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Improving Surgical Safety and Patient Outcomes

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Keynote talk delivered at New Jersey Hospital Association Seminary on Improving Surgical Safety & Patient Outcomes held on September 25, 2013 at their Conference Center in Princeton New Jersey. Over ...

Keynote talk delivered at New Jersey Hospital Association Seminary on Improving Surgical Safety & Patient Outcomes held on September 25, 2013 at their Conference Center in Princeton New Jersey. Over physicians, administrators, nurses and perioperative services providers in attendance.

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  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.

Improving Surgical Safety and Patient Outcomes Improving Surgical Safety and Patient Outcomes Presentation Transcript

  • Reducing Surgical-Related Harm Through Improved Quality of Care C. Daniel Smith, MD New Jersey Hospital Association Partnership for Patients Improving Surgical Safety and Patient Outcomes September 25, 2013 1
  • • No financial or other relationship with any product or treatment discussed in this talk Conflict of Interest / Disclosure
  • Disclaimers • I am not a quality or safety expert • I am a surgeon and an innovator (really an early adoptor)..innovation in practice, leadership • Leading change at Mayo in Florida for 7 years • Mayo in Florida has become a significant positive outlier in many outcomes and safety measures (NSQIP, FCIP, Leapfrog, USNWR, etc.) • I will not tell you anything today you don’t already know
  • Surgeon Characteristics • Intelligent – typically at top of medical school class • Well educated – competitive course of training, typically 10+ years postgraduate • Strong – emotionally and physically demanding work • Confident – Patients don’t want an unsure surgeon • Action oriented – Like to fix problems and see immediate results • Unique – No one else in medicine quite the same
  • Surgeon Characteristics • Big ego – it takes a big ego to cut people open. “Anyone else does this and they go to jail, patients pay us to do this” • Solo predator – had to compete for limited training opportunities. The person next to you may take away your future. • OCD and Paranoid – healthy traits to prevent doing something stupid or leaving something behind • Martyr – uniquely retain the full spectrum of patient care. “The rest of medicine is going to shift work and separate inpatient/outpatient teams” • Special – “other than God, no one else can see and touch what’s inside my body”
  • Today’s Goals/Objectives • Construct for pursuing improved outcomes / safety in surgery • Case study in SSI reduction • Establishing a culture of safety • Q&A 6
  • Healthcare Delivery Goals 7 To provide the right care To the right patient At the right time In the right place Value = Quality* Cost *Outcomes, Safety, Service
  • How Are We Doing? • 44,000-98,000 Americans die in hospitals as result of medical error • $37.6 billion from adverse events • $17 billion preventable adverse events • More die from medical error than from highway accidents or breast cancer November 1999
  • Never Events in Surgery Electrical / Thermal Injury Specimen Error Medication Error Blood Products Error Patient Fall Drug Diversion Wrong Site Surgery Wrong Patient Surgery Wrong Procedure Retained Foreign Body Operative Death
  • Never Events in Surgery 312 Never Events reported to Minnesota Department of Health 2007-2008
  • Never Events in Surgery Surgery 2013;153:465-72.
  • Never Events in Surgery A surgeon in the United States leaves a foreign object such as a sponge or towel inside a patient's body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week, and operates on the wrong body site 20 times a week. Surgery 2013;153:465-72.
  • Healthcare Delivery Goals 13 To provide the right care To the right patient At the right time In the right place Value = Quality* Cost *Outcomes, Safety, Service
  • Healthcare Delivery Goals 14 Value = Quality* Cost*Outcomes, Safety, Service
  • Value Equation – Quality Defined • Outcome – a final result; end product • Safety – freedom from harm, danger or injury • Service – the action of helping or doing work for someone 15
  • Value Equation – Quality Measured • Outcome • Safety • Service 16 Unexpected return to OR Transfusion requirement LOS OR time Complication
  • Value Equation – Quality Measured • Outcome • Safety • Service 17 Never events UP compliance STOP sign compliance
  • Value Equation – Quality Measured • Outcome • Safety • Service 18 Patient satisfaction survey Call to appointment Door-to-OR
  • Value Equation – Quality Quantified • Outcome • Safety • Service 19 Unexpected return to OR Transfusion requirement LOS OR time Complication Never events UP compliance STOP sign compliance Patient satisfaction survey Call to appointment Door-to-OR
  • Value Equation – Quality Quantified • Outcome • Safety • Service 20 Unexpected return to OR Transfusion requirement LOS OR time Complication Never events UP compliance STOP sign compliance Patient satisfaction survey Call to appointment Door-to-OR Assign a relative value to each Plug into value equation Plot changes/progress over time
  • The Value Equation Realized 21 Value = Quality* Cost *Outcomes, Safety, Service Unexpected return to OR Transfusion requirement LOS OR time Complication Never events UP compliance STOP sign compliance Patient satisfaction survey Call to appointment Door-to-OR 5.6 = 1350 241 *Outcomes, Safety, Service
  • Outcomes in Surgery 22
  • Outcomes Improvement in Surgery 23 Processes • Six Sigma • LEAN • CQI • SCIP • NSQIP • BPBC Standardizing a process will result in improved outcomes…generalized from manufacturing
  • Outcomes Improvement in Surgery 24 Processes • Six Sigma • LEAN • CQI • SCIP • NSQIP • BPBC A recent study performed across 112 Veterans Affairs hospitals and involving a total of 60,853 operations found that the implementation of the SCIP infection- prevention measures did not yield measurable improvement in SSIs at the patient or hospital level or an improvement in adjusted SSI rates over the im- plementation period. “although the processes measured are best practices and should continue, they might be too simplistic or blunt to discriminate hospital quality” Ann Surg 2011;254(3):494–9
  • Outcomes Improvement in Surgery 25 Processes Culture • Process Improvement • “Just do it” • PDSA • Rapid cycles of change ≠ • Six Sigma • LEAN • CQI • SCIP • NSQIP • BPBC
  • Outcomes Improvement in Surgery 26 SSI Case Study Thompson KM, Oldenburg WA, Deschamps C, Rupp, W, Smith CD. Chasing zero: the drive to eliminate surgical site infections. Ann Surg 2011;254(3):430–6
  • Healthcare Associated Infections • 1.7 million infections costing $45 billion • Surgical site infections 2nd most common HAI • SSI is 2nd only to medication error as adverse event in hospitalized patient • Estimated cost of additional $3,000 per SSI infection • Best practices for reducing SSI remains illusive 27
  • SSI Reduction Project - Aim • Test the hypothesis that development of an organized structure to facilitate rapid development and diffusion of multiple infection prevention strategies simultaneously would result in lower rates of surgical site infection 28
  • SSI Reduction Project - Aim • Test the hypothesis that development of an organized structure to facilitate rapid development and diffusion of multiple infection prevention strategies simultaneously would result in lower rates of surgical site infection 29 No single Process (e.g., SCIP) will eliminate SSIs. A BUNDLE of care based on Change & Quality Improvement principles is more likely to work. Pursue an “SSI Elimination Bundle”
  • Mayo Clinic Culture • Fully integrated healthcare practice • Physician leadership (CEO) • All physicians salaried • No productivity-based financial compensation adjustment • Day-to-day operations managed by MD led committees 30
  • Mayo Clinic Florida • 214 bed hospital (19 ORs) and outpatient practice within a single complex/campus • 11,000 admissions/ year: 55% surgical • Single electronic medical record and order entry throughout practice • 12,000 operations/year – complex case mix (e.g., 150 liver transplants, 1,200 NS, 900 GISurg) 31
  • Surgical Site Infections - Background 32 SSIRate(infections/100surgeries) New CEO New Hospital
  • CEO Imperatives • Focus on quality and safety • “Just do it” • Rapid cycle change • Eliminate healthcare associated infections • Leverage organization’s core values (needs of patient come first, teamwork) 33
  • SSI Reduction Project - Design • Project embedded in existing quality/safety management structure • Steering committee to oversee all aspects of project including metrics and impact of interventions • Evidence-based modifiable risk factors identified and gap analysis performed • Specific targets for improvement identified • Multidisciplinary workgroups (frontline workers) assigned each target 34
  • SSI Reduction Project - Design • Pre-op (8) • Holding (2) • Intra-op (11) • Post-op (3) • Surgeon Specific (3) 35 Potential Interventions
  • Pre-operative 1. Identify and treat all infections remote to the surgical site before elective operation 2. Encourage smoking cessation within 30 days before procedure 3. Avoid immunosuppressive medications in the perioperative period if possible 4. Preoperative antiseptic skin cleansing 5. Mechanical preparation of the colon for colorectal surgery patients 6. Administer non-absorbable oral antimicrobial agents on the day before the operation 7. Screen and decolonize Staphylococcus aureus carriers undergoing elective procedures 8. Screen preop blood glucose levels in patients undergoing select elective procedures Holding 9. Only remove hair that is will interfere with the operation 10. Remove hair immediately before the operation with clippers (SCIP 6) Intra-operative 11. Select appropriate antibiotic based on the surgical procedure (SCIP 2) 12. Increase dosing of prophylactic antimicrobial agent for morbidly obese patients 13. Administer prophylactic antimicrobial agents IV on time (SCIP 1) 14. Use an appropriate antiseptic agent for skin preparation 15. Maintain therapeutic levels of the prophylactic antimicrobial agent throughout the operation 16. Use at least 50% fraction of inspired oxygen for select procedures 17. Keep OR doors closed during surgery 18. Maintain peri-operative normothermia (SCIP 9) 19. Adhere to standard principles of operating room asepsis 20. Optimize ventilation, environmental cleaning and sterilization of surgical equipment 21. Minimize flash sterilization Post-operative 22. Adequately control serum blood glucose levels in diabetic patients (SCIP 4) 23. Protect primary-closure incisions with a sterile dressing for 24-48 hours postoperatively 24. Discontinue the prophylactic antimicrobial agent within 24 hours of surgery (SCIP 3) Surgeon Technique 25. Use appropriate antiseptic agent to perform preoperative surgical scrub for surgical team members 26. Handle tissue carefully and eradicate dead space 27. Minimize operative time as much as possible Transparency 28. Feedback surgeon specific infection rates SSI Reduction Project - Design 36
  • SSI Reduction Project - Design Deploy in three phases concurrently 37 Phase One Consistent delivery of SCIP 1-3 interventions Phase Two Modifiable risk factors with scientific evidence linked to SSI reduction Phase Three Focus on intra-op environment and reporting Preoperative Evaluation (POE) Clinic
  • SSI Reduction Project - Design Deploy in three phases concurrently 38 Phase One • Revise order sets • On-time antibiotic delivery • EMR-based alerts • Confirm antibiotics during time out • Clippers in OR • Intraop normothermia Phase Two • S. aureus decolonization • Standard periop skin cleansing • Intraop protocols for skin prep, antibiotic dosing and timing • Hand hygiene • Incision dressing – 24 hrs Phase Three • Intraop flow, attire, coverings • All-or-none metrics Preoperative Evaluation (POE) Clinic
  • Management & Flow 39 Preop Bathing Workgroup CEO & Executive Operations Team Clinical Practice Quality Oversight Committee Healthcare Associated Infection Prevention Steering Committee Surgical Quality Subcommittee (SSI Reporting Task Force) Postop Dressing Workgroup SCIP 3 Workgroup
  • SSI Reduction Project - Communication 40 •CEO’s monthly Department Chair and staff meetings •HOS all staff meetings (MD, nursing, support services) •Standing item on Surgical Committee agenda •Workgroup reports to peers
  • SSI Reduction Project - Transparency 41
  • SSI Reduction Project – Data • Trained infection control practitioners • NHSN definitions to identify and classify SSI • Baseline SSI data collected from May 2008 – Dec 2008 • Data collected thru Jun 2010 and analyzed • Comparison to baseline and rolling 6-month average 42
  • SSI Reduction Project - Results 43 New Hospital
  • SSI Reduction Project - Results 44
  • SSI Reduction Project - Results • Case volume, RVU and case complexity unchanged thru project period • Of 10 surgical services involved: 7 experienced decrease in SSI 2 experienced increase in SSI 1 experienced no change in SSI 45
  • SSI Reduction Project - Summary • Tactics to rapidly identify and optimize delivery of recommended SSI risk reduction strategies is possible on large scale • Significant reduction in SSI was achieved 71% decrease in Class I SSI 49% decrease in Class II SSI 57% overall decrease in SSIs • Estimated institutional cost savings of $668,000 - $1,634,000/year* 46 * From R Scott. The direct medical costs of Healthcare-Associated Infections in U.S Hospitals and the Benefits of Prevention
  • SSI Reduction Project - Observations • Methodology embedded in existing quality/safety culture • Executive leadership driven • Electronic medical record • Communication & Transparency • Multidisciplinary team-based development/deployment • No competing or conflicting individual $ incentives 47
  • SSI Reduction Project - Limitations • Shotgun approach without defining specific actions that correlate to results • Absence of “All-or-None” metrics • Observed reductions may be related to improved culture, more attention from leadership, or improved performance of surgical teams • Short-term results 48
  • Value Equation – Quality Defined • Outcome – a final result; end product • Safety – freedom from harm, danger or injury • Service – the action of helping or doing work for someone 49
  • Never Events in Surgery A surgeon in the United States leaves a foreign object such as a sponge or towel inside a patient's body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week, and operates on the wrong body site 20 times a week. Surgery 2013;153:465-72.
  • Safety in Surgery 53 Processes • Time out • Stop Sign • Site Marking • Universal protocol • SBAR • Crucial Conversations • LEAN • Six Sigma Culture
  • Safety in Surgery 54 Processes • Time out • Stop Sign • Site Marking • Universal protocol • SBAR • Crucial Conversations • LEAN • Six Sigma • Speak-up without fear • Communication openness • Shared behavior expectations / goals • Fair and just response to errors Culture ≠
  • Safety in Surgery 55 Processes • Time out • Stop Sign • Site Marking • Universal protocol • SBAR • Crucial Conversations • LEAN • Six Sigma Culture • Speak-up without fear • Communication openness • Shared behavior expectations / goals • Fair and just response to errors
  • Safety in Surgery 56 Processes • Time out • Stop Sign • Site Marking • Universal protocol • SBAR • Crucial Conversations • LEAN • Six Sigma Culture • Speak-up without fear • Communication openness • Shared behavior expectations / goals • Fair and just response to errors • Trust • How We Manage Errors
  • N o N o N o Y e s Y e s N o Y e s N o Y e s Y e s Y e s N o N o N o Y e s Y e s N o D im in is h in g c u lp a b ilit y D e c is io n T r e e f o r D e t e r m in in g C u lp a b ilit y o f U n s a f e A c t s S a b o t a g e , m a le v o le n t d a m a g e , s u ic id e , e t c . S u b s t a n c e a b u s e w it h o u t m it ig a t io n S u b s t a n c e a b u s e w it h m it ig a t io n P o s s ib le r e c k le s s v io la t io n S y s t e m - in d u c e d v io la t io n P o s s ib le n e g lig e n t e r r o r S y s t e m - in d u c e d e r r o r B la m e le s s e r r o r B la m e le s s e r r o r b u t c o r r e c t iv e t r a in in g , c o u n s e lin g n e e d e d W e r e t h e a c t io n s a s in t e n d e d ? U n a u t h o r iz e d s u b s t a n c e ? K n o w in g ly v io la t e s a f e o p e r a t in g p r o c e d u r e s ? P a s s s u b s t it u t io n t e s t ? Y e s H is t o r y o f u n s a f e a c t s ? W e r e t h e c o n s e q u e n c e s a s in t e n d e d ? M e d ic a l c o n d it io n ? W e r e p r o c e d u r e s a v a ila b le , w o r k a b le , in t e llig ib le a n d c o r r e c t ? D e f ic ie n c ie s in t r a in in g & s e le c t io n o r in e x p e r ie n c e ? Reason, J., Managing the Risks of Organizational Accidents Reason, J: Managing the Risk of Organizational Accidents
  • Safety in Surgery 58 Processes • Time out • Stop Sign • Site Marking • Universal protocol • SBAR • Crucial Conversations • LEAN • Six Sigma • Commitment Patient & Colleagues • Humility - Errors Inevitable • Metacognition – Error Prevention & Mitigation Culture
  • Change in Surgery 59
  • Hazards of Leading of Change 60 “And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous to administer than to introduce a new order to things; for he who introduces it has all those who profit from the old order as his enemies; and he has only lukewarm allies in all those who might profit from the new. ” from Niccolo Machiavelli's "The Prince"