Improving the Quality of your Practice
CRASH 2016
Patrick Guffey, MDAssistant Professor, University of Colorado
Associate Medical Director, Dept. of AnesthesiologyACMIO, Children’s Hospital Colorado
AQI AIRS Committee Chair
Travel & Expense support from the ASA, AQI, Omnicell
Indirect research support from Codonics and Omnicell
Presentation contains unpublished data from the AQI registries
and data, slides used with permission
Disclosures
1. Getting the data to understand your practice
2. Leveraging analytics to produce results
3. Emerging trends in clinical pathways
4. Moving towards highly reliable operations
ObjectivesTriple Aim and Quality Improvement
PopulationHealth
PatientExperience
Cost of Care
Triple Aim
The D
omains o
f Health
care Q
uality
Safe
Equitable
Efficient
Patient Centered
Effective
Timely
Healthcare Spending Optimism
The case for optimism: “American efficiency and productivity drove and will continue to drive that growth”
Guffey, Patrick, MD Improving the Quality of Your Practice
US Anesthesia Partners
Dr. Rick Dutton
Former Executive DirectorAnesthesia Quality Institute
Chief Quality OfficerUS Anesthesia Partners
“My goal is to say USAP is the best anesthesia practice in the business and be able to prove it” What is Value in Healthcare?
Michael E. Porter PhDNEJM 2010; 363: 2477‐2481
Value in healthcare is measured in terms of
patient outcomes achieved per dollar expended
Reward for• Best overall care• Lowest cost• Minimize complications
Value Proposition
To Error is Human
What’s wrong with this picture?
Humans make hundreds of mistakes every day
100,000
10,000
1,000
100
10
11 10 100 1,000 10,000 100K 1M 10M
Number of encounters for each death
Tota
l liv
es lo
st p
er y
ear
BungeeJumping
Mountaineering
HealthCare
(1 of 616) DrivingIn US
CharteredFlights
Chemical Manufacturing
ScheduledCommercial
Airlines
EuropeanRailroads
NuclearPower
Dangerous(>1/1,000)
Ultra Safe(<1/100K)
How Safe is Healthcare?
Risk of Harm
Checking a bag Handing over a child
THE RISK IS THE SAME
Minor:
10.21%Major:
0.52% MORTALITY
0.03%
Patient Harm in the OREight Million Cases – AQI Registries PACU and Operating Room
Guffey, Patrick, MD Improving the Quality of Your Practice
Risk of Anesthesia ‐ Perioperative
PreoperativePreoperative SurgerySurgery InpatientInpatient Recovery Recovery
Perioperative Mortality1.85% all cause
(0.07% hernia‐5.97% major vascular)
Perioperative Harm
Netherlands, 3 million cases, Noordzji PG, Anesthesiology 2010
Basic Tenets of Human Error
Everyone commits errors
Human error is generally the result of circumstances beyond the control of those committing the errors
Humans make more errors during routine activities, less when focused and thinking critically
Types of Errors
Active FailuresActs committed by those in direct contact with the patients: slips,
lapses, fumbles, mistakes, procedural violations.
These are mosquitoes
Latent Conditions The resident pathogens in the system: time pressure, inadequate
equipment, fatigue, non‐fail safe procedures, design and construction deficiencies.
This is the swamp
Culture of Medical Error
Past: Individual is always responsible
Shame and blame culture
Hiding mistakes
Improvement difficult
Low morale ‐ fear
Future: Culture of Safety
Recognize systems contribute
Speak openly about mistakes / errors
Concerns are valued and acted upon
Participants take ownership
The System
Humans make mistakes
The system stops human error from reaching the patient
Systems or processes that depend on perfect human performance are inherently flawed
Fix the System
Incredibly complex
Dependencies on everything and everyone
Highly variable
Can’t fix what we don’t know about
Guffey, Patrick, MD Improving the Quality of Your Practice
A History of Reporting in Anesthesia
University of California, San Francisco & University of Colorado
Focused on near misses
3500 reports from faculty, housestaff and CRNA/AAs
Researched why individuals choose not to report and optimized system to address needs of anesthesiologists
With interventions, reporting increased ~20 fold compared to using hospital systems.
United States ‐ Patient Safety Organization
Creates a framework of aggregating information across institutions
Approved in 2009
Allows for a national anesthesia reporting system that is secure
Disincentives for Reporting
Cognitive and behavioral reasons
Poor education about what constitutes an event
Concern over legal or credentialing consequences
Personal shame
Fear of implicating others
Systems reasons
Time consuming
Difficult to access
Lack of anonymity
Potentially discoverable
Slow infrastructure
Arduous, poorly designed interfaces
Lack of feedback and follow‐up, no perceived value
Tenets of a successful system
Secure and non‐discoverable
AIRS is part of AQI which is a registered PSO
Quick entry time and ease of use
Balance of data resolution against time
Accessibility
Ideally, from any computer, anywhere in the world
Captures both near misses and incidents of patient harm
Option of anonymity
Searchable
Summary reports to departments, hospitals
Many events are locally influenced
Well Designed Systems Work
UCSF 750 / year reportsHistorically, virtually none
CHCO 500 / year reportsHistorically, about 10 / year
Benefits of Reporting
Advance the safety of perioperative care
Discover system issues you can fix
Gather quantitative data to influence organizations
Avoid repeating mistakes!
Getting what you need
Anecdotal evidence vs. quantifiable reports
Guffey, Patrick, MD Improving the Quality of Your Practice
How to start
Paper form – all cases or notable events
Collaborate with hospital / facilityAdapt an existing electronic system
Build your own systemNeed IT infrastructure and support
Use the AQI’s system Local vs. national reporting / reports
Accessing AIRS
Event Reporting from Epic
AIRS data
0 50 100 150 200 250 300
Equipment
Infrastructure /…
Medication
Cardiac
Documentation
Pulmonary /…
Airway
Procedural…
Other
Amesthetic /…
Neurological
Regional Anesthesia
Administrative
Vascular
Blood Bank
Mortality
Corneal Abrasion
Immunological
Event Classification
2000 Cases
90 InstitutionsHundreds of reporters
Some are bulk submitted
AIRS data
0 50 100 150 200 250
General Surgery
Orthopedic Surgery
Neurosurgery
OB/GYN
Other
Cardiothoracic Surgery
Urology
Interventional Radiology
OHNS/OMFS/ENT/Plastics
Procedure Types
Guffey, Patrick, MD Improving the Quality of Your Practice
AIRS data
Cases preventable by 3:1
0 100 200 300 400 500
Near Miss
Unsafe Condition
Not Provided
No Harm
Temporary Harm
Temp Harm, add'l treatment
Permanent Harm
Severe Permanent Harm
Death
Case Severity
Trending
Hazards of Electronic medical records and AIMS
Air embolus during ERCP
Drug errors due to shortages
Importance of teamwork
Place for cognitive aids
Trending IT
Charting on the wrong patient
Sudden system failure
Failure to record vital signs
Failure of pharmacy dispensing systems
Incorrect calculations
Flawed / Incorrect decision support
Distraction from all these issues
Trending ‐ Equipment
After induction, no blood pressure reading, weak pulses –checked O2 sat, didn’t work
No ECG cable in room noticed after case
No BP for an hour
No suction, needed suction
Monitor broken
No capnograph in room
Where is the Abnormality?P36
Guffey, Patrick, MD Improving the Quality of Your Practice
Seeing Your ProblemsP37
Now, where is the abnormality?
You cannot see the abnormal until you have defined the normal
P38
Why standardize in Anesthesiology
Reducing variability highlights deviation
Implement best practice
Change quickly when necessary
Support downstream processes
Foundation of Perioperative Home
Research opportunities
Physician Autonomy
A matter of perspective…
1 Case1 MD
1 Case1 MD
1 Case1 MD
1 Case1 MD
1 Case1 MD
1 Case1 MD1 Case
1 MD
1 Case1 MD
1 Case1 MD
1 Case1 MD
1 Case1 MD
Barriers and Solutions
Physician AutonomyDevelop the protocol as a teamAllow influence over all cases
Recall the protocolIntegrate into Epic AnesthesiaMacros specific to case type
Real time guidanceUse macros, events, and reminders to create decision support
High Reliability
Anesthesia Protocols
• Use Epic Anesthesia to standardize provider performance• Pre‐op: Review and acknowledge protocol
• Intra‐op: Use scripting (Macros, Reminders) as cognitive aids
• Post‐op (in progress): Make the performance data available• Self Serve Analytics
• Change Management• Opt‐In model vs Department / Service line requirement
• Assigned person accountable for cases
• Review data with providers
Guffey, Patrick, MD Improving the Quality of Your Practice
Case Study – Spine Fusions
Complex ProcedureEngaged Perioperative Team (Surgeons, Nursing, Quality)Multiple Opportunities for decision support
Appointed a service liaison, Dr. Mindy CohenFormed an opt‐in teamDeveloped a protocolUse evidence when available, when not:
Best guessConsider cost
Protocols
Protocols Protocols: Reminders
Spine Protocol ResultsImplemented Protocol
Manual Process
Developed electronic decision support
Median length of stay 4.08
The median post‐operative day of discharge POD 4
3.28
POD 3
Dashboards: The Case for Data
Physicians want to do the right thingBut don’t know where they are relative to others
Need data – usually work alone in a vacuumCan’t see how others are succeeding or where we are
Peer Pressure ‐ highly motivationalMay be the most effective change factor, no one wants to be at the bottom of the scale
Learn from those doing it betterStill have a lot to learn – this is real time improvement
Identify those who need more helpThose at the lower end can be identified and coached
48
Guffey, Patrick, MD Improving the Quality of Your Practice
Dashboards: Requirements for Success
AccuratePhysicians will search for inaccuracy and perceived excuses
Real TimeNeed to be able to see the effect of interventions
Reliable Metric cannot change over time, upgrades cannot reset system
AvailableMust be easy to find and use – self serve analytics
49
Dashboards: What to consider trackingASA Score SummariesAnesthesia Start to Ready Times (by Service)Airway placement, Line placement, Block placementPACU recovery times, pain scores, opioid administrationOPPE MetricsEmergence AgitationNausea / VomitingEfficiency MetricsBlock UtilizationRoom UtilizationCase VolumeCancellationsRoom TurnoverPercent of First Case Late Starts
50
Dashboards: ASA Status
ASA score summariesDistribution of medical complexity
Start to Ready Times by ServiceEfficiency
51
Dashboards: OPPE Metrics
Dashboards: PACU
53
Dashboards: Nausea and Vomiting
Results in severe patient dissatisfactionMay be influenced by anesthetic plan
54
Guffey, Patrick, MD Improving the Quality of Your Practice
Dashboards: Emergence Delirium
Child wakes inconsolable and disassociated from the environment
55
Dashboards: OR Metrics
Dashboards: Change Management
ScorecardEvery 6 months
Self serve analytics available anytime
Two standard deviations below meanOutlier management
Cases reviewed with clinical management teamSuggestions offered for improvement
Dashboards: Compliance Reporting
The Intersection of Quality and Informatics is:
High Reliability
Systems or processes that depend on perfect human performance are inherently flawed
High Reliability Organizations (HROs) are a subset of organizations which exhibit continuous, nearly error free operation, even in multifaceted, turbulent, and dangerous task environments. HROs include aircraft carriers, nuclear submarines and power plants, air traffic control systems…
High Reliability
Guffey, Patrick, MD Improving the Quality of Your Practice
PROCEDURAL SAFETY CHECKLIST EVERY PATIENT – EVERY TIME – EVERYONE PARTICIPATES
Before Induction in Room Prior to Incision/Procedure Before Attending Proceduralist Leaves Room
ANESTHESIA SIGN-IN PERFORMED BY ANESTHETIST
PROCEDURAL TIME OUT PERFORMED BY PROCEDURALIST
ALL TEAM MEMBERS: 1. Introduce self by name and role 2. Discuss fire risk assessment (nursing) PROCEDURALIST VERIFIES WITH TEAM: 1. Patient identification • Two identifiers (Name and MRN) • Check armband, consent, labels 2. Procedure matches consent 3. Site marking visible adjacent to incision site, if applicable (refer to chart on back of checklist) 4. Positioning appropriate for procedure 5. Post‐op disposition (e.g., discharge; floor; ICU) 6. Any questions or concerns? ANESTHESIOLGIST VERIFIES: 1. Antibiotic administered within 60 min prior to incision (120 min for Vancomycin) PROCEDURE‐SPECIFIC SPECIAL CONSIDERATIONS REVIEWED BY PROCEDURALIST, WHEN APPLICABLE: 1. Special equipment; implants 2. Imaging, lab and other relevant tests 3. Dental site verification process after x‐rays 4. Estimated blood loss/blood available 5. Critical steps, anticipated risks
d l d h f l bl
PROCEDURALIST VERIFIES: 1. Name of procedure to be recorded CIRCULATOR/SCRUB NURSE VERIFIES: 1. Final counts, if applicable • sponges‐instruments‐sharps 2. Correct labeling of specimens, if applicable ALL TEAM MEMBERS: 1. Verify post‐op disposition (PACU; ICU) 2. Reminder to write timely post‐op orders 3. Key concerns for postoperative period 4. What went well and what can be improved? 5. Anticipated needs for next case, if applicable. 6. Estimated time in room for next patient (wheels out to wheels in), if applicable.
DEBRIEFING FACILITATED BY NURSING
ANESTHESIOLOGIST & CIRCULATOR: 1. Verify patient identification • Use two identifiers (Name and MRN) • Check armband and consent • Verify information with family, if applicable 2. Procedure and anesthetic • Verify on consent • State anesthetic technique • Discuss regional block(s) and check for block/surgical site mark(s) if applicable • Blood consent signed, if appropriate 3. State weight and allergies 4. State VTE risk assessment and prevention strategies (SCDs on, if appropriate) 5. Verify information against whiteboard
AFTER EACH SECTION, STOP AND ASK FOR QUESTIONS FROM THE TEAM. EVERYONE IS RESPONSIBLE FOR STOPPING THE PROCESS WITH CONCERNS.
Note: If a combined time out is performed, both the anesthesiologist and surgeon must be present and all elements of both the Anesthesia Sign-in and Procedural Time Out must be included.
Preventing Harm: Anesthesia Sign‐In
Early Warning System: Display
63
Early Warning System: Reports
Emergency ProtocolsCognitive Aids
Guffey, Patrick, MD Improving the Quality of Your Practice
Emergency Protocols Pulseless Arrest
Patrick [email protected]
University of Colorado
Guffey, Patrick, MD Improving the Quality of Your Practice