Temple University HospitalHouse Staff Orientation

High Value Care

Susan L. Freeman, MD, MS

Chief Medical Officer

Temple University Health System

June/July, 2013

PART ONEHigh Value Care

What is it?

The Triple Aim

Population

Health

Per Capita Cost

Patient Experience

Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)

Value PropositionHigh value health care =

high quality outcomes / low costHigh value can only occur if: • The culture supports communication,

collaboration and consistently safe care• Frontline employees and physicians (including

house staff) are engaged at every level• The entities of the health system are aligned

from Board to bedside

Quality Construct

Electronic Communication and Health Information

High Value Care, Every Patient, Every Day

CultureExecution

And Diffusion

Engineering

AndDesign

Infrastructure: Integrated Care Across The Continuum

TUHS Value Construct

Adopted from the Mayo Clinic Value Construct Model, 2012

High Value Care

Are we consistently delivering it?

Wrapping Your Head Around the Problem of Medical Errors

• To Err is Human – the landmark report of the IOM in 1999 – up to 98,000 people die each year in the U.S. from medical errors.

The Numbers are Staggering

• Every day and a half a fully loaded 747 would have to fall from the sky before the airline passenger loss of life would surpass that of hospitals

Adverse Events at TUH

•Wrong site surgery•Retained sponge•Medication errors•Falls• Infections•Death

SERIOUSLY?

HealthcareQUALITY

begins with PATIENT SAFETY

Kenneth Kaiser, MD, MPHNational Quality Forum

• Freedom from injury• Consistent care 24 x 7 x 365• Seamless transitions/handoffs• Informed, satisfied patients• Transparency in care and

data• Open, honest, non- punitive

reporting• A culture obsessed with

safety

Defining Quality

•No needless deaths•No needless pain or suffering•No unwanted waits•No helplessness•No waste

For Anyone….

Institute for Healthcare Improvement

The Six Dimensions of Quality

•Patient Safety•Patient Centeredness•Timeliness•Effectiveness•Efficiency•Equity

From the IOM: Crossing the Quality Chasm (2001)

Why So Many Errors?

•Why are hospitals unsafe?•Why are errors made?•Can they be prevented?

Humans Make ErrorsYou are sitting on the unit entering orders after rounds

There are a series of orders for different patients

Midway through, your cell phone goes off. You take the call.

You turn back to the ordering tasks and pull up Mr. Jones. You order 100mg of methadone orally. The medication is administered to Mr. Jones.

Two hours later you get a call from the nurse, that Mr. Smith wants to know where his methadone is.

You realize at that point that you ordered methadone on the wrong patient.

Distraction

Human Error

Human Factors

• Human information processing is influenced by multiple factors:– Attention – may be limited in duration or focus– Memory constraints – working memory is limited– Automaticity – consistent, over-learned responses

may become automatic, and completed without conscious thought

– Situation awareness – a person’s perception of elements in the environment may affect their processing of information

(Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science 1974; 185:1124-31)

Human Factors and Bias

• Pattern matching instead of careful reasoning• What has worked before is used when there is uncertainty • Availability heuristic – giving undue weight to facts that come

readily to mind, and ignoring that which is not immediately present

• Confirmation bias – once a decision is reached, there is a tendency to seek evidence to support it

• Selectivity – focus of attention on what is logically important vs. what is psychologically salient

• Frequency gambling – betting on the condition that occurs most frequently

Human Error

•An unsafe act is “an error or a violation committed in the presence of a potential hazard”

•Two categories: errors and violations

(James Reason, Human Error, 1990)

Errors and Violations

Errors

An action does not go as intended

An action goes as intended,

but it’s the wrongaction

MistakeLapseSlip

Violations

A deliberate deviation

from an operatingprocedure, standard or rule

(James Reason, Human Error, 1990)

Human Factors

Humans will always make mistakes regardless of training, experience and determination

Human infallibility is impossibleThose who build systems that depend on

the absence of human error will fail

John Nance. Why Hospitals Should Fly. 2008, page 45

Systems are Designed to Prevent Errors from Reaching

the Patient• What is a system?

– A series of actions that, when followed, provides for the delivery of safe care to every patient, every time

• Codified in policies, procedures, standard order sets, check lists

– A series of redundancies that provides multiple check points

• An order is written, checked by the pharmacy, checked by the nurse, reconciled with the medication list

Redundant Processes (James Reason)

Each layer is a defense against potential error impacting the outcome

Failure at Every Level

Circumstances in which planned actions fail to achieve the desired outcomes

Culture of Safety

• Shared perceptions and actions around what is good, right, important, valued, supported, rewarded and expected

• Culture is shaped by the alignment of people and systems; attitudes; knowledge; practices; leadership; trust; accountabilities; and a commitment to safety

• Culture is linked to outcomes – strong culture decreases medication errors, hospital acquired UTI’s, nurse turnover and absenteeism, nurse satisfaction, malpractice claims, back injuries, patient satisfaction, needle sticks

Halligan, M. and A. Zecevic. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. Qual Saf Health Care/. 2011. doi:101136/bmjqs.2010.040964.

High Value Care

Evidence-Based care delivered efficiently, at the highest standard in the absence of error or adverse event by a team that has created a

culture to support superior outcomes.

High Value Care

How is this accomplished?

KNOW THE SYSTEM

High Value Care

Communication

Care Delivery

Hospital Acquired Conditions

Risk Management

Breakout Sessions• 319A Risk Management• 319B Care Delivery• 319C Quality and Hospital Acquired Conditions• 319D Communication

  A-G H-L M-P R-Z

8:10 - 8:30 Auditorium

8:35 - 9:05 319A 319D 319C 319B

9:10 - 9:40 319B 319A 319D 319C

9:45 - 10:15 319C 319B 319A 319D

10:20 - 10:45 319D 319C 319B 319A

10:50 - 11:00 Auditorium

PART TWOHigh Value Care

THE TOP TEN

House Staff Orientation:TOP TEN

1. Patient safety and quality of care are the top priorities

2. Humans make errors

3. Systems are designed to prevent those errors from reaching the patient (processes, policies, best practices)

4. Systems only work in the presence of individual accountability

5. The majority of errors occur because of lack of communication

6. Teamwork is vital – it takes a village - use the resources and expertise available (Nurses, CM, RM, PT, Pharmacy, etc.)

7. Basic medication safety rules, consent, documentation

8. Universal protocol

9. Infection prevention

10. The patient and the patient’s well being must be at the center of everything you do – it’s about the patient experience and the clinical outcomes

Adopted from: Tsilimingras, et.al. The Challenge of Developing a Patient Safety Curriculum for Medical School. Med Sci Edu 2012;22(2):65-72.

Keep the Patient at the Center of Everything You Do

PATIENT

AttendingsHouse StaffExtenders

Nursing

Case ManagersSocial Workers

TransportSupply Chain

EVSFacility

Performance Improvement Patient Safety

Facilitators

PharmacistsTherapists

NutritionistsInfection Preventionists

The National Agenda: The Triple Aim

Population Health

Per Capita Cost

Patient Experience

Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)

Get Involved in Quality and Safety

Medical Staff Committees:

Patient SafetyPerformance ImprovementPeer Review

House StaffQuality Council

& Program LevelPI/QI

Accountable CareUnit:

HuddlesMultidisc Rounds

Mini RCA’sThroughput

Patient SatisfactionCore MeasuresInfection Control

RESIDENTINTEGRATION

INTOQUALITY

PATIENT SAFETY

You Are The Key to Preventing Medical Errors

ANDProviding Safe, Quality

Patient Care