakes’
    • Punishment myth
      • ‘ If we punish people when they make mistakes they will make fewer of them’
    • Performance myth
      • ‘ I will measure success by my actions not the ultimate outcomes’
  • 15. Finding the right balance The “system” Provider
  • 16. This is not an option…
  • 17. External Drivers of Change
    • Payment reform
      • No reimbursement for preventable complications
      • Outcome based reimbursement (P4P)
      • Tiering of providers based on quality measures
    • Accreditation / Licensure issues
      • Formal accreditations standards may become a requirement in all practice settings
      • MOC requirement to evaluate performance in practice
    • Malpractice cases punishing providers when things go wrong
  • 18. How does this relate to dermatology?
    • Focus to date has been hospital setting… but most care is delivered in ambulatory setting
      • Many handoffs
      • Multiple providers
    • Dermatology encompasses a broad range of practice..and therefore potential for error
      • Surgery, laser, light, immunomodulatory drugs…
    • Dermatology utilizes a range of providers
  • 19. AAD Efforts to Date
    • 2008: Taskforce on Patient Safety and Quality
    • 2009: Committee on Patient Safety and Quality
      • Data measurement
      • Patient safety
      • Medical errors
  • 20. Key questions
    • Do we deliver care that is safe and free from error?
    • Do we deliver care of the highest quality?
    • If not, what can we do to get there?
  • 21. It wasn’t an error – just a near miss The patient was harmed so someone must be at fault
  • 22. What are errors?
    • An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome (AHRQ)
    • Framework for error
      • Slips vs. mistakes
      • Active vs. latent error
  • 23. KEY POINT: not all errors result in harm to patients Error spectrum Harm No harm Near miss / Close call
  • 24. What are adverse events?
    • An injury caused by medical care
    • Adverse events are relatively rare compared to errors
  • 25. KEY POINT: adverse events can occur in the absence of an error Adverse event spectrum No error Error
  • 26. How do the two relate? Error Adverse event
  • 27. Errors in Dermatology
    • Survey study
    • Data points
      • Demographics (personal and practice)
      • Most recent error and its consequences
      • Most serious error
    • Goals
      • Define scope of error in dermatology practice
      • Identify priorities for improvement
  • 28.  
  • 29. Respondents
    • 150 respondents
      • 63% male
      • 60% >50 years old
      • 60% group / solo practice
    • Area of specialty
  • 30. Classification system
    • Assessment
      • History / Exam
        • Error in Hx / Exam
        • Omission in Hx/Exam
      • Investigations
        • Preanalytic error
        • Analytic error
        • Post analytic error
      • Diagnosis
        • Incorrect diagnosis – error in clinical judgment
        • Incorrect diagnosis – failure to review test results
        • Incorrect diagnosis – inappropriate interpretation of test results
    • Intervention
    • Administrative
    • Communication
  • 31. What was reported?
    • Assessment errors – 41% of total
      • 90% related to investigations
      • Biopsy pathway-related
    • Intervention errors – 44% of total
      • 54% related to medication
      • 46% related to procedures
  • 32. Investigation errors
    • ‘ Wrong biopsy site location on pathology specimen’ (27 variations on a theme)
    • ‘ A biopsy specimen was lost somewhere between the patient and the processing. I don't know for sure if the specimen did not make it into the bottle or if it was lost at the lab’
    • ‘ When a patient's chart was pulled for another reason, I found a path report from 2 months earlier the chart that had not been seen by me or reported to the patient. It was a basal cell skin cancer’
  • 33. Medication errors
    • Administration error by patient (3) or provider (7)
    • Wrong drug or dose dispensed (10)
    • Monitoring error (2)
    • Prescribing errors e.g. give drug despite known allergy / CI (6)
  • 34. Procedural Errors
    • Surgical (20 of which wrong site surgery -5)
      • ‘ I removed the wrong site on a young woman's scalp. She had an atypical nevus on the crown and I erroneously removed a different lesion nearby’
    • Laser (6)
      • ‘ I used a CO2 laser which was slightly different and got scarring which led to a lawsuit’
    • Phototherapy (4)
      • ‘ Malfunction in on/off timer with light therapy unit- patient not removed from machine. Patient severely burned (approximately 20 times normal exposure)’
  • 35. Measures of Quality Type of measure Description Examples Strengths Weaknesses Outcome Measure the end results of care - 5-year survival rate amongst patients with melanoma - Surgical infection rate following out-patient procedures - Quality of life in a patient with psoriasis - Ultimate end-product of clinical care - Hard to manipulate - Promote innovation around how to get there - Often not perceived to be under physician control -Multifactorial -Prone to create perverse incentive - Long term horizon - Can be hard to define or to capture Process Measure performance at different steps within the care pathway - Wait time for clinic appointment for patients with pigmented lesion - Proportion of patients advised to perform monthly skin self-examination - May directly impact patient experience - Short time course - Closely linked to provider actions - Easy to identify remedial action required - Open to manipulation - May correlate poorly with clinical outcomes - Can lead to ‘quick-fixes’ rather than comprehensive solutions - May become outdated as new technology introduced Structural Measure system-level adjuncts to multiple care processes - Implementation of an EMR - Staff training in CPR - May impact multiple care pathways - Can lead to step change improvements in clinical effectiveness - Promote safe environment for patients - Often costly as large-ticket items - May require extensive training to ensure efficiency gains
  • 36. Quality of care in dermatology
    • Challenges
      • No objective markers e.g. BP, A1c
      • Need to risk adjust
    • Who better to lead the process?
    • Performance measures taskforce
      • Melanoma measures / PQRI
      • Bone protection
  • 37. Ready for a challenge?
  • 38.
    • Start the dialogue
    • Introduce a checklist
    • Pick something to improve
  • 39. Start the Dialogue
    • Why?
      • Culture of openness is critical to safety
      • You want to hear about problems in your practice
      • Learn from near-misses in order to avert disasters
    Note: Openness ratings performed blind to error rate * Judged by interviewees’ opinion, leadership style, attire etc. ** Actual and potential adverse drug events Source: Edmondson (2004) Qual & Safety Healthcare
  • 40. Source: British Airways (NPSA adapted) British Airways air safety reports, 1994-99 Total events 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 1994 1995 1996 1997 1998 1999 High/medium risk events 0 20 40 60 80 100 120 140 Total reported events Number of reported events: high and medium risk
  • 41. Start the dialogue
    • How?
      • Add this to the agenda of your next practice meeting
      • Send out an email to staff asking for feedback
      • Ask patients and their families for comments
  • 42. This is not culture change…!
  • 43. Remember…
    • View feedback constructively
    • Show people you listen and that things can change
  • 44. Introduce a checklist
    • Why?
      • Simple and effective driver of change
      • Empowers all members of the team
      • Raises the baseline of acceptable performance
  • 45. Example from the ICU
    • 5 actions to reduce catheter related bloodstream infections
      • Handwashing
      • Full barrier precautions during insertion of line
      • Cleaning skin with chlorhexidine
      • Avoid femoral site
      • Remove unnecessary catheters
  • 46. Pronovost et al NEJM 2006
  • 47. Introduce a checklist
    • How?
      • Sit down with team and write out what is expected
      • Empower people to call out when anything is missed
    • Examples
      • Biopsy checklist
      • Laser safety
      • Medication specific e.g. accutane
  • 48. Pick something to improve
    • Why?
      • Knowing your numbers changes behavior
      • Provides focus and sense of accomplishment
      • Allows investigation into root causes of a problem
      • ‘ If you cannot measure it, you cannot manage it’
      • Don Berwick
  • 49. Pick something to improve
    • How
      • Pick something people care about
      • Set an aspirational goal
      • Measure – change - measure
    • Examples
      • Sharps injury prevention
      • Wound infection
      • Waiting time
  • 50. Remember…
    • Don’t just aim to be average – set a high bar
    • Do something small now rather than something big in the future - don’t let perfect be the enemy of good!
    • You know all you need to get started
  • 51. Let me know how you get on and how I can help! [email_address]