Quality & Safety at Hadassah:Quality & Safety at Hadassah:

A Progress ReportA Progress ReportSeptember 8, 2009September 8, 2009

Mayer Brezis, MD MPHMayer Brezis, MD MPHProfessor of MedicineProfessor of Medicine

Center for Clinical Quality & SafetyCenter for Clinical Quality & Safety

Family’s Involvement during Physician’s Rounds Family’s Involvement during Physician’s Rounds Oded Lagstein, Liran Levy, Matan Cohen, Lois Gordon & Oded Lagstein, Liran Levy, Matan Cohen, Lois Gordon &

Mayer BrezisMayer Brezis

Ventilator-Associated Pneumonia Ventilator-Associated Pneumonia Ina Apelbaum, Nurit Katz, Philip Levine, Shmulick Ina Apelbaum, Nurit Katz, Philip Levine, Shmulick

Benenson, Carmela Shwartz, Colin Block, Lois Gordon & Mayer Benenson, Carmela Shwartz, Colin Block, Lois Gordon & Mayer BrezisBrezis

Disruptive BehaviorDisruptive BehaviorOrit Samuel Ben-Dov, Robert Cohen & Mayer BrezisOrit Samuel Ben-Dov, Robert Cohen & Mayer Brezis

Perspective on recent years of activity by the Center of Perspective on recent years of activity by the Center of Clinical Quality & Safety Clinical Quality & Safety

Several Projects of Clinical QualitySeveral Projects of Clinical Quality

National Priorities PartnershipNational Priorities Partnership©©

Setting a National Setting a National Agenda for Healthcare Agenda for Healthcare Quality and SafetyQuality and Safety

Patient and family engagementPatient and family engagement

Population health Population health

SafetySafety

Care coordinationCare coordination

Palliative carePalliative care

OveruseOveruse

Involvement of family during Involvement of family during physician’s rounds in the physician’s rounds in the departments of Medicinedepartments of Medicine

Oded Lagstein, BA, Liran Levy, MD, Oded Lagstein, BA, Liran Levy, MD, Matan Cohen, MD MPH, Lois Gordon, Matan Cohen, MD MPH, Lois Gordon,

MPH & Mayer Brezis, MD MPHMPH & Mayer Brezis, MD MPH

Center for Clinical Quality & SafetyCenter for Clinical Quality & Safety

To what extent would you like a family member next to you during doctors' visit? Very much 78%

Does presence of family member help getting information on your condition? 92% on your treatment 95% making treatment decisions 84%

Patients (n=93)

Does presence of a family member help reducing your family's anxiety 85%

To what extent would you like to be present during doctors' visit? Very much 70%

Does presence of a family member help getting information on pt’s condition? 96% on the treatment 92% making treatment decisions 82%

Family (n=105)

Does the presence of a family member help reducing family's anxiety 88%

To what extent do you support presence of family during doctors' visit? Very much 56%

To what extent family involvement is important for patient’s treatment? Very much 71%

Nurses (n=55)

How does family presence affect communication with the patient? “Improves communication” 63%

To what extent do you support presence of family during doctors' visit? Very much 55%

To what extent family involvement is important for patient’s treatment? Very much 85%

Physicians (n=31)

How does family presence affect communication with the patient? “Improves communication” 55%

Duration of rounds was not affected Duration of rounds was not affected by presence of relativesby presence of relatives

Observations on 129 Observations on 129 rounds in 3 depts of rounds in 3 depts of

MedicineMedicine

Involvement of family during Involvement of family during physician’s rounds: conclusionphysician’s rounds: conclusion

A majority of patients, relatives, nurses A majority of patients, relatives, nurses and physicians:and physicians:

• support the ideasupport the idea

• think it improves communication think it improves communication

• and relieves family’s anxiety and relieves family’s anxiety

Observations show presence of relatives Observations show presence of relatives during round does not affect its durationduring round does not affect its duration

Findings are consistent with literature Findings are consistent with literature and suggest need for change in policy and suggest need for change in policy

Ventilator-Associated PneumoniaVentilator-Associated Pneumonia

Project aim: reduce VAP incidence at Hadassah

Ina Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson, Ina Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson, Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer BrezisCarmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis

General Intensive Care, Unit for Infection Control and General Intensive Care, Unit for Infection Control and the Center for Clinical Quality and Safetythe Center for Clinical Quality and Safety

VAP Prevention: VAP Prevention: Recommendations Rated Recommendations Rated

With High Level of EvidenceWith High Level of Evidence

ICHE 2008ICHE 2008

Survey resultsSurvey results

Period of observationPeriod of observation:: February – March February – March 2009 2009

Department

Mean ventilation

days/pt.

Ventilation days during

observation period

Total ventilated

patients during observation

period

ICU A 12 449 32

ICU B 11 175 19

Neurosurgical ICU 16 195 11

Medical ICU 10 220 17

Total 12 1039 79

Intern. Medicine A 11 212 17

Intern. Medicine B 10 139 13

Intern. Medicine C 9 238 25

Total 10 589 55

Diagnostic criteria for Diagnostic criteria for VAPVAP

Department ICUsInternal

Medicine Total

Patients observed 43 24 67

Ventilation days 827 296 1123

Cases of VAP 15 5 20

Percent developing VAP 35% 21% 30%

VAP cases/1000 ventilation days 18‰ 17‰ 18‰

Mean cases/1000 ventilation days in literature* 11‰ (95%CI, 10-13)

Rates of Ventilator-Associated Rates of Ventilator-Associated Pneumonia: Hadassah vs literaturePneumonia: Hadassah vs literature

* * Chest 2008 (Chest 2008 (beforebefore interventions, down by 50% interventions, down by 50% afterafter interventions) interventions)

Process of Care MeasuresProcess of Care Measures

All variables are dichotomous (yes/no)All variables are dichotomous (yes/no)

Variable Definition Data Source

Elevation of head of bed

Head of the bed elevated at 30o- 45o; measured daily with a protractor but not during treatment of patient

Daily observation

Hand hygiene Washing hands with soap and water or an alcohol-based solution before and after contact with ventilator, patient or patient’s belongings

Patient record

Oral care Documentation in patient record regarding oral treatment with chlorhexidine solution, once every shift

Patient record

Cleaning of ventilator tubing

No visible discharge or dirt in ventilator tubing

Daily observation

Adherence to VAP GuidelinesAdherence to VAP Guidelines

DepartmentTotal days observed

Head of bed up to 30o - 45o

Oral care documented

Ventilator tubing clean

% % %

ICU A 187 59 68 74

ICU B 78 58 69 75

Neurosurgical ICU 86 32 46 68

Medical ICU 81 54 68 72

Total 432 %48 61% 72%

Intern. Medicine A 79 36 34 71

Intern. Medicine B 55 37 35 68

Intern. Medicine C 106 37 37 69

Total 240 37% 35% 68%

Adherence to Hand Hygiene Adherence to Hand Hygiene (nurses) (nurses)

DepartmentHands washed before contact

Hands washed after contact

Gloves put on before contact

% % %

ICU A 35 55 65

ICU B 33 52 62

Neurosurgical ICU 30 40 23

Medical ICU 35 48 55

Total 33% 47% 46%

Intern. Medicine A 29 40 22

Intern. Medicine B 27 37 25

Intern. Medicine C 27 38 24

Total 27% 38% 23%

Department

Hands washed before contact

Hands washed after contact

Gloves put on before contact

% % %

ICU A 12 59 58

ICU B 13 60 61

Neurosurgical ICU 8 45 40

Medical ICU 11 56 58

Total 11% 54% 53%

Intern. Medicine A 11 49 44

Intern. Medicine B 10 47 42

Intern. Medicine C 9 48 45

Total 10% 47% 43%

Adherence to Hand Hygiene Adherence to Hand Hygiene (Respiratory Technicians) (Respiratory Technicians)

Summary for the VAP projectSummary for the VAP project1.1. The incidence of VAP in the ICUs of Hadassah The incidence of VAP in the ICUs of Hadassah

is higher than those reported in the literature.is higher than those reported in the literature.

2.2. The percent of adherence to guidelines The percent of adherence to guidelines recommended for VAP prevention is lower than recommended for VAP prevention is lower than desirable.desirable.

3.3. How can adherence to these guidelines be How can adherence to these guidelines be improved? E.g.:improved? E.g.: Elevating the head of the bed between 30Elevating the head of the bed between 30oo- 45- 45oo

Hand washing by staff before and after contact Hand washing by staff before and after contact with ventilator, patient and patient’s belongingswith ventilator, patient and patient’s belongings

Oral hygiene (including brushing and Oral hygiene (including brushing and documentation)documentation)

Discontinuation of sedation once a dayDiscontinuation of sedation once a day

InterventionInterventionFindings discussed with senior staff Findings discussed with senior staff

of surgical ICU’sof surgical ICU’s

• Review of guidelines at staff meetingsReview of guidelines at staff meetings

• Email or newsletterEmail or newsletter

• Sign at room entrance Sign at room entrance

• PostersPosters

• Buttons or tagsButtons or tags

• ScreensaversScreensavers

before and after contact with ventilator, patient or patient’s belongings

No visible discharge or dirt in breathing tube

Head of the bed elevated at 30o- 45o

Oral hygiene (chlorhexidine solution), once per shift

Hand washing: soap & water or alcohol-based solution

Button on physician’s or nurse’s uniform

Don’t touch me until Don’t touch me until you’ve washed your you’ve washed your

hands!hands!

“Ask Me if I’ve Washed My Hands”

Poster on door or bed

InterventionInterventionFindings discussed with senior Findings discussed with senior

staff of surgical ICU’sstaff of surgical ICU’s

• Review of guidelines at staff meetingsReview of guidelines at staff meetings

• Email or newsletterEmail or newsletter

• Sign at room entrance Sign at room entrance

• PostersPosters

• Buttons or tagsButtons or tags

• ScreensaversScreensavers

Re-evaluation scheduled for early 2010Re-evaluation scheduled for early 2010

Joint Commission now requires hospitals to have a written code of conduct and a process for enforcing it

Disruptive BehaviorDisruptive Behavior

Mark Chassin, MD, MPP, MPHProfessor of Medicine & VP for ExcellenceMount Sinai School of Medicine President of the Joint Commission

“Do you have disruptive behavior at Hadassah?”

Disruptive behavior is a form of physician impairment and has become a focus of public health attention due to its destructive impact onhospital staff, institutions, and patient care (The Physician Executive 2008).

Disruptive BehaviorDisruptive Behavior

““Conduct by individual Conduct by individual working in the organization working in the organization that intimidates others to that intimidates others to the extent that quality and the extent that quality and safety are compromised”safety are compromised”

Joint Commission DefinitionJoint Commission Definition

Disruptive Behavior at Hadassah:

Survey of communication measures critical to quality & safety

Orit Samuel Ben-Dov, MD, Robert Cohen PhD, Mayer Brezis, MD MPH

Center for Clinical Quality & Safety, Hadassah & Hebrew University

“Don’t be shamed of learning truth from any source, even from a lower person” Rabbi Solomon Ibn Gabirol (ca. year 1030)

MethodsMethods

Surveys tools validated in the literature (AHRQ)Surveys tools validated in the literature (AHRQ) Departments of Medicine & Surgery, EK & MSDepartments of Medicine & Surgery, EK & MS Convenient sample during morning workdaysConvenient sample during morning workdays Compliance: 96/108 (86%) Compliance: 96/108 (86%) 37 physicians (29 residents, 8 seniors)37 physicians (29 residents, 8 seniors) 59 nurses59 nurses Average length of service 5 years (1 month – 39 Average length of service 5 years (1 month – 39

years)years) Standard statisticsStandard statistics

Frequently or Frequently or Very frequentlyVery frequently

SometimesSometimesRarely Rarely

or Neveror NeverDidn’t Didn’t answeranswer

Refuses to answer Refuses to answer questions/callsquestions/calls 99 3030 6060 11

Arrogant toneArrogant tone 1818 4848 3232 11Impatience to answer Impatience to answer

questionsquestions 2222 4141 3636 11

Strong verbal insultStrong verbal insult 99 1616 7373 22Threatening body Threatening body

languagelanguage 99 1515 7676 11

““Just do it”Just do it” 88 1616 7575 11

Physical violencePhysical violence 00 33 9797 00

Last year exposure to intimidating behavior (%)Last year exposure to intimidating behavior (%)

Results (cont’d)Results (cont’d) 29% report most of the time they don’t speak 29% report most of the time they don’t speak

freely when they perceive a risk to a patientfreely when they perceive a risk to a patient

23% report they pretended an order was correct, in 23% report they pretended an order was correct, in spite of their doubts, to avoid conflicts spite of their doubts, to avoid conflicts

20% feel pressured to fulfill orders despite their 20% feel pressured to fulfill orders despite their reservations about safety (3x during last year) reservations about safety (3x during last year)

5% report their were involved in an error during 5% report their were involved in an error during last year, related to threatening behaviorlast year, related to threatening behavior

Perceived threat higher in surgery than medicine; Perceived threat higher in surgery than medicine; similar among nurses and physicianssimilar among nurses and physicians

38% feel poor handover between shifts affects 38% feel poor handover between shifts affects qualityquality

Perspective on recent years of activity by the Perspective on recent years of activity by the Center of Clinical Quality & SafetyCenter of Clinical Quality & Safety

Achievements

Dozens of projects in important fields, e.g.:Prevention of thrombo-embolismTraining patients for warfarin useSafety in drug administrationCoronary care measuresPalliative careER (waiting, pain Rx, ankle Dx, UTI Rx)Reliability of imaging readingsSpecific surgeries (Hernias, Eye, ENT) Hand hygieneImpact of translatorsInfections in central lines hadassah.org.il/departments/quality

Challenges

No translation of project into routine work

No continous measure of quality indices

No increase in error reporting by physicians

No cultural change

Correct identification of Correct identification of improvement improvement opportunitiesopportunities

Failure in a shift to Failure in a shift to

systematic systematic

improvementimprovement