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Fall Meeting
AAOS
Orthopaedic Surgery Safety Update
2012
William J Robb III MDChair
AAOS Orthopaedic Surgery Safety Summit
AAOS Patient Safety Committee
Disclosure
Consultant – Blue Cross Blue Shield Association
TJR - Centers of Distinction Program Consultant (Unpaid) - Smith and Nephew Investor – emmi Solutions
Chair – AAOS Orthopaedic Surgery Safety Summit Chair – AAOS Patient Safety Committee
Is there an Orthopaedic Surgery Safety Problem 2012?
MediaABC News Report - Maryland 2012
Report on Surgical Errors CMS - only 14% errors reported in hospitals Advised patients ask about checklists Report
SSI’s shoulder surgery Wrong site pediatric eye surgery
Is there an Orthopaedic Surgery Safety Problem 2012? HealthGrades - 2010
>350,000 patient safety errors/year 2006-2008
Cost $9B
1/10 safety errors results deaths
>100,000 surgical error deaths/year
Top 5% Hospitals – only 43% reduction safety incidents
Wrong Site Surgery (WSS) rates - 1/20,000 surgeries
Hospital SSI rates 2-3%
NO evidence safety/quality improvement 2000-2010
Is there an Orthopaedic Surgery Safety problem 2012?
JC 2009-2010 Wrong Site/Procedure/Patient Surgery (WSS)
Mandatory State –bsed WSS Reporting Minnesota (48 - WSS) Pennsylvania (58 - WSS)
35.4 WSS/wk. in US (estimated)
Wrong finger
Wrong side, other
Wrong side, knee
Other
Wrong side, ankle
Wrong level
Wrong side, hip
Wrong organ
Wrong patient
0
5
10
15
20
25
30
35
40
34
30
27
24
109 9
1 1
JC Sentinel Events Data Base 2007-2011
54 Orthopaedic WSS
Is there a Orthopaedic Surgery Safety Problem 2012?
Hospital Data JC - 2011
>7 wrong site/side/level/implant/procedure/patient surgeries /day
System errors – NOT Surgeon errors
Most frequent causes: inadequate/missing surgical information scheduling discrepancies/errors irregularities in pre-op holding process inadequate/absent surgical site marking poor communication distractions in OR inadequate/absent OR process/‘time-out’
Mark Chassin MD, MPP, MPH
Is there an Orthopaedic Surgery Safety problem 2012?
ABOS Certification/Recertification Data Base – 2011 WSS Rate - 1/30,000 orthopaedic surgeries NO CHANGE 2000-2011
Surgical Safety/Quality/Value Timeline
1997 - AAOS - ‘Sign Your Site’ Program - (safety)
1999 - IOM Report - To Error is Human: Building a SaferHealth System – (safety)(44-88,00 deaths in hospitals/year from medical errors)
2001 - IOM Report – Crossing the Quality Chasm: A NewHealth System for the 21st Century (quality)
2003 - VA National Directive to reduce Risk WSS (safety)
2004 - JCAHO – ‘Universal Protocol’ (safety/quality)
2004 - SCOAP** (safety/quality) voluntary hospital-based surgical safety/quality – Washington
Surgical Safety/Quality/Value Timeline
2007 - SCIP* (quality) mandated national surgical quality standards
2007 - WHO ‘Safe Surgery-Saves Lives’ (safety/quality)
2009 - Checklist Manifesto –Atul Gwande MD (safety and quality)
2010 - Berwick*** CMS Administrator (safety/quality/value) CMS payments - financial penalties for Never Events CMS/PQRS payments – financial incentives for ‘quality reporting’
2012 – CMS Public Quality Data Reporting Program (safety/quality/value)
Hospital SSI Rates Surgical Re-admission Rates * Surgical Care Outcome Assessment Program – Washington State Hospital Association ** Surgical Care Improvement Program – US Department of Health and Human Services *** Former President and CEO, Institute for Healthcare Improvement (IHI)
Evidence Surgical Safety/Quality/Value Programs are Effective
2006 – Central Line Checklists – Peter Pronovost MD
Reduction central line infections - 40% to <1%
2008 – WHO ‘Safe Surgery - Saves Lives’ - Atul Gwande MD 50% reduction surgical mortality/complications (multi-nation study)
2010 – Surgical Care Outcomes Assessment Program (SCOAP) Universal Protocol (UP) adopted in all Washington OR’s
< Complications - appendectomy, colectomy, bariatric surgery
< Hospital Costs
Evidence Safety/Quality/Value Programs are Effective
2010 – Northern New England Cardiovascular Disease Study
Group
improved Cardiovascular surgery outcomes - participating medical centers
2011 – VA Surgical Safety Program
reduced surgical errors 25% - 2006-2009
AAOS Orthopaedic Surgery Safety/Quality Survey 2011
Survey Goals Assess safety/quality in orthopaedics
Evaluate differences by:
sub-specialty length of practice practice type
Evaluate orthopaedic leadership attitudes regarding safety/quality
Assess orthopaedic safety practices/culture /errors
Identify opportunities/barriers for change
Survey Participants
Participating Practice Types
Participating Orthopaedic Sub-Specialties
Participant Surgical Settings
Results
Positive Findings
>90% use Universal Protocol (UP) in Hospital OR’s
82% Believe UP Improves Surgical Safety/Quality
No differences in utilization/understanding UP by: Years in practice
Sub-specialty
Results Negative Findings
Surgical errors reported ALL orthopaedic settings
Most ‘undereducated’ safety science
<50% UP use in surgi-centers - rare in office/procedure rooms
Few surgeon safety leaders/champions
Younger surgeons < team communication knowledge
Model Safe Orthopaedic Surgical Care
HistoricalOrthopaedic Surgery Culture
Surgical Processes
• Highly variable surgical techniques
• Surgeon specific care plans
• Surgeon-centric care
Data
• Experience/ Memory driven
• Limited systematic data collection
Communication
• ‘Top-down’ surgical hierarchy
• Limited shared decision making
ModelOrthopaedic Surgery ‘Culture of Safety’
Surgical Processes
• Standardized techniques
• Reliable evidence/ consensus-based care plans
• System-centric care
Data
• Systematic data collection and analysis
• Active data management demonstrating improvement/s
Communication
• Shared authority ‘team model’
• Delegated responsibilities
• Transparency
Definition
Safe Orthopaedic Surgical Care
Safe surgical care is: surgical care delivered with a highly reliable surgical system designed to reduce, with a goal of eliminating,
preventable harm/s continuously monitored through safety data collection effectively integrating interfaces between surgical:
patient and family physicians, surgeons and staff suppliers and equipment and environments.*
* Modified from Dev Raheja - Safer Hospital Care
Definition
Quality Orthopaedic Surgical Care
Quality Surgical Care is: standardized surgical care based upon
medical evidence and/or consensus-based ‘best’ surgical practices
continually improved through innovation validated through surgical quality data collection and analysis achieving optimal composite surgical outcomes
Definition Value
Orthopaedic Surgical Care
Value in surgical care: focused on patient-centered outcomes evaluated continually with surgical benchmarking supported by only essential resources ($$$) effectively coordinated through the entire surgical care episode*
* Modified from Michael Porter – Redefining Healthcare
Relationship
Safety, Quality and ValueValue
Optimal Outcomes with ONLY
Essential Resources
QualityReliable Care Improvement
Systems
SafetyOrganized Error
Elimination
What is needed to improve Orthopaedic Surgical Safety?
Change historical orthopaedic surgical behaviors Implement surgical safety science and behaviors into ALL
orthopaedic settings Shift focus from ‘surgeon’ to ‘team’ performance Establish sustainable ‘culture’ of surgical safety Build and maintain orthopaedic safety/quality data bases Validate safety programs in orthopaedic settings Collaboration with other safety stakeholder organizations
Key Elements Orthopaedic Surgical Safety
6 C’s (1) Communication – effective surgical team communication (2) Consent – accurate timely informed consent (3) Confirmation – proper surgical site marking/identification (4) Checklists – use validated standardized processes (5) Concentration – focused team without distraction (6) Collection – systematic safety/quality data collection
Submitted to CORR 10/2012 – Kuo, Robb
AAOS Surgical Safety Program 2012
2011 Fall Board Workshop TeamSTEPPS 80 Hospital/Surgicenter training sites 2012-2014
2012 Spring Board Workshop Develop orthopaedic checklists Establish/collaborate orthopaedic safety data bases
Surgical Safety Board Oversight Work Group 2012-2014 Chair - Dr. Fred Azar
Orthopaedic Surgery Safety Summit Chicago – 2012
Orthopaedic Surgery Sub-Specialty Pilot Programs Validate Pilot Safety Programs 2012-2014
Orthopaedic Safety Summit Goals
Unify orthopaedics regarding safety Reduce errors/ ‘preventable harm/s’
wrong site/side/level/procedure/implant/patient surgery surgical complications readmissions
Establish surgical safety as a specialty priority Improve orthopaedic outcomes Collaborate with other surgical safety stakeholder organizations
Participating/Presenting Organizations
1. American College of Surgeons (ACS)
2. Surgical Care Outcomes Assessment Program (SCOAP)
3. Centers for Disease Control and Prevention (CDC)
4. Centers for Medicare and Medicaid Services (CMS)
5. Agency for Healthcare Research and Quality (AHRQ)
6. The Joint Commission (TJC)
7. Ambulatory Surgical Center Association (ASCA)
8. Accreditation Association for Ambulatory Healthcare (AAAH)
9. Association of Operating Room Nurses (AORN)
10. Webster Healthcare Consulting
11. Pascal Metrics
Participating Orthopaedic Organizations
1. American Academy of Orthopaedic Surgeons (AAOS)
2. American Association for Hand Surgery (AAHS)
3. American Orthopaedic Foot and Ankle Society (AOFAS)
4. American Association of Hip and Knee Surgery (AAHKS)
5. American Orthopaedic Society for Sports Medicine (AOSSM)
6. American Shoulder and Elbow Society (ASES)
7. American Society for Surgery of the Hand (ASSH)
8. American Spinal Injury Association (ASIA)
9. Arthroscopy Association of North America (AANA)
10. Cervical Spine Research Society (CSRS)
11. Hip Society (HS)
12. Knee Society (KS)
Participating Orthopaedic Organizations
13. Limb Lengthening and Reconstruction Society (LLRS)
14. Musculoskeletal Tumor Society (MSTS)
15. North American Spine Society (NASS)
16. Orthopaedic Trauma Association (OTA)
17. Pediatric Orthopaedic Society of North America (POSNA)
18. Scoliosis Research Society (SRS)
19. Society of Military Orthopaedic Surgeons (SMOS)
20. American Academy of Orthopaedic Surgeons (AAOS)
Board of Directors (BOD)
Board of Specialty Societies (BOS)
Board of Councilors (BOC)
Council on Research and Quality (CoRQ)
Patient Safety Committee (PSC)
Summit Work Group Safety Projects
Hand/Foot Ankle – Opioid Abuse Hip/Knee/Tumor – SSI Prevention ‘Bundle’ Pediatrics – Peds Patient/ Family Checklist Spine – Wrong Level Spine Surgery Sports – ‘UP’ in Surgicenters Trauma – Hip Fracture
Patient Safety Summit
Next Steps Develop Pilot Projects Explore data relationships
ACS, SCOAP Explore Global SSI Prevention Program
CDC, AHRQ, AAOS Unified Orthopaedic Safety Information Statement Explore BOS Safety role
Safety Barriers
Surgeon resistance to change Inadequate surgeon knowledge Limited utilization of surgical team safety science Limited surgeon data contribution and benchmarking Inadequate surgeon leadership
Orthopaedic Surgical Safety Journey
Safety is no Accident AAOS Sign Your Site Program 1997
Paradigm Shifts Orthopaedic Safety Programs
Education
Orthopaedic education programs New focus/balance safety, quality and value science in all
orthopaedic education programs/products • Orthopaedic Quality Institute• Safety Summit
Standardization system-based focus vs. implant/surgical technique focus
Paradigm Shifts Orthopaedic Safety Programs
Data New safety/quality data programs
CMS Public Reporting (PACA) • national benchmarking• regional benchmarking (by state)
HVHC - Dartmouth Institute – private benchmarking collaborative System performance vs. surgeon performance System focus ‘prevention harm’ vs. ‘good results’
• Deming – count bad light bulbs not good light bulbs Patient outcomes vs. surgeon outcomes reporting Multi-center vs. single center trials reporting
Paradigm Shifts Orthopaedic Safety Programs
Clinical New standardized system-based interdisciplinary surgical
care programs Geisinger ProvenCare
• Patient contract Intermountain Health System ACO’s ‘Bundled Care’ products NorthShore University HealthSystem
• Care reliability (LOS, Costs)• Complication prevention• Readmission management
AAOS Orthopaedic Surgery Safety Summit Chicago, 2012
6 Ortho Sub-Specialty Work Groups Conference Calls. April - July
Safety Webinar Tuesday, July 31
Safety Summit Sunday, August 5 - Monday, August 6
Hand – Foot/AnkleWork Group
Opioid misuse/abuse Orthopaedic prescribing practices Orthopaedic education
Build consensus standards Collaboration – national organizations/federal
government/advocacy
Is there an Orthopaedic Surgery Safety Problem 2012?
Orthopaedic Evidence
Orthopaedic surgical outcomes highly variable - by surgeon/hospital/healthcare system/region
Limited local, regional, national orthopaedic safety/quality data
Slow adoption Safety/Quality communication and process
Few recognized surgeon safety leaders/champions
Hip, Knee, TumorWork Group
SSI Prevention ‘bundle’ Pre-op checklist
• Diabetic optimization• smoking cessation
OR checklist• Skin Prep• Antibiotic optimization
Post-op checklist• Wound care optimization
PIM/OKO modules Collaboration – AHRQ, AAHKS, HS, KS, MSTS, CMS, AORN
Pediatric Work Group
Patient/Family Checklist 10-15 elective procedures
Focus – patient safety, quality, value Collaboration – POSNA, SRS, Peds Hospitals Pilot Study
Spine Work Group
Wrong-level Surgery Prevention Sign Mark and X-ray
(SMaX) OR Checklist Confirmation with imaging Pilot Study Develop PIM Collaboration - NASS Educate
Sports Work Group
Universal Protocol (UP)- Surgicenters & Offices Pilot Project
Scheduling Pre-op Holding OR Patient focus
Collaboration – AOSSM,
AANA, JC
Trauma Work Group
Hip FX Quality Pathway Checklists/order-sets Pilot Study
SSI Prevention New SSI Quality ‘bundle’ Pilot study
Hip FX PIM/s Collaboration - CDC, AHRQ, OTA, AGS
AAOSSafe Orthopaedic Surgical Programs
Surgical Team Communication effective patient and surgical team communication
TeamSTEPPS human factors supporting a Culture of Safety distraction-free/focused OR environment
Standardized Surgical Processes accurate timely patient-centered informed consent proper marking and confirmation of:
site - side - level - implant - procedure - patient regular use standardized surgical checklists
Surgical Data Systematic surgical data collection and analysis
Orthopaedic Safety Summit
Ortho Sub-Specialty Work Groups
Hand/Foot-Ankle David Ring MD
Hip/Knee/Tumor Mark Froimson MD
Pediatrics Kit Song MD
Spine Paul Huddleston MD
Sports Laurence Higgins MD
Trauma Steve Olson MD
CMS NorthShore THR/TKR All-Cause Readmissions
consensus building among surgeons
collaboration hospital administration
surgical team communication
patient-centered care with optimized outcomes
reducing/controlling unnecessary costs
validate innovation improvements
surgeon self reporting - safety/quality/value data
Thanks
Historical ‘Unsafe’
Surgical Behaviors
Process - surgical techniques/care plans - highly variable surgeon-unique
Data -surgical care experience-based little/no surgical data collection/analysis
Communication - surgical authority hierarchal surgeon ‘top down’ to surgical team
Model Needed for‘Safe’
Surgical Behaviors
Process - surgical techniques/care plans standardized and evidence/consensus-based ‘best’ practices
consistent/reliable Data - surgical data systemically collected and analyzed
improvements data/active management driven Communication - Surgeon authority shared in ‘team model’
surgeon as leader supporting transparency and authority
delegation
Model Orthopaedic Surgical Safety
How?
Introduce OR behaviors benefitting entire surgical team Embrace safety science in orthopaedic practices Own orthopaedic surgical safety data and errors Shift focus surgeon to surgical care system improvement Celebrate improvements Partner with patient, stakeholder and safety organizations
Safety Summit
No! cultural change resistance other industries safety change > decade
Options embrace change – improve care resist change – accept regulatory mandates/financial penalties
Safety Summit designed to expand safety practices introduced by AAOS in 1997 build new orthopaedic specific safety ‘tools’ affirm orthopaedic leadership/commitment
Safety Summit
Summary Overview
Participant Recognition: Prioritize Safety for ALL orthopaedic settings 6 sub-specialty work groups : PILOT new orthopaedic safety
programs Safety collaboration - CMS, AHRQ, JCAHO, ACS, SCOAP Unify Orthopaedic community :
UNIFIED Orthopaedic Safety Information Statement BOS and AAOS collaboration new safety programs /products
Summit SafetyOutcomes Summary
Unified Position Statement on Orthopaedic Surgical Safety Develop funding support for Work Group pilot safety programs Continue communication CMS, JCAHO, AHRQ Explore partnering with ACS/SCOAP for surgical safety data Explore ongoing support and coordination of the Orthopaedic Safety
programs ? new BOS Safety Committee
Collaborate with AAOS Surgical Safety TeamSTEPPS Communication Program (80 Centers/3 years)
Safety Recommendations Trauma Work Group
Recommend to AAOS - SSI Prevention Guideline Develop SSI Prevention Checklist (Bundle)
Antibiotic management HbA1C/Hypergylcemia Management Surgical warming (>35c.) Albumin/Nutritional management Smoking Cessation Blood manageent
Pilot a Standardized Hip Fracture Patient Care Pathway Standardized Order Sets
Pre-op Post-op Discharge
Hip Fracture PIM
Goals: decreased LOS, decreased costs and improved Fx outcomes
Safety Recommendations Sports Work Group
Develop a Surgical Safety Program for Ambulatory Surgery Centers Collaborate with JCAHO, ASCA Develop training modules Collaborate with AAOS TeamSTEPPS training program
Currently only 50% of orthopaedic surgicenters use Universal Protocol
Safety Recommendations Spine Work Group
Recommend to AAOS - SSI Infection Prevention Guideline Pilot - Wrong Level Spine Surgery Checklist
Define imaging requirements Define ‘wrong level’ surgery Define exception/outlier management – obesity, retained implants
Safety Recommendations Pediatric Work Group
Pilot a Family/Patient Focused Peri-operative Checklist Pre-op
Care team review Consent, Team huddle
Surgical Post-op surgeon review
Post-op Care plan review
Discharge Follow-up appointment
10-15 pilot centers identified Potential funding sources identified
Safety Recommendations Hip/Knee/Tumor Work Group
Recommend to AAOS - SSI Prevention Guideline Develop SSI Prevention education products
OKO PIM
With AHRQ pilot Pre-op Optimization SSI Prevention
Checklist (Bundle): Obesity (BMI>40 counseling) Smoking Cessation (Pre-op counseling/cessation) Diabetic Management (Optimize Pre-op HbA1C <7) Anemia Assessment (for pre-op Hb<10)
Results
Wrong Site/Procedure Errors
2010-11 - Wrong Site/Procedure Surgeries
Hospital OR’s - 0.4/yr.
Surgi-Center OR’s - 0.25/yr.
Office Procedure Rooms – 0.05/yr.
Career - Wrong Site/Procedure Surgeries
Hospital OR’s – estimated -1/20,000 surgeries
Surgi-Center OR’s – estimated -1/80,000 surgeries
Office Procedure Rooms – insufficient data (rare)
Safety Recommendations Hand/Foot-Ankle Work Group
Develop an comprehensive opioid drug misuse/abuse
management and education program to: decrease peri-operative opioid drug events, improve orthopaedic outcome satisfaction reduce opioid dependency/abuse
80% of worlds opioid drugs consumed in US Opioids - #1 cause of accidental death in young adults in US