Post on 11-Jan-2016
description
Quality & Patient Safety TOH
Linda Hunter Director, Quality and Patient Safety
2011
Deep River & District Hospital
Pembroke General Hospital
Renfrew Victoria Hospital
Arnprior & District Memorial Hospital
Almonte General Hospital
Carleton Place & District Hospital
Ottawa Area Hospitals - The Ottawa Hospital - Royal Ottawa - CHEO - Montfort
Hawkesbury & District General Hospital
Glengarry Memorial Hospital
Hotel Dieu HospitalCornwall General Hospital
Winchester District Memorial Hospital
Kemptville District Hospital
Perth & Smith's Falls District Hospital
St. Francis Memrial Hospital
- Queensway-Carleton Hospital - Bruyere Continuing Care
Champlain LHIN
Capacity
• ~$1B Operating Budget
• 1,172 Inpatient Beds
• 12,000 Staff
• 1,200 Physicians
The Ottawa HospitalFacts and Figures
Activity
• 46,000 Admissions
• 49,000 Surgical Cases
• 127,000 ED Visits
Patient Volumes
Service Excellence Performance Measurement
Physician Engagement & Accountability
To Become a Top 10% Performer in Quality and Patient Safety in North America
To provide each patient with the world class care, exceptional service and compassion that we
would want for our loved ones
Vision
Our Patients
Our Environment
Our Staff
Our Finances
Our Partners
Commitment to Quality
Working TogetherRespect
for the Individual Compassion
Communication & Community Outreach Plan
AccessWait Times:DI, Hip/Knee, Cancer & ED
EfficiencyALOS-ELOSCPWC
SafetyHSMRHospital Infections:MRSA, VRE & C-Difficile
Outcomes
Milestones& Tactics
Create a culture of compassionate people, world-class careCulture
EffectivenessRe-admission ratesSurg. Site Infections
SatisfactionOverallPainTransition
Patient Experience
Staff Engagement
Enabling environments
Clinical transformations
Information Services Plan
Capital Plan
Operating Plan
Human Resources Plan
Research Plan
Quality Plan
Values
Quality and Performance Measurement
• Define • Align • Prioritize• Measure• Report
Definition of Quality
Providing the patient with appropriate consistent health care in a clean and safe environment in which the patient is treated with respect.
- TOH Board, January 2003, reconfirmed 2008
Defining the Quadrants ACCESS
Patients should be able to get the right care at the right time in the right setting by the right healthcare provider (OHQC)
SAFETY Patients should not be harmed by an accident or mistakes when they receive care (OHQC)
SATISFACTIONHealth services are respectful and responsive to user needs, preferences and expectations (HQCA)
APPROPRIATEEfficient: The hospital should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information (OHQC)
Effective: Patients should receive care that achieves the expected benefit and is based on the best available scientific information (OHQC)
OHQC: Attributes of a High-Performing Health System, Ontario Health Quality Council HQCA: Quality Matrix for Health, Health Quality Council of Alberta
AlignmentWith:• TOH Strategic Direction• Best Practice• Legislation• Accreditation Recommendations • Ministry of Health Mandated Requirements• Future Trends• Others?
Corporate Quality Plan Prioritization
• Corporate in scope• Aligns with TOH mission and vision• Aligns with at least one of the following:
– Addresses issues occurring frequently or to a high volume of patients
– Addresses high risk for patient safety issues– Addresses accreditation or regulatory requirements
• High probability of impact on outcomes/process measurement/indicators
Reporting
• Scorecard• Workplan• Colour coded – green, yellow, red• Trend charts• Others
…to different end stakeholder groups
The Ottawa HospitalCorporate Quality PlanBalanced Scorecard
AccessEmergency Offload (Q)
•90th percentile CTAS 190th percentile CTAS 2-5
Emergency Access Times (Q)•% admitted ED LOS < 8 hrs•% non-admit waiting < 8 hrs for CTAS 1&2•% non-admit wait < 6 hrs, CTAS 3•% non-admit wait < 4 hrs, CTAS 4&5
Number of cancer surgeries (Q)Number of knee surgeries (Q)Number of hip surgeries (Q)Number of cataract procedures (Q)Number of hours MRI delivered (Q)Number of hours CT delivered (Q)
AppropriateEffectiveOttawa Model for Diabetes (Q)Inpatient satisfaction with pain control (Q)
•Medicine•Surgery•Obstetrics and Gynecology•Emergency Department•Rehabilitation
EfficientCost per weighted case (A)% clinical pathways revised (Q)# new clinical pathways / program (Q)
Safety
Ventilator Associated Pneumonia rate (Q)Central Line Infection rate (Q)Surgical Site Infection rate (Q)Hand Hygiene compliance rate (Q)Hip fractures receiving surgery < 48 hours (Q)C Difficile rate (Q)MRSA rate (Q)VRE rate (Q)HSMR (Q)
Satisfaction
NRC-Picker Pt Satisfaction Results (Q)•Medicine•Surgery•Obstetrics and Gynecology•Emergency Department•Same Day Surgery•Rehabilitation•Ambulatory Care
- Data currently available
A - Reported annually
Q - Reported quarterly
Infection Control Dashboard
Hand Hygiene by Unit – Selection Criteria
Statistics Table by Campus
Selection criteria for indicators:– Data is available – Data is timely– Indicator is valid and reliable– Indicator is actionable– Impact on high volume, high cost and high risk
Focus on the vital few versus the trivial many
Indicator Assumptions
Mandatory IndicatorsFor accreditation:• Percentage of patients
receiving medication reconciliation at admission
• MRSA infection rate• C. Diff infection rate• Rate of post surgical infections• Rate of timely administration of
prophylactic antibiotic
Submitted quarterly in each three year cycle
For MOH Public Reporting:• CLI rate • VAP rate• MRSA• C. Diff• VRE• SSI antibx• HH compliance• HSMR• SSCL
Submitted quarterly to annually
2010/2011 Public Reporting Indicators
Updated Jan 2011
Jun-10 Q1 Q1 Q1 Q1 Q1 Q1 Mar-10 Mar-10 FY08-09
Institution/Health Centre CampusC Diff MRSA VRE CLI VAP SSIP SSCC
HH % Before Pt.
Env.
HH % After Pt.
EnvHSMR
TOH
TOH Civic 0.46 0.03 0 1.03 2.63 91.8% 99.6% 65.26 83.4494
TOH General 0.51 0 0 1.04 4.12 98.1% 99.7% 52.12 68.92
TOH HI 0 0 0 0.52 5.54 96.6% 79.31 85.83
TOH Rehab 0 0 0 91.94 93.33
SMH SMH 0.42 0.08 0 1.98 0.74 99.5% 99.1% 33.6 56.71 83
Sunnybrook
Sunnybrook 0.23 0.02 0 0.29 5.69 92.6% 87.9% 61.03 81.61 88
Ortho 0 0 0 0 97.1% 100.0% 53.16 80.13
Hamilton Health Science Centre
McMaster 0 0.04 0 7.52 0 47.1% 61.84 78.76
92 Hamilton 0.19 0.06 0 1.22 1.61 34.4% 66.67 82.34
Henderson 0.14 0 0 0 0 100.0% 64.1% 49.21 71.16
London Health Science Centre
University 0.61 0.2 0 1.48 1.76 98.4% 62.2% 51.64 83.48
103 South St. 0 0 0
Victoria 0.63 0 0.03 2.8 0.78 81.3% 62.1% 57.65 79.91
Mt. Sinai Mt. Sinai 0.21 0.06 0 1.45 1.44 96.9% 97.2% 61.68 75.8 92
Kingston Kgn General 1.33 0.03 0 0.75 4.37 88.1% 96.0% 33.72 48.42 111
UHN
UHN General 0.72 0.03 0 1.77 4.22 76.7% 51.26 76.93
77 Western 0.31 0 0 0.71 3.77 95.5% 99.9% 37.15 65.89
Princess M 0.3 0 0 100.0% 56.26 79.83
Not Eligible
Reporting: Infection Rates
Central Line Bloodstream Infections / 1,000 Line Days
0.00.51.01.52.02.53.03.5
Nov-0
9
Dec-0
9
Jan-1
0
Feb-1
0
Mar-
10
Apr-
10
May-
10
Jun-1
0
Jul-10
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Civic 0.00 0.00 0.00 1.54 0.00 1.63 0.00 1.40 1.92 1.63 0.00 1.51 1.68 0.00
General 2.85 1.51 1.38 0.00 0.00 0.00 3.01 0.00 0.00 2.99 1.55 0.00 0.00 0.00
Target 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
TOH 1.42 0.75 0.71 0.77 0.00 0.74 1.56 0.81 0.88 2.34 0.87 0.74 0.83 0.00
Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10
Ventilator Associated Pneumonia per 1,000 Ventilator Days
0
1
2
3
4
5
6
7
8
Civic 7.59 3.48 3.76 3.23 1.53 2.63 0.00 0.00
General 3.01 3.96 2.55 2.62 1.75 4.12 0.73 1.60
Target 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00
Jan - Mar 09 Apr - Jun 09 Jul - Sep 09 Oct - Dec 09 Jan - Mar 10 Apr - Jun 10 Jul - Sep 10 Oct - Dec 10
Reporting: Central Line Infection – Line Insertions
Hand Hygiene for CLI Insertion
97% 97%100%
96%98% 97%
73%
93%
76%71%
90% 92% 92%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Hand Hygiene Target
Maximal Barrier Precautions Used
5% 6%
47%
77% 73%68%
73% 76%69%
62%71%
64% 64%
0%
20%
40%
60%
80%
100%
Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Full barrier precautions Target
Chlorhexadine Skin Antisepsis
97% 97%98%
89%
96%
100%
94%93%
91%
98%96% 97%
100%
80%
85%
90%
95%
100%
Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Skin asepsis Target
Optimal Catheter Site Selection
97%100%
98% 98%95%
97%
94%
98%
91%
98% 98%97%
94%
70%
75%
80%
85%
90%
95%
100%
Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Optimal site selection Target
Reporting: Ventilator Associated Pneumonia
Head of Bed Elevation Over 30 Degrees
97.5%99.0% 98.2%
96.0%
100.0% 100.0%99.0% 98.3% 98.2%
100.0%
95.3%
97.7%95.8%
85%
90%
95%
100%
Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11
HOB Elevated Goal
Use of EVAC ETT
90.0%87.8%
96.4% 96.0%92.8% 94.5%
89.9% 91.7% 93.6% 94.4% 93.0%
81.4%
92.4%
60%
70%
80%
90%
100%
Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11
EVAC ETT Goal
Daily Sedation Vacation
85.0%
79.6%
94.6%
85.0%
94.8%96.7% 96.0%
92.6%94.5% 94.4% 94.2%
96.5% 96.6%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11
Sedation Vacation Goal
Use of Oral vs Nasal Tubes
73.8%79.6%
92.9% 95.0% 94.8% 92.3%87.9%
92.6% 91.8% 93.1% 95.3% 95.3% 95.8%
40%
50%
60%
70%
80%
90%
100%
Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11
OG Tube Goal
Patient Safety Indicators on the Infonet
Insanity is doing the same thing over and over again and expecting a
different result.
-Albert Einstein
It’s not the data.It’s what you do with it.
Quality Monitoring
Model of a work system
Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P. Alvarado, C. J., Smith, M., and Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Healthcare, 15(Suppl I), i50-i58.
UW-Madison Systems Engineering Initiative for Patient Safety (SEIPS)
Definitions
• Patient safety is defined as the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes.
• Patient Safety Culture is defined as a commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.
(CPSI, 2008)
CPSI – The Safety CompetenciesFramework which includes 6 core domains that provide for safer patient care:
Domain 1: Contribute to a Culture of Patient SafetyDomain 2: Work in Teams for Patient SafetyDomain 3: Communicate Effectively for Patient SafetyDomain 4: Manage Safety RisksDomain 5: Optimize Human and Environmental FactorsDomain 6: Recognize, Respond to and Disclose Adverse Events
Visit CPSI – Safety Competencies www.safetycomp.ca for complete framework information.
Fostering Patient Safety Culture at TOHNeed:
• A vision of where we want to go• Senior leadership buy-in• Actions to get us there• Passionate clinicians and support staff• Accountabilities defined• An action plan to move forward
The Survey on Patient Safety Culture (AHRQ) was launched in August 2006, and offered to all staff, physicians and volunteers at TOH.
A second survey, the Patient Safety Culture in Healthcare Organizations Survey, a tool developed by Stanford and modified by York University and supported by AC was run on four TOH inpatient units the following year. Further surveys were done in 2010 and 2011.
There were six survey items where the large majority of staff members responded the same way in both surveys. (i.e. there was very little variation in responses); these include:
• Asking for help is a sign of incompetence (93% disagree)• If I make mistake, and nobody notices, I do not tell anyone (95% disagree)• I will suffer negative consequence if I report a patient safety problem (86%
disagree; 9% neutral)• I engage in unsafe practices in order to get the job done (95% disagree)• I report the errors I make (86% often/always; 11% occasionally)• I learn from errors made by my colleagues (81% often/always; 16% occasionally)
Patient Safety Culture Surveys at TOH
Develop a Culture of Safety
• Relay safety reports at shift changes• Create an adverse event respond team• Re-enact adverse events• Appoint a patient safety champion for every area/unit• Simulate possible adverse events• Involve patients in safety initiatives• Create a reporting system (PSLS)• Designate a patient safety officer• Conduct safety briefings• Provide feedback to frontline staff• Conduct patient safety walkabouts (rounds)
Comparison of Patient Safety Culture Surveys
Patient Safety Culture in Healthcare Organizations Survey (n 109)
Survey on Patient Safety Culture (n 738)
Both sets of survey results reflect staff with direct patient interaction only.
Required Organizational Practices
Adverse Event Reporting
Focus on how we can prevent and intercept errors
Statistical data that can be analyzed to determine trends
Understand and improve practices that promote a safe care environment for patients
Response
Detection
Analysis
Definitions
A reportable incident is … any unusual occurrence that is inconsistent with the routine care of a patient; or that adversely affects patients, volunteers, visitors or hospital property; or an unexpected negative treatment outcome.
e.g. falls, med errors, equipment problems, lab incidents
Injury does not have to occur for an event to be reportable (“near misses”)
More definitions
As defined in TOH Critical Incident Review Policy and in accordance with the Public Hospitals Act a “Critical Incident” means any unintended event that occurs when a patient receives treatment in the hospital:
(a) that results in death, or serious disability, injury or harm to the patient, and (b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing the treatment.
As defined in TOH Patient / Visitor Incident Reporting Policy a “Serious Incident” is one that results in a fracture, haemorrhage, aspiration, serious drug variance/reaction or death, transfer to a critical care area, increased length of stay or admission to hospital.
Patient Safety Learning System (PSLS)
Identify
Event
Report/Record
Analyze/Classify
Escalate
Causal Analysis
Corrective Action
Learn & Educate
Voluntary reportingElectronic triggers
Patient Safety Learning System
TOH Risk ManagementQuality CoordinatorsData Warehouse Department Head/Clinical ExpertsSeverity of risk or AE will determine work flow
TOH Critical Incident Policy & Procedure
Department/Function QI Internal Process
Data Warehouse AE Analysis
Safety Rounds M&M Rounds
Patient Safety Learning System
Department & Division Front Line Staff
System Improvement
Ongoing Surveillance
Disclosure Disclosure is a professional, ethical, moral and legislative requirement
“Disclosure” refers to the communication of information regarding anadverse event, adverse outcome or critical incident.
Public Hospitals Act directs that the disclosure conversation must include:
(a) the material facts of what occurred with respect to the critical incident;(b) the consequences for the patient of the critical incident, as they become known; and(c) the actions taken and recommended to be taken to address the consequences to the patient of the critical incident, including any health care or treatment that is advisable.
Documentation of the disclosure discussion is also a legislative requirement. TOH Disclosure Toolkit available
Goals of Root Cause Analysis (RCA)
To find out:• What happened• Why it happened• What can be done to reduce the likelihood of a
recurrence?
Resources: CPSI RCA Toolkit & TOH RCA Lite Toolkit
Steps of a RCA1. Determine the team2. Organize the meeting 3. Gather information and the facts of the incident
Who, What, Where, When but not the Why4. At the meeting
Review the information gathered and determine what did happen compared with what should have happened
5. Determine contributing factors and root causes Keep asking “why” until the contributing factors and root
causes are found6. Develop actions and determine performance measurements 7. Implement the actions 8. Measure and evaluate the effectiveness of the actions
Common Root Causes
Rules, Policies, Procedures, Protocols and Processes: Lack of awareness of what protocols, policies and procedures are available Lack of standardization of processes
Communication Issues: Breakdown in communication primarily at the point of transition, both
internally and externally Lack of information in the patient health record
Equipment Issues: Lack of available equipment (department specific requirements)
Staff Factors (Knowledge, skill) Incomplete & inaccurate documentation across all disciplines Lack of ongoing education related to policies, procedures and protocols
CPSI/TOH Patient Safety Culture Project
Questions?