Download Slide 1

University Medical Center
Tucson, Arizona
Evidence Based Approach
to Quality Improvement
Andreas A. Theodorou, MD
Chief, Pediatric Critical Care Medicine
Associate Head, Department of Pediatrics
Professor, Clinical Pediatrics
The University of Arizona
Chief Medical Officer, UMC
© 2010 College of Medicine
To Err Is Human: Building a Safer
Health System (IOM, 2000)
•
The first of 4 IOM reports
• “The burden of harm conveyed by the
collective impact of all of our health
care quality problems is staggering.”
• 44,000-98,000 people die each year
from mistakes
• UMC Responded!
•
“Quality and Safety First”
© 2010 College of Medicine
Crossing the Quality Chasm: A New Health
System for the 21st Century (IOM, 2001)
 Second
of 4 IOM reports
 Safety problems because:
Inability to translate knowledge into practice,
apply new technology safely and
appropriately and to make the best use of
resources (financial and human)
 Blaming health providers is not the
answer!
 We must address the system flaws

© 2010 College of Medicine
Health Professions Education: A Bridge
to Quality (IOM, 2003)
•
Third of 4 IOM reports
•
“All health professionals should be
educated to deliver patient-centered
care as members of an
interdisciplinary team, emphasizing
evidence-based practice, quality
improvement approaches, and
informatics.”
© 2010 College of Medicine
J. Lyle Bootman (co-chair) Dean, U of A College of Pharmacy
© 2010 College of Medicine
Several Evidence Based Clinical
Guidelines Including…
•
•
•
•
•
•
•
Stroke
Traumatic Brain Injury
Sepsis
Core Measures
Central Line Bundle
Ventilator Associated Pneumonia Bundle
“Time-Out” check list
© 2010 College of Medicine
National Patient Safety Goals
• Established by The Joint Commission
• Statistically found to be problem areas
• Improve the accuracy of patient identification.
• Improve the effectiveness of communication among
caregivers.
• Improve the safety of using medications.
• Reduce the risk of health care-associated infections.
• Accurately and completely reconcile medications across the
continuum of care.
• Reduce the risk of patient harm resulting from falls.
© 2010 College of Medicine
National Patient Safety Goals
Continued…
•
Encourage Patients’ active involvement in their own care
as a patient safety strategy
•
Identify patients at risk for suicide.
•
Fulfill expectations set forth in the Universal Protocol
(prevent wrong-site, wrong person, wrong procedure)
•
Reduce the likelihood of patient harm with the use of
anticoagulation therapy
•
Recognize and Respond to Change in Patient’s Condition
(RRT/EMT)
© 2010 College of Medicine
How Do We Measure Quality?
Who’s Doing the Measuring?
 Internally










Incident reports
Peer Reviews
Physician Profiles
Sentinel Events
M & M’s
Patient Satisfaction
QI “projects”
Root Cause Analysis
FMEA
Externally (some allow
public access)
 Gov’t Agencies
 CMS
 AHRQ
 Medical Boards

Private Agencies

 The Joint Commission
 NQF
 UHC
 HealthGrades
 “Best Hospitals”
 “Best Docs”
Health Care Plans
© 2010 College of Medicine
Must have a reliable data source
 University


HealthSystem Consortium
The University HealthSystem Consortium (UHC), Oak
Brook, Illinois, formed in 1984, is an alliance of 103
academic medical centers and 219 of their affiliated
hospitals representing approximately 90% of the
nation's non-profit academic medical centers.
UHC offers an array of performance improvement
products and services. Powerful databases provide
comparative data in clinical, operational, faculty
practice management, financial, patient safety, and
supply chain areas.
© 2010 College of Medicine
Core Measures
•
•
Acute Myocardial Infarction
Heart failure
Pneumonia
Surgical Care Improvement Project
Children’s Asthma Care
•
http://www.hospitalcompare.hhs.gov/
•
•
•
© 2010 College of Medicine
• Relationship Between Medicare’s
Hospital Compare Performance
Measures and Mortality Rates
• Rachel M. Werner, MD, PhD; Eric T.
Bradlow, PhD JAMA. 2006;296:2694-2702.
© 2010 College of Medicine
UMC MICU
Quality Improvement Projects
• Multidisciplinary approach
• Nursing, physician, pharmacy, RT, quality
improvement
• Data collection by staff/QI
• Success related to investment of individuals
• Introduce innovations
• Improvements in daily practice
• Evidence based
© 2010 College of Medicine
UMC MICU
Quality Improvement Projects
• Monthly meetings- forum for
discussion
• Literature review of best practice
• Discover problems and look for cause
• Leaders in each project area
• Discuss new ideas for change in
practice
© 2010 College of Medicine
5 East Blood Stream Infections per 1000 CVL Days
PICC
CVL
Checklist
Checklist
Revised
2Q06
3Q06
CVL
1200Insertion
Packs
2Q04
Full Clave Team
body
4Q07 1Q08
Drape in
Packs
Infection
3Q07
Control
Update
1Q08
IHI
2Q05
1000
14.00
Arrow kits
w Anti
microbial 12.00
catheter
3Q08
CVL Days
8.00
600
Great Job, 5East!
BSI's = 0!
400
6.00
4.00
200
0
BSI
CVL Days
Rate
2.00
2Q
04
3Q
04
4Q
04
1Q
05
2Q
05
3Q
05
4Q
05
1Q
06
2Q
06
3Q
06
4Q
06
1Q
07
2Q
07
3Q
07
4Q
1Q08 2Q08
07
3Q
08
3
7
4
3
6
5
3
4
6
3
3
3
4
5
3
1
1
0
624 966 801 971 745 752 502 566 499 889 778 893 811 765 887 853 889 825
4.81 7.25 4.99 3.09 8.05 6.65 5.98 7.06 12.02 3.37 3.86 3.36 4.93 6.54 3.38 1.17 1.12 0.00
Data Source: Infection Prevention
Graph: G Priestley, RN
© 2010 College of Medicine
0.00
rate per 1000 CVL days
10.00
800
5East Ventilator-associated Pneumonia Rate
Infection Prevention
Update 1Q08
18
VAP Rate / 1,000 Ventilator Days
16
Focus on Oral
Care 2Q08
Sedation Update:
Intermittent Bolus
Option 1Q09
14
12
10
8
6
Prior
Interventions:
RASS, HOB, Oral
Care, Daily Wakeup,
4
2
0
5East VAP Rate
1Q 07
2Q 07
3Q 07
4Q 07
1Q08
2Q08
3Q08
4Q08
1Q09
2Q09
15.66
15.6
9.33
4.33
4.4
2.9
7.33
7.82
4.4
6.22
Data: Infection Prevention
Graph: G Priestley, RN
© 2010 College of Medicine
Medication Error Reduction Strategies
• What is the evidence of value of other
technological innovations?
• What level of evidence is needed to
justify expense of such innovations?
• Automated dispensing devices
• Smart infusion pumps
• Bar coding
Leape et al. JAMA 2002;288:501
© 2010 College of Medicine
Patient Safety Meets
Evidence-Based Medicine
• Shonjania et al. Making health Care Safer:
A Critical Analysis of Patient Safety
Practices;2001. AHRQ publication 01-E058
• UCSF-Stanford University Evidence-Based
Practice Center
• 40 investigators around the country
• Over 80 “safety practices” reviewed
© 2010 College of Medicine
Medication Error Reduction Strategies
Medium strength of evidence1
• Computerized physician order entry (CPOE)fully implemented in few health systems
• On-site pharmacist with participation on ICU
rounds- approximately 30% of health systems
report having a pharmacist on attending rounds
(survey not specific to ICU setting)2
1. Shojania K et al. JAMA 2002;288:508-11
2. Pedersen et al. Am J Health-Syst Pharm 2001;58:2251
© 2010 College of Medicine
Medication Error Reduction Strategies
• Medication Reconciliation
Pronovost et al. Journal of Critical Care, Vol 18, No 4 (December),
2003: pp 201-205
• 46% of medication errors occur on
admission or discharge
• Marked decrease in errors after initiation of
discharge survey
• The Joint Commission (Patient Safety Goal)
© 2010 College of Medicine
The National Quality Forum/
Agency for Healthcare Research and Quality
• 30 Safe Practices for Better Health Care
• AHRQ March 2005, Pub No. 05-P007
• Pharmacists should actively participate in the
medication-use process
• Implement CPOE system
• Standardize the methods for labeling, packaging,
and storing medication
• Identify “high alert” drugs
• Dispense medications in unit-dose or unit-of-use
form, whenever possible
© 2010 College of Medicine
Organization-wide UMC QI Project
• Medication Delivery System
• Implementations:
•
•
•
•
•
•
•
•
Computerized Physician Order Entry (SCM)
Electronic Medication Administration Record
Established Medication Use Subcommittee
Weekly audits of med bins and Pyxis
Clinical pharmacists assigned to specific units
Changed bin fill times
Established 3rd Floor Pharmacy Satellite Clinic
Separated look alike/sound alike drugs in pharmacy
• Evaluation showed Improvements:
• Reported distribution errors decreased 16%
• Rate of prescription errors reduced by 95%
• Medications missing from patient bins decreased by 50%
© 2010 College of Medicine
Medication Error Reduction Strategies
Smart Infusion Pumps
• Rothschild et al. A controlled trial of smart infusion
pumps to improve medication safety in critically ill
patients. Crit Care Med 2005;33(3):533-540
• I.V. med errors and ADEs can be detected by smart pumps
• No measurable impact on serious error rate due to poor compliance
• “Smart pumps have great promise…”
• Leape. Crit Care Med 2005;33(3): 679-80
• “Humans can always defeat technology if it is
perceived as a barrier.”
© 2010 College of Medicine
Five Years After To Err is Human
What Have we Learned?
Leape and Berwick. JAMA 2005;293: 2384
Intervention
Result
CPOE
81% reduction in med errors
Pharmacist rounding with team
66 - 78% reduction of
preventable ADEs
Reconciliation Medication
Practices
90% Reduction in medication
errors
Reconciling and standardizing
medication practices
60-64% Reduction in ADEs
Standardizing insulin dosing
Hypoglycemic episodes
decrease 63%
Standardizing warfarin dosing
Out-of-range INR decrease 60%
Trigger tool and automation
ADEs decrease by 62%
© 2010 College of Medicine
The New Yorker: The Checklist
December 10, 2007 Atul Gawande
© 2010 College of Medicine
A Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Population
Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz,
Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph,
M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A.,
F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., Atul A.
Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group. NEJM January 2009
•
•
Results :The rate of death was 1.5% before the
checklist was introduced and declined to 0.8%
afterward (P=0.003). Inpatient complications
occurred in 11.0% of patients at baseline and in
7.0% after introduction of the checklist (P<0.001).
Conclusions: Implementation of the checklist was
associated with concomitant reductions in the rates
of death and complications among patients at least
16 years of age who were undergoing noncardiac
surgery in a diverse group of hospitals.
© 2010 College of Medicine
UHC Data with Benchmarks
UMC
© 2010 College of Medicine
© 2010 College of Medicine