Diagnostics Azhar Ali, MD Frank Federico, RPh. Description Delivering safe care involves...

DiagnosticsAzhar Ali, MDFrank Federico, RPh

Description

Delivering safe care involves understanding the root of the defects that impact safe.    In order for us to understand our systems of care, we need a diagnostic journey that moves out of a model for judgment and into a model for learning.  A number of data sources are available for organizations to identify the rate and type of harm that patients may be experiencing, Using the data from diagnostics can be helpful to draw conclusions to help focus improvement efforts. During this session, participants will learn and share their experiences with using diagnostics to improving safety.

Objectives

Describe the diagnostic journey that organizations must take in order to improve patient safety

List the diagnostic tools available to identify defects

Develop a plan to use diagnostics in your organization

Why Are You Here?

What interest brought you to a data session?

What data do you use every day to improve care?

Juran Trilogy

QUALITY PLANNING

QUALITY IMPROVEMENT

QUALITY CONTROL

Data Uses

Data is used for several purposes in healthcare

– Research– Accountability– Improvement

What data uses do you see in daily work?

The Three Faces of Performance MeasurementAspect Improvement Accountability Research

Aim Improvement of care(efficiency & effectiveness)

Comparison, choice, reassurance, motivation for

change

New knowledge(efficacy)

Methods:• Test Observability

Test observableNo test, evaluate current

performance Test blinded or controlled

• Bias Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

• Sample Size “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

• Flexibility of Hypothesis

Flexible hypotheses, changes as learning takes place No hypothesis

Fixed hypothesis(null hypothesis)

• Testing Strategy Sequential tests No tests One large test

• Determining if a change is an improvement

Run & Control chartsAnalytic Statistics

(statistical process control)

No change focus(maybe compute a percent change or rank order the

results)

Enumerative Statistics(t-test, F-test, chi square, p-values)

• Confidentiality of the data

Data used only by those involved with improvement

Data available for public consumption and review

Research subjects’ identities protected

Solberg, L I; Mosser, G; McDonald, S "The three faces of performance measurement: improvement, accountability, and research." The Joint Commission journal on quality improvement 23, No. 3 1997, pp. 135-47.

Vulnerable System Syndrome

Three core pathologies

- Blame

- Denial

- And the pursuit of (the wrong

kind of) excellence

How can we learn about our system performance?

Sources of Information

Mortality Review

Trigger tools

Concurrent review

Incident Reports

Waste Report

Observation

Pharmacy Interactions

Patient Complaints

KPI and Reliability of processes

Culture of safety assessment

Access

Diagnostic Journey

Do people die unnecessarily every day in our hospitals?

In order for us to understand this, we need a diagnostic journey that moves out of a model for judgment and into a model for learning.

The Mortality Diagnostic – 2x2 Matrix

Review most recent 50 consecutive deaths.Place them into a two by two matrix based on:- Was the patient admitted for palliative care?- Was the patient admitted to the ICU?Focus your work initially on boxes that have at least 20% of your mortality.

Diagnostic – The 2 x 2 Matrix

Admitted to the ICU?

Yes No

Admitted forPalliativeCareOnly?

Yes

No

Box #1 Box #2

Box #3 Box #4

The Mortality Diagnostic- Failure to Recognize, Plan, Communicate

Analyze deaths in box 3 and 4 for evidence of failure to: recognize, communicate, plan.

This will help you understand the local environment.

Recognize, Communicate, Plan

- Failure to Recognize: Any situation in which a patient has died and there was evidence that an intervention could have been made anytime prior to the patient’s death Example: the staff was worried, change in heart rate, change in respiratory rate, change in blood pressure, change in O2 saturation or change in consciousness or neurological status that was not responded to.

- Failure to Plan, such as: diagnosis, treatment, or calling a rescue team.

- Failure to Communicate: Patient to staff, clinician to clinician, inadequate documentation, inadequate supervisor, leadership (no quarterback for the team), etc.

The Mortality Diagnostic- The Impact of Care

Evaluate ALL deaths in box 3 and box 4 to assess the estimated impact of our care on mortality:

*As you review the deaths in box 3 & 4, ask yourself the questions honestly (focusing on learning, not judgment):

– Was perfect care rendered?– If perfect care wasn’t rendered, could the outcome

of death have been prevented if the care had been better?

– What number of deaths could have been prevented?

The Mortality Diagnostic- Evidence of Adverse Events

Analyze deaths in box 3 and 4 for evidence of adverse events using the Global Trigger Tool.

This will give some further direction to local problems.

Source; Helen Lau, R.N., M.H.R.O.D., Kerry C. Litman, M.D. “Saving Lives by Studying Deaths: Using Standardized Mortality Reviews to Improve Inpatient Safety” The Joint

Commission Journal on Quality and Patient Safety. September 2011 Volume 37 Number 9

Accepting the Harm Burden

Concept of moving from a focus on error and the preventable to the measurement of global institutional harm whether preventable or not

Definition of Harm

In the IHI Global Trigger Tool, the definition used for harm is as follows:

Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.

New (Harm) vs. Old (Errors)

Concentrates less on people more on systemsLooks at all unintended resultsMakes measurement easier Concentrates on harm and those errors that cause harm

Errors are the focus of discussion and solutions

Tends to focus only on those results felt to be related to error, ignores other events

Requires judgment

Human found responsible for most of the errors

Why Use Trigger Tools?

Traditional reporting of errors, incidents, or events does not reliably occur in the best of health care culturesVoluntary methods markedly underestimate adverse eventsEvents can be reliably detected without resorting to as yet unproven electronic surveillance methods Can be integrated into a good sampling methodology to follow event rates over time

IHI Global Trigger Tool

Review chart for triggers that are sensitive and specific for harm

Find a trigger- was there harm?

Not all triggers mean there was harm!

IHI Global Trigger Tool Modules

Cares (General)

Critical Care

Medication

Surgery

L&D

ED

  Cares Module Triggers

C1 Transfusion or use of blood products

C2 Any Code or arrest

C3 Dialysis

C4 Positive blood culture

C5 X-Ray or Doppler studies for emboli

C6 Abrupt drop of greater than 25% in Hg or Hemtocrit

C7 Patient fall

C8 Decubiti

C9 Readmission within 30 days

C10 Restraint use

C11 Infection of any kind

C12 In hospital Stroke

C13 Transfer to higher level of care

C14 Any procedure complication

C15 Other

How it is Actually Done

1 - Set your timer for 20 minutes

2 - Review the coding summary (look for e-

codes and obvious events)

3 - Review the discharge summary

4 - Review the lab

5 - Review the x-ray reports

6 - Review the procedure notes

7 - Any time left over, review nurse notes

Example of a Trigger:Transfer to higher level of care

Endoscopy

Post procedure somnolent and hypotensive (BP 80) transferred to ICU

Placed on Bi-Pap

Received standard meperidine and midazolam for procedure

Given flumazenil; stayed in unit 12 hours.

Concurrent Review

• Definition of Concurrent Review:

- Real-time view of patient care related to the specific quality indicator being measured.

• Goal:

- Improve quality of care during present patient admission.

• Reviewer Qualifications:

- Adequate (clinical) knowledge/experience of subject matter and ability to synthesize and provide feedback.

Concurrent Review Process

Identify patients with a need for daily review– This can be the most challenging piece– Use IT/administrative systems when possibleReview specifics of chartAnalyze and synthesize informationProvide feedback (with the potential for an intervention …)– One-on-one dialogue– Weekly Reports/feedback from leadership

– Stats– Outliers– Review of guideline in question– Documentation issues– Staff Kudos!

60

70

80

90

100

Bas

elin

e

Q1

2008

Q2

2008

Q3

2008

Q4

2008

Q1

2009

Q2

2009

Q3

2009

Q 4

200

9

Q1

2010

Timeline

Pe

rfo

rma

nc

e (

%)

BC Drawn Prior to Initial ABX Started (ED) ABX Timing (6 hours)

Concurrent review begins

1 missed case per measure.

Cases not picked up on concurrent

review

Pneumonia Performance: ED Measures

Pneumonia Performance:Vaccine Measures

60

70

80

90

100

Baseline 2007 2008 2009 2010

Timeline

Per

form

ance

(%

)

Pneumovax Flu Vaccine

Concurrent review begins

Q3 2008

Incident/Voluntary Reports

Effectiveness

Findings from IHI GTT studies

How Much Harm

‘Global Trigger Tool’ Shows That Events in Hospitals May Be Ten Times Greater Than Previously

MeasuredClassen DC, Resar R, Griffin F, et al. Global Trigger Tool shows that adverse

events in hospitals may be ten times greater than previously measured. Health Affairs. 2011 Apr;30(4):581-589

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Waste Identification Tool

Ward Module

Bed Occupied or Used Inappropriately

Healthcare-Associated Infection

Adverse Drug Event

Procedure Complication

Unnecessary Hospitalization

Flow Delay

Clinical Care Delay

Patient Care Module

Monitoring

Invasive Devices

Medications

Tests

Therapies

Diagnosis Module

Urinalysis

Thyroid function studies

Electrocardiogram (ECG)

Chest x-ray (CXR)

Metabolic panel (typically includes glucose, electrolytes, proteins, kidney function tests, and liver enzymes)

Treatment Module

Anticoagulation

Glucose management

Post-operative care for high-volume procedures

Pain control

Others

Patient Module

The Patient Module is meant to function as a reality check regarding what patient perceive as helpful and valuable in their inpatient care.

Qualitative Measure

Patient Module

Identify five adult patients scheduled for discharge to the home setting and who are capable of participating in a brief interview.

First explain the purpose of the interview and obtain permission.

Be sure to inform patients as to what information will be noted and how it will be used.

Patient Module

Only interview patients who are willing to participate.

Record some brief notes with the patient’s comments and perspectives in the worksheet.

Analysis

The modules and various waste streams described in this Tool represent the starting point in a journey to reduce significant waste in an acute care hospital.

Observation Method

Direct observation of a process in the natural setting

Developed by Ken Barker at Auburn University

Observation Method

The method is easily understood,

Data are easy to use for identifying trends and benchmarking,

Data are available within hours

The method is systems oriented and views errors in doses as defects in a system,

The method is objective and does not assign blame

Observation Method

The method is defensible, with all doses being examined and errors witnessed

The method enables problem-based continuing education that focuses on “our” errors

The method facilitates evidence-based testing that can evaluate proposed system changes

Quality can be measured quantitatively by third parties

Pharmacy Interventions

Source of information for medication errors and medication-related events

Source of valuable information

Not used to full potential

Patient Complaints

http://www.ncbi.nlm.nih.gov/books/NBK43703/

Culture of Safety

Access and Flow

Reliability is failure free operation over time.

0

5

10

15

20

25

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Failures: readmissions within 31 days related dx

31 Day Readmission Analysis

100 random charts reviewed (total of 244 readmissions within 31 days for the year).

Charts reviewed by physicians with a standard chart review worksheet.

Worksheets reviewed and data for production defects, environmental defects extracted.

Production Defects

37.50%

22.50%

15%12.50%

10%

2.50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Poor Discharge SurgicalComplicatons

Poor Hospital care Procedure/Rx notsuccessful

Infection Other

Environmental Defects

59%

11%15%

3.70% 3.70% 3.70%

0%

10%

20%

30%

40%

50%

60%

Poor OutpatientManagement

Lack of Support LTC FacilityProblems

Non CompliantPatient

Unable to get meds Unable to getappointment

Poor Outpatient Management

Poor outpatient pain control program (31%)

Poor CHF outpatient follow up program (31%)

Multiple other issues (37.5%)

Primarycare

CHF

ED Direct admit transfer

Med-surg.unit

Home/rehab/nursing home

Defects that arise over the LOS: variation from best care,

Defects that arise from factors that affect care over time: Nutrition, environment, medication availability, poor discharge planning,

Reliability: failure free operation over time for a patient

Defects arise from access to care, medication, self care strategies

High reliability organizations are continually on the lookout for novel types of system

failure and have several contingency plans.

Sensemaking

How does one make sense of all of the data?

Meyer GS, Nelson EC, Pryor DB, James B, Swensen SJ,

Kaplan GS, et al. More quality measures versus measuring

what matters: a call for balance and parsimony.

BMJ Qual Saf. 2012 Aug 14.

A Structure of Measures & Improvement

Project

“Meso-System”

Whole System

“Meso-System”

“Meso-System”

Project Project

ProjectProject

Project

Project

Project

Tier 1Macro

Tier 2Meso

Tier 3Micro

A Structure of Measures & Improvement

Project

“Meso-System”

Whole System

“Meso-System”

“Meso-System”

Project Project

ProjectProject

Project

Project

Project

Tier 1Macro

Tier 2Meso

Tier 3Micro

Impact of Different Measures

Macro System• Leadership • Support for mission and goals• Sets the agenda • Structures that assure process and outcomes in place

• E.g. Skills and time for daily improvement

Macro System Measures

IOM Dimension Whole System Measures

Safe • Adverse events that cause harm• Work days lost

Effective • Hospital standardized mortality ratio• Unadjusted (raw) mortality• Functional outcomes• Readmission percentage

Patient-Centered • Patient experience

Timely • 3rd next appointment available; waits and delays

Efficient • Patient days during the last 6 months of life • Costs per capita

Equitable – for all

Impact of Different Measures

Meso System• Outcomes important to guide actions• Process measures guide activities to support excellent, safe care• Managers use data to set agenda to support larger organizational

goals• Daily improvement

Meso System Measures

Aims Measures

Safe • Falls this month• Fall rate• Employee injury rate

Effective • Sepsis protocol implementation %• DVT bundle• Transitions home steps implemented

Patient-Centered • Bedside change of shift report• Physician communication steps implemented

Timely • 3rd next appointment available

Efficient • Flow delays (E.g. ED to inpatient; OR room turnover)

Equitable – for all

Impact of Different Measures

Microsystem• Process measures help focus on daily activities

• What can we learn from this case – this one?• This fall; this missed lab; this wrong dose

• Drives planning of work and resources• Outcomes important for focus

• For day-to-day activities, focus is ‘what can I do to change all the things that need to improve?!

Micro System Measures

Aims Measures

Safe • Falls this month• Fall rate• Employee injury rate

Effective • Sepsis protocol implementation %• DVT bundle• Transitions home steps implemented

Patient-Centered • Bedside change of shift report• Physician communication steps implemented

Timely • Patient rooming process in clinic

Efficient • Flow delays (E.g. ED to inpatient; OR room turnover)

Equitable – for all

The Differences Are…

Where you are in the organizationPrimary roleScope of influence

Display of Data

One Example of Data UseSafe Care – Measures

Measures of – • Misuse

• DVT care not fully completed

• Over-use• Prolonged sedation in the ICU

• Under-use• Access to care; waits and delays due to flow problems

http://www.psnet.ahrq.gov/popup_glossary.aspx?name=underuseoverusemisuse

Types of Measures

Process– Measure the effectiveness of a process, which if done well should deliver

a good outcome

Outcome– Measure the effectiveness of a change or intervention in delivering the

desired outcome

Balancing Measure

Why is it important to link multiple measures?

No one measure provides the complete picture

Activities in one area impact results in an other

Process measures should be linked through evidence to outcomes

Balancing measures help understand unintended consequences

Focus on the Vital Few!

There are many things in life that are interesting to know.

It important to work on those things that are essential to quality and safety.

The challenge, therefore, is to be disciplined enough to focus on the essential, vital few.

Building a

cascading

system of

measurement

Resources

White papers – Mortality

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/MoveYourDotMeasuringEvaluatingandReducingHospitalMortalityRates.aspx

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ReducingHospitalMortalityRatesPart2.aspx

– Global Trigger Tool

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/IHIGlobalTriggerToolWhitePaper.aspx

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