10 years after “To Err is Human”

An RCA of Patient Safety Research?

Peter Pronovost, MD, PhD

Objectives

• To reflect on some of the barriers to patient safety research

• To consider an overview for training in patient research

Bilateral cued finger movements

System Failures Slowing Progress in Patient Safety

Failure to viewthe delivery of care

as a science

Insufficiently robust research

Insufficient partnershipsBetween academic and

quality communities

Insufficient capacity totrain researchers

Reason model

Patients continue to suffer preventable harm

Reason

Translational Research Model

UnderstandingDisease Biology

T1Translating to Humans

ImprovedHealth

Outcomes

Identifying andComparing Effective

Therapies

T2Translating to Practice

Implementing,Disseminating and

Sustaining Research,Monitoring Outcomes

Summarizingevidence andunderstanding

if and howthese therapieswork in practice

Formulating,Analyzing, and

TestingPre-Clinical

Models

Figure 1

Translation Superhighway

System Failures Slowing Progress in Patient Safety

Failure to viewthe delivery of care

as a science

Insufficiently robust research

Focus on differences rather than similarities

with other types of research

Insufficient capacity totrain researchers

Reason model

Patients continue to suffer preventable harm

Reason

Central Mandate

Local Wisdom

Scientifically Sound Feasible

xx

ExercisePlease answer each question with a score of 1 to 5.

1 is below average, 3 is average and 5 is above average

• How smart am I

• How hard do I work

• How kind am I

• How tall am I

• How good is the quality of care we provide

Improving Sepsis Care(n= 19 ICUs)

Mortality

13.1

21.9

41.8

0.0

10.0

20.0

30.0

40.0

50.0

Oct - Dec2003

Mar - May2004

July - Sept2004

%

69% Reduction (p < 0.001)

ICU LOS

6.2

7.6

10.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Oct - Dec2003

Mar - May2004

July - Sept2004

Day

s

36% Reduction (NS)

Improving Sepsis Care(n= 19 ICUs)

Mortality

13.1

21.9

41.8

0.0

10.0

20.0

30.0

40.0

50.0

Oct - Dec2003

Mar - May2004

July - Sept2004

%

69% Reduction (p < 0.001)

ICU LOS

6.2

7.6

10.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Oct - Dec2003

Mar - May2004

July - Sept2004

Day

s

36% Reduction (NS)

Framework for Patient Safety Research and Practice

• Measuring Patient Safety

• Translating Evidence Intro Practice (TRIP)

• Identifying and Mitigating hazards

• Improving Culture and Communication

• Building Capacity and Organizing for Safety

• Reducing Diagnostic Errors

Pronovost Circulation in press

Translating EvidenceInto Practice

* Envision the problemwithin the larger health

care system

* Engage collaborativemulti-disciplinaryteams centrally(stages 1,2,&3)

and locally(stage 4)

1. Summarize the Evidence

Convert interventions to behaviors

2. Identify local barriers toimplementation: understandthe process and context of

work

3. Measure Performance

4. Ensure all patientsreceive the interventions

Identify Interventions associatedwith improved outcomes

Select interventions with the largestbenefit and lowest barriers to use

Enlist all stakeholders to shareconcerns and identify potentialgains/losses associated withintervention implementation

Observe staff performing theinterventions

"Walk the process" to identifydefects in each step of intervention

implementation

Measure Baseline Performance

Develop and pilot test measures

Select Measures(process and/or outcome)

Engage

Explain why the interventions are

important

Execute

Design an intervention “toolkit” targeted to barriers employing standardization,

independent checks and reminders, and learning from mistakes

Educate

Share the evidence supporting the interventions

Evaluate

Regularly assess performance

measures

Pronovost BMJ in press

•Identify Hazards•(

3. Mitigate Risks

2. Analyze & Prioritize Hazards

4. Evaluate Effectiveness of Risk Reduction

Patient Safety Learning Communities

Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control.

System Failures Slowing Progress

Failure to viewthe delivery of care

as a science

Insufficiently robust research

Focus on differences rather than similarities

with other types of research

Insufficient capacity totrain researchers

Reason model

Patients continue to suffer preventable harm

Reason

Context become Mechanism

ContextMechanism Outcome

Pawson Tilley

System Failures Slowing Progress in Patient Safety

Failure to viewthe delivery of care

as a science

Insufficiently robust research

Focus on differences rather than similarities

with other types of research

Insufficient capacity totrain researchers

Reason model

Patients continue to suffer preventable harm

Reason

Simple Rules for Producing Researchers

• Obtain formal degree

• Identify willing and capable mentor

• Obtain protected time to participate in research project

Core Skills for Patient Safety Researchers

• Epidemiology• Biostatistics• Health services • Economics• Sociology• Psychology• Informatics• Systems analysis

• Qualitative• Leadership• Change management• Project management

EPI

/Stats

Psych

/Soc

HSR Econ

Critical care

Surgery

Pediatrics

Medicine

Quality and Safety Research Group Mixing Bowl

Improving Patient Safety in Michigan ICUs

Funded by AHRQ

24

Time period Median CRBSI rate Incidence rate ratio

Baseline 2.7 1

Peri intervention 1.6 076

0-3 months 0 0.62

4-6 months 0 0.56

7-9 months 0 0.47

10-12 months 0 0.42

13-15 months 0 0.37

16-18 months 0 0.34

2 year results from 103 ICUs

Pronovost NEJM 2006

  84% 82%

23% 22%

0

10

20

30

40

50

60

70

80

90

100

Safety Climate TeamworkClimate

2004 2007

"Needs Improvement“ Statewide Michigan CUSP ICU Results

•Less than 60% of respondents reporting good safety climate =“needs improvement”

•Statewide in 2004 84% needed improvement, in 2006 41%•Non-teaching and Faith-based ICUs improved the most•Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

Keystone ICU Safety Dashboard

2004 2006

How often did we harm (BSI)

2.8/1000 0

How often do we do what we should

66% 95%

How often did we learn from mistakes

30% 100%

% Needs improvement in Safety climate

Teamwork climate

84%

82%

43%

42%

Focus and Execute