Patient Safety: Applying Industrial Quality Models in Healthcare Settings Tempora mutantur, nos et mutamur in illis
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1 Patient Safety: Applying Industrial Quality Models in Healthcare Settings Tempora mutantur, nos et mutamur in illis Julie Louise Gerberding, MD MPH Division of Healthcare Quality Promotion National Center for Infectious Diseases
2 Quality problems are everywhere. Between the health care we have and the care we could have lies not just a gap, but a chasm. The frustration level of both patients and clinicians has never been higher. Health care today harms too frequently and routinely fails to deliver its potential benefits. Crossing the Quality Chasm Institute of Medicine, 2001
3 Contemporary Healthcare Stacey, R.D chaos chaos zone of complexity simplicity High Low Certainty about Outcomes Agreement High Low
4
5 Chaos in Healthcare! Flow diagram for medication delivery to an intensive care unit
6 Patient Safety is Healthcare without unintended harm, free from errors and near misses A surrogate term for healthcare quality An organizing principle to motivate healthcare quality improvements An extremely compelling tag line that has effectively engaged consumers, healthcare organizations, purchasers, and decision makers A critical public health issue for infectious diseases clinicians and CDC!
7 Goals of Healthcare Appropriate treatment Short length of stay / efficient resource utilization Low mortality in hospital and after Best possible functional status Patient satisfaction Healthcare provider satisfaction
8 Patient Safety
9 CDC / NCID Division of Healthcare Quality Promotion 7 Healthcare Safety Challenges In 5 years: Reduce targeted catheter-associated adverse events by 50% Reduce targeted surgical adverse events by 50% Reduce targeted antimicrobial-resistant bacterial infections by 50%
10 CDC / NCID Division of Healthcare Quality Promotion 7 Healthcare Safety Challenges In 5 years: Reduce mortality and hospitalizations due to respiratory infections among long term care patients by 50% Eliminate microbiology laboratory errors leading to adverse patient outcomes Eliminate occupational needle injuries among healthcare personnel Achieve 100% compliance with ACIP guidelines for immunization of healthcare personnel
11 Strategies for Improving Healthcare Safety Goal: Prevent Catheter Infections Benchmarking / Continuous Quality Improvement
12 Benchmarking for Quality Improvement Hospital A NNIS Benchmarks (percentile) Site Infection Rate* 10% 25% 50% 75% 90% UTI BSI VAP * Rate = # infections per 1000 device-days UTI = urinary catheter-associated infection BSI = central catheter-associated bloodstream infection VAP = ventilator-associated pneumonia
13 Quality Promotion / Infection Prevention Cycle for Success Is there an important problem? Compare local rates to NNIS benchmarks Why? What? Multidisciplinary committees Do the changes work? Monitor progress toward improvement How to affect change? Education Feedback Decision support
14 A Decade of Progress: Hospital-onset Infection Rates in Intensive Care Units Decline (NNIS Hospitals) Percent Decline in Rate Type of ICU BSI* VAP* UTI* coronary 43% 42% 40% medical 44% 56% 46% surgical 31% 38% 30% pediatric 32% 26% 59% BSI = central line-associated bloodstream infection rate VAP= ventilator-associated pneumonia rate UTI = catheter-associated urinary tract infection rate CDC NNIS System,
15 Strategies for Improving Healthcare Safety Goal: Prevent Catheter Infections Benchmarking / Continuous Quality Improvement Root Cause Review / Analysis
16 Root Causes Review* of Fatal Catheter-associated Bacteremia: Delay in Treatment Work processes / timeline fever noted / MD alerted / patient evaluated tests ordered / tests performed / results available results reviewed / treatments ordered / administered Communication / supervision channels nurse / houseofficers / attending / consultants Structural issues / competing priorities staffing / census hours on call / consecutive shifts worked
17 Strategies for Improving Healthcare Safety Goal: Prevent Catheter Infections Benchmarking / Continuous Quality Improvement Root Cause Review / Analysis Six Sigma Analysis
18 What is Six Sigma? 3.4 defects per million process opportunities A business process that allows companies to drastically improve their bottom line by designing and monitoring everyday business activities in ways that minimize waste and resources while increasing customer satisfaction M Harry & R Schroeder: Six Sigma; 2000 the most important initiative GE has ever undertaken. Jack Welch, General Electric
19 What is Six Sigma Breakthrough Strategy? Measurement: data collection and reporting Analysis: statistical evaluation of process data Improvement: re-design, change processes Control: continuous process monitoring
20 Six Sigma Strategy Focus: persistent (endemic) problems, not just sporadic (epidemic) problems Hidden problems; ton of feathers Evade attention Erode quality Ton of feathers Most quality problems are persistent!
21 Benchmarking for Quality Improvement Hospital A NNIS Benchmarks (percentile) Site Infection Rate* 10% 25% 50% 75% 90% UTI BSI VAP * Rate = # infections per 1000 device-days UTI = urinary catheter-associated infection BSI = central catheter-associated bloodstream infection VAP = ventilator-associated pneumonia
22 Six Sigma: Breakthrough Catheter Infection Prevention Measure Analyze Monitor Improve
23 Strategies for Improving Healthcare Safety Goal: Prevent Catheter Infections Benchmarking / Continuous Quality Improvement Root Cause Review / Analysis Six Sigma Analysis Toyota Production System
24 TPS Goals Quantity control: adapt to daily and monthly fluctuations in demand in terms of quantities and variety Quality assurance: assures that each process will supply only good units to the subsequent processes Respect-for-humanity: cultivated while utilizing human resources to attain cost and quality objectives.
25 Muda Waste of time Waste of overuse Waste from transporting Waste of over processing Waste of inventory Excess motion of operators and workers Waste from scrap and rework. Human under utilization Improper use of computers Working to the wrong metrics
26 Chaos in Healthcare! Flow diagram for medication delivery to an intensive care unit
27 TPS: Promoting Patient Safety The Goals: Error-free care 1:1 contact No waste Immediate response Safety Clinician Request Response Patient
28 Pittsburgh Regional Health Initiative A community coalition: 31 hospitals / 4 insurance plans / all major healthcare purchasers State Attorney General United by a common mission: Providing patients what they need when they need it without waste or error Perfection Zero Goals: Zero medication errors Zero hospital-acquired infections Perfect clinical outcomes: Invasive cardiac procedures, hip and knee replacement surgery, depression, c-sections, diabetes
29 Strategies for Improving Healthcare Safety Goal: Prevent Catheter Infections Benchmarking / Continuous Quality Improvement Root Cause Review / Analysis Six Sigma Analysis Toyota Production System
30 Tempora mutantur, nos et mutamur in illis Systems must Times change, and we change with them too Owen's Epigrammata, 1615
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