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Lawrence W. Way, MD

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  • Our goal is to reduce the accident rate
  • Transcript

    • 1. ASA Building Safer Systems
    • 2. ASA Without data, you are just another person with an opinion.
    • 3. ASA Safety Safety is not a specific thing. In complex organizations, safety is created by people as they do their work. There are strategies and designs that favor safe performance.
    • 4. Safety is Produced by SocioTechnical Systems ….“preventing errors and improving safety require a systems approach….” “The problem is not bad people; the problem is that the system needs to be made safer.” “Safety is a characteristic of systems and not of their components. Safety is an emergent property of systems.” “….healthcare organizations must develop a systems orientation to patient safety….” “Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.” “….this higher level of quality cannot be achieved by further stressing current systems of care… Trying harder will not work.” IOM 2001
    • 5. ASA HRO’s: High Reliability Organizations: Characteristics Process auditing and other active searches (eg, equip testing) for possible failures. High quality standards Risk perception: examining even small but unexpected events. Command and control: – Fluid decision-making (flex hierarchy) – Formal rules and procedures (but flexible) – Constant training Karlene Roberts, 2005
    • 6. ASA Safety in Medicine: Needed Changes Specify limits to maximum performance. [How many cases should we do?] Decrease individual autonomy: – Regulations – the minimum necessary – Teamwork – specialization Fatigue, overtime, excessive work schedules, staff shortages, stress. Amalberti R, 2005
    • 7. ASA Accident Models
    • 8. ASA hazards Some holes due to active failures Other holes due to latent conditions (resident pathogens) losses Successive layers of defenses, barriers, and safeguards This model is being increasingly criticized as an example of how to understand accidents. It is too static; the defects are often transient; and the whole system is more dynamic than the model suggests.
    • 9. ASA Sequential accident models inevitably lead to a root cause, which is the basis of the root cause analysis. The search for a root cause (often a human), tends to perpetuate the blame-the-person outcome. It also suggests that eliminating a root cause will solve the problem.
    • 10. ASA A detailed inquiry finds multiple parallel factors that led to the event considered to be the root cause. Systemic (not sequential) accident model
    • 11. ASA Systemic Accident Model Before the accident.
    • 12. ASA Systemic Accident Model Retrospective analysis might suggest that the outcome of the actions taken was predictable. We have not completely escaped blame-&-train.
    • 13. ASA System Features
    • 14. ASA Aviation has achieved a 10-6 rate of injurious accidents. Surgery is said to have a 10-4 rate.
    • 15. ASA “In the medical arena, the most common system failure is in education. The person at the sharp end (eg, the surgeon) did not know enough or was not experienced enough to make the correct judgment or action.” Training Experience High/low volume VA Hernia Trial: 85% of participating surgeons were still climbing the learning curve. System Features Who is responsible?
    • 16. ASA 1965 1975 1985 1995 2005 2015 Year Hull loss accidents per year Hull loss accident rate Airplanes in service Millions of departures 25,400 2015 19,077 2004 AccidentRate/MillionDeparture Our Goal Departures 2004 17.5 Million 438 1960 The Evolution of Aviation Safety 1965 - 2004 Boeing 2004 Statistical Data – May 2005
    • 17. ASA Teams in Aviation & Medicine Improved safety in commercial aviation, stemmed from better aircraft, better system designs, automation, and rule-making. Work in aviation and medicine is done by teams. Aviation: CRM reduced cockpit hierarchy, and communication improved. Moved on the LOSA & TEM. Medicine is practiced by teams, and team development is now a major issue. That leads to CRM; better communication; and observational studies of surgical work (LOSA). System Features
    • 18. ASA System Features Importance of Teams in Surgical Performance Error Management in Pediatric Cardiac Surgery: Carthey, J et al (unpublished) Multicenter study of neonatal arterial switch operation in GB. 173 ASO’s observed by experts in error management. Errors defined as major or minor, and compensated or uncompensated. The total number of minor errors in a case, whether compensated or not, was directly related to the chances that a major error would not be corrected, and a serious complication or death would result. Minor errors and uncompensated major errors and deaths were less common with stable teams.
    • 19. ASA O.R. Vicious Cycle High nurse turnover Nurse Dissatisfaction Nurse less able Random case assignments SPD dysfunctional Equipment missing Surgeon angry Flow interrupted Case more difficult O.R. tension mounts Performance drop Dysfunctional team.
    • 20. ASA Hypothetical staffing pattern during a four-hour case. Nurses, surgeon, and anesthesiologists can be a different mix several times per hour. No stable teams; communication affected; information lost. System Features
    • 21. ASA System FeaturesO.R. Communication – A Team Activity Lingard L et al. Communication failures in the O.R. Qual Saf Health Care 2004;13:330. Lingard L et al. Getting teams to talk. Qual Saf Health Care 2004;14:340 Lingard L et al. Team Communications in the O.R.: Patterns and sites of tension. Acad Med 2002;77:232. Seek harmony to preserve teams and avoid unsafe behaviors. How the surgeon acts is key. Bottom Line:
    • 22. ASA Loose coupling Tight coupling Tight coupling connects parts of the system so rigidly that actions at one place are immediately transmitted throughout. Prediction and control become harder, and accidents increase. An Important Failure Mode: Tight Coupling In systems-talk, this is “going solid.” System Features
    • 23. ASA System FeaturesEveryday Examples of Tight Coupling No hospital beds No ICU beds Overbooked IR schedule Shortage of surgical instruments: cases delayed Inadequate resources to staff O.R. cases Lengthy queues for operations. Elective surgery in off hours. Long queues for routine outpatient appointments. Examples of failing to set production limits that match production capacity.
    • 24. ASA The Useful Concept of Gaps SBAR (or SCAP) Read-back Face-to-face Hand-off IT (van Eaton) Checklists Standardized orders Complexity creates gaps in care, where information can be lost. Every transition in care constitutes a gap. The increasing fragmentation of medical care is producing more gaps. Information loss at gaps can be decreased by handoff routines and checklists. HANDOFFS CHECKLISTS & ETC. System Features
    • 25. ASA Checklists & Standardized Orders Pre-op planning O.R. scheduling Admission scheduling Night before checklist Pre-op checklist (briefing) Post-op care checklist Admission and pre- op orders Postop orders Transition orders Discharge orders Discharge instructions As many as 11 checklists between evaluation in the clinic and discharge from the hospital. Checklists Orders System Features
    • 26. ASA Anesthesia1 Patient Surgeon Prepare Surgical Ward Clinic R.R. OperationO.R. Nurses O.R. Nurses Anesthesia2 O.R. Suite PreOp Home Nurses Nurses Referring MD Nurses Nurses Surgical Patient Flowchart System Features
    • 27. ASA Anesthesia1 Patient Surgeon Prepare Surgical Ward Clinic R.R. OperationO.R. Nurses O.R. Nurses Anesthesia2 O.R. Suite PreOp Home Nurses Nurses Referring MD Nurses Nurses 1.2. 3. 4. 5. 6. 7. 8. 9.&10. 11. ·Eleven handoffs ·Eight procedural subsystems 1. 2. 3. 4. 5. 6. 7. 8. System Features
    • 28. ASA Christian CK, Zinner MJ, Dierks MM: A prospective study of patient safety in the operating room. Surgery 2006;139:159. Communication deficits during the operation -- lost information. Poorly synchronized multitasking that delayed case progress. Observational study of O.R. systems during general surgery cases. Hand-offs during inappropriate times -- information loss. Counting protocol delayed case and of questionable quality. Circulating nurses performed retrieval errands too often. Good work: LW System Features
    • 29. ASA Demonstrates how investigations done in the O.R. by surgeons can detect system faults. And eliminate unsafe practices. And presumably, improve efficiency. The findings of this study could probably be replicated in most large hospitals. As surgeons troubleshoot O.R. systems, surgeons require a share of administrative authority to implement the changes . Christian CK, Zinner MJ, Dierks MM: A prospective study of patient safety in the operating room. Surgery 2006;139:159. System Features
    • 30. ASA Conclusions Progress in understanding – The systems nature of safety – The nature of surgical systems – System faults that affect safety – And how to fix them Surgeons must be directly involved in 1) O.R. administration and 2) observational studies of the surgical system to bring about the required changes.
    • 31. ASA
    • 32. ASA “To Err is Human. . . Or Is It? ACS Efforts – Error Prevention and Patient Safety Thomas R. Russell, MD, FACS April 20, 2006
    • 33. ASAOmnibus per artem fidemque prodesse
    • 34. ASA The American College of Surgeons “Dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”
    • 35. ASA
    • 36. ASA Institutes of Medicine Three reports, starting with To Err Is Human: Building a Safer Health System, published in 2000. • Demonstrate that our current health care system neither controls spending nor ensures access to quality care • Clarion call for all to reevaluate their role – Quality – Cost
    • 37. ASA • Shift from saving lives by preventing errors to implementing evidence-based practices to improve quality • Domain of effectiveness of service, test or therapy to create better outcomes – i.e. “statistical lives” To Err Is Human
    • 38. ASA
    • 39. ASA Quality Surgical Care • Correct Diagnosis • Proper Staging • Proper Risk Assessment – Disease – Treatment • Proper Treatment – Best evidence – Best technology – Best technique • Proper Outcome – Survival – No complications – Disease cured – Symptoms relieved – Function restored – Death with dignity • ACS is working in all these areas
    • 40. ASA Quality Surgical Care • Structure • Process • Outcomes
    • 41. ASA Education
    • 42. ASA ACGME/ABMS Core Competencies • Medical Knowledge • Patient Care • Interpersonal and Communication Skills • Professionalism • Practice-based Learning and Improvement • Systems-based Practice
    • 43. ASA
    • 44. ASA
    • 45. ASA American College of Surgeons Case Logging System Practice-Based Learning & Improvement
    • 46. ASA Closed Claims Project • A standardized collection of reviews of claims involving surgical mishaps from records kept by liability insurance companies • 461 claims reviewed to date • Purpose – to identify common problems and develop best practices and protective systems to improve patient safety
    • 47. ASA
    • 48. ASA
    • 49. ASA Education Program for Accreditation of Educational Institutes • Will serve as regional sites where surgeons may learn new procedures, emerging technologies, and rarely performed procedures
    • 50. ASA ACS Efforts to Enhance Education in Surgical Skills
    • 51. ASA Education E-FACS.org • Content in clinical areas and broad-based subjects of interest • Supports e-learning, case logs, and sharing information about their practices • Maintain and submit documentation regarding MOC-related activities
    • 52. ASA
    • 53. ASA ACS Efforts to Define Curriculum Content for Entering Surgery Residents
    • 54. ASA Research and Optimal Patient Care
    • 55. ASA Current ACS Quality Improvement Programs • Facility Certification Programs – Trauma centers – Cancer centers – Bariatric centers • Continuous Quality Improvement – ACS National Surgical Quality Improvement Program (NSQIP) – American College of Surgeons Oncology Group • National Outcomes Data Bases – National Trauma DataBank – National Cancer Data Base – NSQIP
    • 56. ASA
    • 57. ASA Development of ACOSOG • May 1998: Initial NCI Award • March 1999: 1st trial opens • September 1999: NCI Site visit in Chicago • May 2000: 5 Year NCI Award
    • 58. ASA Future Directions • Expand clinical trials to include studies in trauma, burns / critical care, vascular and cardiovascular diseases • Expand Center’s programs in Continuing Medical Education to educate surgeons in the performance of new operations and use of new technology
    • 59. ASA American College of Surgeons Data Bases • National Cancer Data Base- NCDB • National Trauma Data Base- NTDB • American College of Surgeons National Surgical Quality Improvement Program- ACS NSQIP • ACS Bariatric Surgery Data Base • ACS Individual Fellow Self-Reporting Data Base • Collaborations in Progress – SAGES – STS – AAOS – SVS
    • 60. ASA Collaborative Efforts • CMS Surgical Care Improvement Project (steering committee) (SCIP) • Physicians Consortium for Quality Improvement (AMA) – Perioperative Care Work Group (co-chair) • National Quality Forum (NQF) • Ambulatory Care Quality Alliance (steering committee) (AQA) – Subgroup on Surgery and Procedures (chair) • Surgical Quality Alliance (chair) (SQA) – Developing quality measure priorities and consensus across surgical specialties
    • 61. ASA National Quality Forum • Cancer Care Quality Indicators – Colon Cancer • Colonoscopy preoperative or within 6 months • At least 12 nodes resected for non-metastatic disease • Adjuvant chemotherapy for node positive disease
    • 62. ASA Membership
    • 63. ASA Membership Expanded membership base • RAS-ACS • Affiliate Member category
    • 64. ASA
    • 65. ASA Membership Innovative methods of communicating with membership • Journal of the American College of Surgeons now distributed to all ACS Fellows free of charge • Surgery News, new monthly newspaper • Electronic methods: ACS NewsScope, e- mail alerts, College’s Web site, and Web portal
    • 66. ASA
    • 67. ASA THANK YOU!