Do No Harm: Culture, Technology, Teamwork and Design Change

Nancy G. Pratt RN, MSN, SVP, Clinical Effectiveness

Sharp HealthCareFebruary 5, 2007

Sharp’s Strategic Plan for Patient Safety

CultureHumanFactors

TechnologyDesign

Develop a Culture of Safety Use Technology to Improve Safety

Address Human Factors: Teamwork and CommunicationRedesign the Processes

Develop a Culture of Safety Use Technology to Improve Safety

Address Human Factors: Teamwork and CommunicationRedesign the Processes

Reduce Reduce Harm by Harm by 50% over 5 50% over 5 yearsyears

Strategic Priorities: Patient Safety

• Implement a Culture of Safety • Anonymous reporting• Collaboration: San Diego Patient Safety Consortium• Adverse Events Program

• Teamwork and Communication• Team Resource Management• Standard Work Processes

• Use Technology to Improve Safety• Bar Coding• Electronic Safety Triggers• Electronic variance reporting • Smart Pumps – IV, PCA, Syringe

• Redesign for Safety• Human Factors Engineering• Design for Six Sigma• Product, supply, process review• JCAHO National Patient Safety Goals

Six Sigma Projects: Patient Safety

Six Sigma Projects

Status

Medication Safety Done

Pharmacy Order Cycle Time Done

SMH Discharge Project Underway

SCV Discharge to SNF Underway

SGH Discharge Project Underway

SHC Cerner CPOE Paper Lite Started

ROMACC (Reconciliation of Medications) Started

Physician gives order

RN can’t get med out of Pyxis

Fax doesn’t go through!

Pharmacist not available

Drug not available

Pharmacy informs RN med has been there for 2 hours

RN faxes & calls pharmacy again!

Onset of Complaints!

Pharmacy Tech delivers med

someplace in SICU

RN Calls pharmacy, faxes

order again!! Fills out standard

pharmacy complaint – QVR!

RN writesorder &

faxes to

Pharmacy

Alternate Actual Process

Orders by Hour

0

2

4

6

8

10

12

14

16

18

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour

Ord

ers

0

1

2

3

4

5

6

7

8

Sta

ff i

n P

har

mac

y

Avg Number of Orders Pharmacist Staffing

PharmacyPharmacyStaffingStaffing

# Medication# MedicationOrdersOrders

Time of DayTime of Day

Pharmacy Staffing Not Matched to Medication Order Volume

Pharmacy Order Cycle Time

Pharmacy Order Cycle Time

Fax to Verification Time

Frequency

8006004002000-200

120

90

60

30

0

8006004002000-200

120

90

60

30

0

aBefore After

Well After zLast

aBefore

39.66StDev 50.53N 129

Well AfterMean 81.66StDev 185.1

Mean

N 80

zLastMean 22.60StDev 31.57N 187

81.57StDev 132.4N 155

AfterMean

Histogram (with Normal Curve) of Fax to Verification Time by Series

Panel variable: Series

After Pharmacy IT System Changed

After Initial Improves

Baseline

After Fax Server

Installed

Figure 7.5-9 Pharmacy Turnaround Time Improvement at Sharp Memorial - SICU

8254

132

40 5123 3220 12

0306090

120150

MeanTurnaround Time

MedianTurnaround Time

Std Deviation ofTurnaround Time

Min

ute

s

Pre-Intervention After Initial Improve Post Final Improve

Goal < 30 minutes

Better

Pharmacy Order Cycle Time

Med Admin Flow Map

(Ideal)

Average time~ 7 mins

RN Prompted to give med

RN interprets MAR (5Rs)

RN explains med to pt

RN washes hands

RN identifies patient

RN procures med/IV & supplies

(5Rs)

RN preps med

RN performs preadministration

assessment / checks allergies RN

prepares to admin med(final 5Rs)

RN gives med

RN documents

med

RN evals effects of med

RN washes hands

Medication Safety Project: Decrease Interruptions

Med Admin Flow Map(More real)

Average time ~ 20 mins

RN Prompted to give med

RN interprets MAR (5Rs)

RN explains med to pt

RN washes hands

RN identifies patient

RN procures med/IV & supplies

(5Rs)

RN preps med

RN performs preadministration

assessment / checks allergies

RN prepares to admin med

(final 5Rs)

RN gives med

Phone call

Need to clarify

Call MD;Wait;Get

clarification

Order is questionable

Unexpected nsg task

Can’t find med; look in 4 places;

call pharm

Wait in line

Phone call

Unexpected nsg task

Locate Missing supply

Phone call

RN documents

med

RN evals

effects of med

RN washes hands

1. Waited in line to get meds @ 9:00

2. One med grayed out – not here, one gray ed at – in refrigerator

3. Search refrigerator

4. Went to P #1, found 1 med – MVI still missing, tapped drawer to get cubie to open

5. Two meds left to find – may be in room. Crushed meds in paper cups

6. Piston syringe in room – No date – went to supply room to get another

7. Found MVI but NO med cups - ? Refrigerator MVI

8. Searched room for fiber or med cup – on bedside table – no way to administer

9. Back to med room

10.Back to room

11.Mixed meds in cup in admin – DONE 0920

Medication Delivery Total Time – 13 minutes

CR

28 1&2 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 1&2

LinenDocRm

MD

Doc

30 MDP #1

31

LeadOffice

32 1&2Supplies P #2 Kitchen Mg

33 1&2 34 35 36 37 38 3 4 5 6 7 8 9 10 11 1&2

29 1&2

Nur

se S

tatio

n #2

Kitc

hen

Util

ity H

all

What Does the Literature Tell Us? Top High Risk Situations Causing Sentinel Events

• Distractions before or during administration of meds or treatment• High alert drugs used without double-checks• Multi-tasking• Care provided under a human-error-prone situation (dark, noisy, shift

change) without appropriate compensatory actions

Reason, JT. Understanding adverse events: human factors. In VincentCA (ed) Clinical Risk Management. London: BMJ Pub; 1995

Medication Safety Action Plan

Create a standard environment for medication room design and processes

5’S’ Principles- Sort- Shine- Simplify- Standardize- Sustain

Minimize interruptions and distractions during medication administration– Respect med admin as a critical activity – Divert and discourage unnecessary calls– Encourage all disciplines to limit interruptions Create Scripting

examples for nurses– Evaluate workload demands during high volume med admin times

Medication Safety Action Plan

Develop a standard guideline for

medication preparation and administration– Avoid conversations in med room– Discourage interruptions/distractions– Verify using 7 “Rights”– Prepare and administer to 1 pt at a time– Independent double check insulin, heparin, warfarin– Use MAR or Pyxis label to verify 7 ‘R’s – Document

Grossmont - Delivered Doses by Time of DayJune 2004

0100020003000400050006000700080009000

100001100012000130001400015000160001700018000190002000021000220002300024000

Time Dose Delivered

# D

ose

s D

eliv

ered

N=114,755 doses* Only units on Clinicomp represented in data* Excludes PRN and IV meds

24 06 09 12 17 21

Number of ‘Unnecessary’ Interruptions During Med Pass: Pre and Post*

3.8 4

2.2

0.71 0.8

0

0.5

1

1.5

2

2.5

3

3.5

4

Pre (n=14) Post (n=29)

Mean Median SD*No statistical difference in number or route of meds given

p=0.000

SGH 5E Pilot Med Pass TimePre and Post*

15.1 15

5.9

11.610

4.7

0

2

4

6

8

10

12

14

16

Minutes

Pre (n=14) Post (n=29)

Mean Median SD*No statistical difference in number or route of meds given

p=0.037

Emergency Department: RME

• ED patients expect quick service and to be seen

by an ED doctor, regardless of diagnosis

• 40% of ED pts are non-emergent

• Rapid Medical Exam (RME) designed to promptly

and appropriately “treat & release”

• Issues: long waits, space, multiple entry points,

flow, communication…

ED Waits Decrease Satisfaction

89.3 90.0

86.5 86.9

80.8 80.979.6

84.385.2

<0.5h(n=10)

0.5h-1h(n=6)

1h-1.5h(n=23)

1.5h-2h(n=37)

2h-2.5h(n=59)

2.5h-3h(n=46)

3h-3.5h(n=96)

3.5h-4h(n=48)

4h +(n=404)

Hours Held in ED

Pat

ien

t S

atis

fact

ion

Overall Satisfaction (scale: 0-100) Goal 86.3

Growth of ED Visits

• 1992: 12 beds = 16,640 visits. 2006: 22 bed =45,456 visits. • 173% increase in visits since current ED was opened in 1992. • 83% increase in beds over same period.

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

FY92FY93

FY94FY95

FY96FY97

FY98FY99

FY00FY01

FY02FY03

FY04FY05

FY06

ED Outpatient Overall Satisfaction(scale 0-100)

76.6

81.1 81.8 82.5 82.2

31,62235,531

40,506 42,86745,956

FY02 FY03 FY04 FY05 FY06

Mean Volume

Lack of open ED beds creates bottlenecks. Many patients wait in front lobby area.

Bottlenecks in the ED

RME

LOBBY

PHLEBOTOMY

TRIAGE

Key Process Steps

See podium? Fill

out reg. form

Go to Triage Coordinator “behind the

glass”

Visitor?Patient?

Triage CoordinatorVisitor- send

back?

Triage: ESI? Standing Orders variable.

Respond to waiting

patient’s questions?

Patients Wait

Patients to Lab/ x-ray/ triage one/two. More

orders put in?

Patients Wait

Patients called back

to RME or to bed.

Patient and family Arrives

Security

Triage Standing Orders

RME triage criteria and bounce back

process.

RME Project Goals

1. Take vitals of all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%)

2. “Arrival noticed quickly” satisfaction = 85th percentile (baseline 18% Dec-06)

3. Establish RME triage standard to set stage for RME cycle time project

ED RME Outcomes

• Goal: Vitals on all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%). Improvements:– Guard providing safe environment– LVN assigned to check vitals – Designed EmStat report to monitor lobby patients

ED RME Outcomes

ED Outpatient Satisfaction with "Wait before arrival noticed"

19% 18%

35% 35%

80%

82.2 82.0

85.1 84.8

90.0

Dec-06(n=52)

Jan-07(n=61)

Feb-07(n=74)

Mar-07(n=64)

Apr 1-18(n=25)

%tile Rank (N=888 facilities) Mean Rating (0-100)

Goal: 80th %tile

RoMACC at Grossmont Hospital

Reconciliation of medications across the continuum of care

Project Description / Vision:

Implement a ‘Lean’ RoMACC process that demonstrates value, not just in terms of patient safety but in efficiency for practitioners.

Sponsor: Michele Tarbet

MD Partner/ Process Owner:Dr. Margaret Elizondo

Start Date: September 2006 Go Live: December 5th End Date: March 2007

Participants:

Next Sustain and Improve!Next Sustain and Improve!

Champion/Green Belt:Julie McCoyJackie Parson

Black Belt: Kurt Hanft

Process MeasureProcess Measure

RoMACC Measurement Method:

Reconciliation of medications across the continuum of care

Physician

writes the Discharge Orders and Addresses the

Discharge Reconciliation.

Unit clerk

verifies the reconciliation has been addressed

and enters a discharge order

Discharge:

Combined projectsCombined projects

RoMACC and Discharge Measurement:

% RoMACC Complete

Carecast Discharge Order Entry Compliance

Number Of Discharges

Time to Discharge a Patient

Average Time of Day a Patient Leaves.

Reconciliation of medications across the continuum of care

Continuous Improvement – Above System Goal of 75%Continuous Improvement – Above System Goal of 75%

RoMACC at Grossmont Hospital

75% System Goal

Carecast Discharge Order Entry Compliance

36%

67%84% 85%

0%

20%

40%

60%

80%

100%

1 2 3 4

%

2245 8266 7614 540010000

1 2 3 4

# o

f D

C's

RoMACC Complete

57%

85% 94% 97%

0%

20%

40%

60%

80%

100%

06 December 5th-31st

07 Jan, Feb, Mar 07 April, May, June 07 July 2-8

%

Reconciliation of medications across the continuum of care

Examples of Patient Safety Improvements:

Bar Code Implementation (Roche) Real Time Event Triggers “On Watch” (Clinicomp)Electronic Quality Variance Reporting (Peminic)Wireless Smart Pumps CQI data (Cardinal)Standardization of IV infusion concentrations (SDPSC)Enteral Tubing connections (Viasys, FDA, AHA)

Innovation with our partners: Cerner

Use Technology to Improve SafetyBar CodingElectronic Safety TriggersElectronic variance reporting Smart Pumps – IV, PCA, Syringe

System Reprogramming: Safety Achieved Quarter 1 2006

Pareto of Reprogrammings > 3X Max

010203040506070

prop

ofol

hepa

rin

MORPHIN

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te

mida

zolam

insuli

n

oxyto

cin

VECuroniu

m

MAGne

sium

sulf (

OB)

hydr

omorpho

ne

fent

anyl

eptifi

batid

# o

f E

ven

ts

0%10%20%30%40%50%60%70%80%90%100%

Events % of Total n=145

Alaris Guardrails

Tubing Misconnections

l

Bag/Bottle of Enteral Feeding

Feeding Bag

Tubing Set

Enteral Feeding Tube

Patient Safety Strategy

• Redesign for Safety• Human Factors Engineering• Design for Six Sigma• Product, supply, process review• JCAHO National Patient Safety Goals

Patient Safety Actions

• Products:– Insulin Syringe– Dopamine Drip Bottle versus Bag– Enteral Feeding Bag versus Bottle– Heparin Flush versus Therapeutic infusion– Anesthesia Tray for Epidural – Cat Scan Contrast Injectors – IV PICC Line Cap Leaking (CLC 2000)– Insulin and Heparin Infusions – standardized– Endotracheal Tube with Sub-glotic suction

San Diego’s Health Care Leader

Gold Eureka Award, 2006

Silver Eureka Award, 2005

Bronze Eureka Award, 2004

Best Integrated Health-Care Network in California, 2007

100 Most Wired Hospitals, 1999-2006

IDG's Computerworld, 2006

Best place to work, 2004

Torch Award for Marketplace Ethics

Excellence in Patient Safety and Health Care Quality, 2006

Magnet Status

Sharp Grossmont

Malcolm Baldrige

National Site Visit, 2006