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LDI Charles Leighton Memorial Lecture with Mark Chassin, MD 5_4_12

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LDI Charles Leighton Memorial Lecture with Mark Chassin, MD 5_4_12

  1. 1. What is High Reliability, andHow C H lth CH Can Health Care G t Th Get There? ? Mark R Chassin, MD FACP MPP MPH M k R. Ch i MD, FACP, MPP, President, The Joint Commission Charles C. Leighton, MD Memorial Lecture Leonard Davis Institute University of Pennsylvania Philadelphia, Philadelphia PA May 4, 2012
  2. 2. Current State of QualityRoutine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of careUncommon, preventable adverse events • Surgery on wrong patient or body part • Fires in ORs, retained foreign objects • Infant abductions, inpatient suicides
  3. 3. Future State F t St t Joint Commission VisionAll people always experience thesafest, highest-quality, best-value health care across all settings.
  4. 4. A Model That WorksTJC hospitals have improved markedly oncore measures in use since 2002; manyare at high levels of consistent excellence Acute MI: 2010 Hospital Performance US avg(%) % > 90%Aspirin on arrival 99 99BB on discharge 99 98 Joint Commission Annual Report 2011
  5. 5. Rapid Improvement p pIn 2000, few measures, no national data collection or reporting • No real world experience real-world • Resistance among hospitalsToday---all that has changedIn a very short time hospitals have time, made major progress toward establishing consistent excellence
  6. 6. Improving MeasurementJoint Commission created first national hospital quality measurement programA great deal of real-world experience real world • Many measures work well; some don’t • Must replace bad measuresNo formal process to assess that experience, learn from it, and act on itTJC working h d t achieve thi goal ki hard to hi this l
  7. 7. Measurement Drives ImprovementMeasures used for “accountability” ( (accreditation, ppublic reporting, p y p g payment) ) lead hospitals to do major work to improveHow does measurement drive improvement? pMeasures with “clinical integrity” engage clinicians---who work to improve because p they believe improving performance will lead to better health outcomes for patientsLack of clinical integrity: • Turns clinicians away from improvement y p • Leads to workarounds and wasted effort
  8. 8. Accountability Measures y NEJM 2010; 363:683-8
  9. 9. Measures With Clinical Integrity: “Accountability Measures”Examples: Aspirin, beta blockers, and ACE inhibitors for acute MI; surgical antibiotic prophylaxis; new perinatal measuresCharacteristics of Accountability Measures • Large volume of research proves relationship to improved outcomes •PProcess i closely connected to outcome is l l d • Measure accurately assesses process • No or minimal unintended adverse effects
  10. 10. Hospital Performance on Accountability Core Measures 100 ercent of Hospitals >90% Performance 90 80 70 P 60 50 s 40 30 20 10Pe 0 2002 2003 2004 2005 2006 2007 2008 2009 2010
  11. 11. Joint Commission Accountability Measure InitiativesDefine accountability criteria for quality measures (process and outcome)Eliminate non-accountability measures y from Joint Commission programsAccreditation requirement for minimum performance: January 2012Top Performers program recognizes extremely high performanceSolution Exchange f ilit t lS l ti E h facilitates learning i
  12. 12. Joint Commission Perinatal Core Measures1. Elective deliveries: % elective of1 El ti d li i l ti f delivered newborns at 37-39 weeks2. Cesarean section: % c-section, previously nulliparous, singleton, vertex presentation3. Antenatal steroids: % full course, 24-32 wks4. Blood stream infections: % with bacteremia5. Exclusive breast feeding: % newborns fed only breast milk since birth
  13. 13. How Have Others Done It?“High reliability organizations” manage very serious hazards extremely well • Commercial aviation, nuclear powerWhat do they all have in common? • Highl effective process impro ement Highly effecti e improvement • Fully functional safety culture y yDiscover and fix unsafe conditions early“Collective i df l“C ll ti mindfulness” ”
  14. 14. US Airline Safety1990-2001 • 129 deaths per year • 9 3 million flights per year 9.3 • Rate = 13.90 deaths per million flights2002-20102002 2010 • 18 deaths per year • 10.6 million flights per year • Rate = 1.74 deaths per million flights
  15. 15. Safety: Airlines vs. Health Care yIOM “To Err is Human” estimate • 44 000 98 000 d h i h 44,000-98,000 deaths in hospitals i l due to errors in care • 34.4 million hospitalizations per year • Rate = 1300-2800 deaths per million p hospitalizationsUS Airlines: 2002-2010 2002 2010 • Rate = 1.74 deaths per million flightsHospital care i 750 1600 tiH it l is 750-1600 times l less safe f
  16. 16. Airlines vs Health Care II Care---IIBest study of errors and harm in hospital care showed that 1% of hospital patients were injured due to negligent errorsHospital rate = 10,000 per millionUS Airlines rate (death plus serious injury) • 2002-2010 = 341 people/95.2M flights • US Ai li Airlines rate = 3 6 per million t 3.6 illiOn this measure, hospital care is 2778 times less safe than air travel
  17. 17. High Reliability ScienceResearch has defined how HROs produce sustained excellence over timeNo health care organizations function at this high level of sustained safetyNo idN guidance on h how t t to transform f organizations from low to high reliabilityHow do we create blueprints for health care to build high reliability?
  18. 18. Leadership High Reliability TrustRPI Improve Report Health Care Safety Culture
  19. 19. From Health Affairs Health Affairs 2011;30:559-68
  20. 20. High Reliability Self-Assessment Self AssessmentLeadership • Board CEO, ph sicians Board, CEO physicians • Quality strategy, quality measures, ITSafety culture • Trust and accountability • Identifying unsafe conditions or practices • Strengthening systems, measurement systemsRobust process improvement • Methods, training, spread
  21. 21. Stages of Maturity g yHigh Reliability Self Assessment Tool (HRST) • S i of questions, b Series f i branching l i hi logic • All 14 components are assessedFour stages of maturity for each component • Beginning • Developing • Ad Advancing i • Approaching
  22. 22. Imperative #1: TrustAim is not a “blame-free” cultureA true safety culture balances learning with accountability g yMust separate blameless errors (for learning) from blameworthy ones (for discipline, equitably applied)Assess errors and patterns uniformlyEstablish one code of behavior
  23. 23. Sentinel Event Alert onIntimidating Behaviors
  24. 24. What Behaviors are Intimidating? gWide range: impatience to physical abuseMost common? • Refusal to answer questions, return calls; q , ; condescending language or voice; impatience with q p questions • About ¼ of nurses and pharmacists personally experienced these from MDs more than 10 times in past yearMedia misrepresented as “disruptive MDs” disruptive MDs
  25. 25. AccountabilityHealth care also fails to apply disciplinary pp y p y procedures equitably and uniformlyLack of uniform accountability also erodes trust, stifles reporting of unsafe conditionsBelief in a completely “blame-free culture blame-free culture” further impairs progress toward accountabilityStriking the balance is critical critical: • Learning from blameless errors • Accountability for adhering to safe practices
  26. 26. Robust Process ImprovementSystematic approach to problem solving: (RPI = lean, six sigma, change management) l i i h t)The Joint Commission is adopting RPI p g • Improve processes and transform culture • Focus on our customers increase value customers,The Joint Commission is adopting all components of safety culture t f f t ltWe measure RPI and safety culture and report on strategic metrics to Board
  27. 27. Center for Transforming Healthcare www.centerfortransforminghealthcare.org
  28. 28. Center for Transforming Healthcare Customers asking us for solutions Delivering p g products at no added cost • TJC: $20M; 9 other major donors • AHA BCBSA BD Cardinal Health AHA, BCBSA, BD, Ecolab, GE, GSK, J&J, Medline 2009: hand hygiene, wrong site surgery 2009 h d h i it and hand-off communications 2010: colorectal surgery SSIs 2011: safety culture, preventable HF y ,p hospitalizations, and falls with injury
  29. 29. Participating HospitalsBarnes-JewishBarnes Jewish Memorial H M i l HermannBaylor NY-PresbyterianCedars-SinaiC d Si i North Shore-LIJ N th Sh LIJCleveland Clinic NorthwesternExempla OSF OSFairview Partners HealthCareFroedtert Stanford HospitalIntermountain Trinity HealthJohns Hopkins VirtuaKaiser-Permanente Wake Forest BaptistMayo Clinic Wentworth-Douglass
  30. 30. Current State of QualityRoutine safety processes fail routinely • Hand hygiene • Medication administration • Patient identification • Communication in transitions of careUncommon, preventable adverse events • Surgery on wrong patient or body part • Fires in ORs, retained foreign objects • Infant abductions, inpatient suicides
  31. 31. Current State of Improvement pUsual approaches: best practices, toolkits, protocols, checklists bundles protocols checklists, “bundles” • Describe a specific set of process steps that th t must b f ll t be followed t solve a problem d to l bl • ICU central line protocol, VAP bundleThey produce consistent results only in limited circumstances • Process varies little from place to place • Causes of failure are few and common
  32. 32. A New Approach is PromisingBest practices often fail to achieve consistently excellent results, because: y , • Complex processes require more sophisticated problem solving methods • Many causes for the same problem • E h cause requires a diff Each i different strategy t t t • Key causes differ from place to placeNext generation of best practices will use RPI to produce solutions---customized to p an organization’s most important causes
  33. 33. Semmelweis’ Original Data g Monthly Death Rates Handwashing Program1841 1842 1843 1844 1845 1846 1847 1848
  34. 34. Some Important Causes of Hand Hygiene Failures1. Faulty data on performance2. Inconvenient location of sinks or hand gel dispensers3. Hands full4. Ineffective education of caregivers5.5 Lack of accountability  Each requires a very different q y strategy to eliminate
  35. 35. Causes Differ by Hospital Each letter = one hospital
  36. 36. Some Important Causes of Hand Off Communication Failures1. Sender1 “Sender” and “receiver” have receiver different expectations2. Lack of teamwork and respect3. Inaccurate or incomplete information4. Receiver has competing priorities5. Interruptions during hand-off6.6 Ineffective communication method
  37. 37. Causes Differ by Hospital Each letter E h l tt = one h hospital it l
  38. 38. Improving TransitionsHand offHand-off communication failed to include adequate information 41% of the timeInterventions reduced this rate to 17%One hospital focused on the transition from its inpatient units to a nursing home Baseline ImproveInadequate hand-offs 29% <1%30-day readmissions y 21%% 10%%
  39. 39. Joint Commission US Customers Program 2011 Ambulatory Care 2000 Behavioral Health 1950 Certification 2450 Home Care 6050 Hospitals 4500 Laboratory 1650 Long Term Care 1000 Total 19,600
  40. 40. Wrong Site SurgeryBest estimate = 40 per week in USJoint Commission Uni ersal Protocol Universal has not solved the problemHigh rates of risks introduced in 3 areas: • Scheduling: 39% of cases had risks • Pre-op area: 52% of cases had risks; 25% with multiple risks • OR: 59% of cases had risks; 32% with multiple risks
  41. 41. Risks of Wrong Site SurgeryScheduling: incomplete data, verbal requests, requests lack of standardizationPre-op area: missing documents, inadequate patient ID, time pressures lead ID to rushing, non-surgeon marks site, marking inconsistent, inconsistent use of non approved markers non-approvedOR: mark covered by drapes, distractions, time out performed without full participation, staff are not empowered to speak up, verification omitted with multiple procedures f
  42. 42. DefensesLeadership TeamworkHiring CoordinationTraining (among teams)Personnel evaluation Staffing (levels (levels, availability, mix)Policies, protocols p Equipment E i tComputer systems EnvironmentCommunication IndividualsSupervision of ( (knowledge, skills, g , , trainees t i stress factors)
  43. 43. The Swiss Cheese Model Errors Defenses with WeaknessesHarm
  44. 44. Reducing the RisksHospitals and ASCs targeted specific interventions to the risks they uncovered i t ti t th i k th d Relative Risk Reduction Scheduling: 46% Pre op: Pre-op: 63% multiple risk cases 72% OR: OR 51% multiple risk cases 75%
  45. 45. Results are ConsistentMore sophisticated improvement methods (RPI) required for complex problems • Measure and discover specific causes • Identify how causes vary among different organizations and settings • Target interventions to specific causes to maximize effectiveness • Avoid wasting resources by targetingThis is the Center’s unique capability Center s
  46. 46. Targeted Solutions Tool (TST) g ( )Uses secure, established extranet channels • N added cost, voluntary, confidential No dd d l fid i l • Can assess performance across systemEducational, no jargon, no special trainingGuides users to customized proven solutions customized,Targeting only your causes means you don’t use resources where they aren’t needed aren tHand hygiene and WSS available now; will add h d ff communication l t thi year dd hand-off i ti later this
  47. 47. Results Through March 2012640 projects are using interventions • Baseline = 51 4% (n = 72 248)* *p<0.0001 51.4% 72,248)* • Improve = 75.0% (n = 187,238)* Unit Baseline Improve • Adult critical care 51% 71% • Emergency dept. 46% 74% • Adult med surg med-surg 46% 74% • Pediatric critical care 62% 82% • Long term care 54% 73%
  48. 48. C. Difficile Rate Declines as Hand Hygiene Improves 100 1.3 C. dif 1.2 12 %) fficile Cas (per 1Hand Hygien Compliance (% 90 1.1 80 1 ses HH 0.9 70 ne C diff 0.8 08 1000 patient days) 60 0.7 0.6 06 50 0.5 40 0.4 04 2007 2008 2009 2010 2011
  49. 49. MRSA Rate Decreases as Hand Hygiene Improves MRS Cases (per 1000 patien days) 100 2.5 %)Han Hygien Compliance (% SA 90 2.0 80 s HH 1.5 70 MRSA ne 60 1.0 50 nd nt 0.5 05 40 30 0.0 2008 2009 2010
  50. 50. The Joint Commission and High Reliabilit ReliabilityConsistent excellence is the visionLeadership + safety culture + RPIAll Joint Commission programs and activities are aligning around this aim: •AAccreditation, performance measurement dit ti f t • JCR education, publication, consulting • Center-developed improvement solutionsHelp customers improve no matter where they are on the journey to high reliability

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