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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
34
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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