The Art and Science of Achieving Compliance to g pChecklists
A/P Sophia Ang BL Vice Chairman Medical BoardPatient Safety and OperationsNational University [email protected]
1. We have a history of being slow to change
• Blood letting and The Lancet. Handwashing.
d bTrained to be autonomous2.
3 Production Pressure3. Production Pressure
Staff have many priorities every dayStaff have many priorities every day
Better AcademiaBetter
FasterEducation
Cheaper
Protocol Related
1 Science Design of Process is Key1. Science‐Design of Process is Key
N t f k B th ldNo extra forms or work. Bury the old way
2. Art‐ Transforming Behaviour and CultureMarketing Campaign Political Campaign Military Campaign
If Missing = social
engineering
=political If Missing resistance
If Missing=loss of momentum
PREVENTION OF PREVENTION OF MISSED CRITICAL INVESTIGATION MISSED CRITICAL INVESTIGATION RESULTS RESULTS
• Hear the PastManual Call Center
• See the Present
• Touch the FutureHybrid System
• Touch the FutureAcknowledgementdocumentedIn Electronic HealthcareRecord
Hear The Past……..Hear The Past……..
Mission Statement
To achieve zero incidence of delayed treatment
due to missed critical investigations by
successfully implementing the Call Centre based
Cl d L C i ti S tClosed Loop Communication System.
Multidisciplinary TeamMultidisciplinary TeamCall Center Medical AffairsLaboratory servicesLaboratory servicesOperationsNursingPhysicianPhysician
Science
1. Reliable sustainableArt
E t f li i i te ab e susta ab e2. Direct to doctor rather than 3rd party 3. Scalable– if another service / lab added
Engagement of clinicians at Medical boardClinical directors/ committee meetings
No extra forms or steps for Doctors LettersEmails
Lab Call Center
Simple Workflow- No extra forms
Lab Call Center
Call Center Contacts DoctorEscalation/DocumentationEscalation/Documentation
Three way conversationThree way conversationLab reads back with doctor
h l h it l l f i
No of critical lab calls to call center a month
Spreadingas quick as possible
pilotwhole hospital- less confusing
haem onco
Pilot phase
haem oncoadjustments
949865
1020
911 947
872 8721000
1200
511
637
872 872
600
800
of c
alls
Jun Jun 0707
Apr Apr 0707
Jan Jan 07 07
Mid Mid Nov Nov
23 23 Oct 06Oct 06
3 3 Oct 06Oct 06
Aug Aug 0606
Jul Jul 0606
Jun 06Jun 06
318382 373
511
400
600
No.
o
Whole Hosp
Radiology
Whole Hosp.
Haematology (excl. OT, ICU & HD)
Chemistry (excl. OT, ICU & HD)
Culture Results
Cancer Ctr
Endocrine Emergency
Lab Med
000o0606
Oct 06Oct 06Oct 06Oct 060606
113 103
0
200
J 06 J l 06A 06S 06O t 06N 06D 06J 07F b 07M 07A 07M 07J 07 J l 07
Whole Hosp.
Cardiac
Hosp.
Jun-06 Jul-06Aug-06Sep-06Oct-06Nov-06Dec-06Jan-07Feb-07Mar-07Apr-07May-07Jun-07 Jul-07
Automated Messaging– ReduceC llCalls
Critical Critical results results
receivedreceived System processes System processes doctor’s reply and doctor’s reply and
returns returns confirmation of confirmation of his action andhis action and
receivedreceived
his action, and his action, and notify all other notify all other
message message recipients of the recipients of the closure of circleclosure of circle--
ofof--carecare
Message Message content is auto content is auto assembled from assembled from backend system backend system
in realin real--timetime1x time 1x time authentication at authentication at shift start and/orshift start and/or
04/12/08 Confidential: © HMS-PL 2008
shift start and/orshift start and/orMultiMulti--factor factor
authenticationauthenticationSimple Reply Simple Reply
AcknowledgementAcknowledgement1, 2 or 31, 2 or 3
Call Centre Assisted Handling Interface
Notification iconNotification iconfor assisted for assisted
handling team handling team
Tracking the Tracking the doctor of caredoctor of careLimited Access Views
04/12/08 Confidential: © HMS-PL 2008
Mean times drop from 30 min to 28.3min limited by lab verfication
37.736 6
40
34.9
32.7
36.6
34.6 34.5
31.6
34.1
33.7
34.434.1
33.3
34.735
29.5
26.4 27.4 28.629.8
26.227.6
26 9
30.1 30.3
28.4 28.3
30
Min
utes
24.825.9
26.9
25.726.6
22.5 22.7
28.3
25
Mean (29 9) Median (29 6)21.5
20
Jun-06Jul-06Aug-06Sep-06Oct-0
6Nov -06Dec-06Jan-07Feb-07Mar-0
7Apr-0
7May-07Jun-07
Jul-07Aug-07Sep-07Oct-0
7Nov -07Dec-07Jan-08Feb-08Mar-0
8Apr-0
8May-08Jun-08
Jul-08Aug-08Sep-08Oct-0
8Nov -08Dec-08Jan-09
Mean (29.9) Median (29.6)
A M A M A
Pilot Manual call Hybrid
Number of Manual Calls Drop Significantly per Month
1600
Number of Manual Calls Drop Significantly per Month
10921149
10571145 1171 1135 1121 1139
12091122
1235
1050
11601258
1403 1404 14411384
1200
1400
1600
670740
939 961 942997
1057 1050
872 872949
865
1020
911 9471005
1063991
852955
10781017
1140
9881050
11451192
1258
752
1032
800
1000
mbe
r of c
alls
167 166
367431
499 487 454392
533 544490
428
318382 373
511
637
400
600Num
113 103
318
0
200
Jun-06Jul-0
6Aug-06Sep-06Oct-0
6Nov-06Dec-06Jan-07Feb-07Mar-0
7Apr-0
7May-07Jun-07
Jul-07
Aug-07Sep-07Oct-0
7Nov-07Dec-07Jan-08Feb-08Mar-0
8Apr-0
8May-08Jun-08
Jul-08
Aug-08Sep-08Oct-0
8Nov-08Dec-08Jan-09
J A S M A M J A S M A M J A S
Calls Made to Notify Doctors Total No. of Critical Results
Communication of Inpatient CLRsCommunication of Inpatient CLRs19–25/11/ 07 14 –20/4/ 08 4 –10/8/08 9 ‐15/2/09
INPATIE NT Audit 1 Audit 2 Audit 3 Audit 4Number of critical results 169 158 177 239Number of critical results 169 158 177 239Number of HMS / HMS ‐Manual calls 144 / 33 100 / 139Number of direct communication of C LR s 68.0% 67.1% 99.4% 95.0%Number of indirect communication 32.0% 32.9% 0.6% 5.0%% f i ti ithi 60 i * 68 9% 71 9% 96 0% 92 0%% of c ommunic ation within 60 mins * 68.9% 71.9% 96.0% 92.0%% of C LR s acknowledged by doctors (with/without time/date) 91.7% 95.6% 100.0% 100%
% of C LR s without date/time of doctors ' 23 4% 5 9% 0 0% 0 0%notification 23.4% 5.9% 0.0% 0.0%
% of C L R s with documented ac tion** 70.0% 99.3% 98.8% 87.1%% documented ac tion with no time 23.1% 12.3%Median time interval from res ultMedian time interval from res ult available to doc tors ' notific ation (min)
24 19.9 13.4 20.4
Mean time interval from result to dr notification (min) 32.3 55.5 24.05 23.2
Median time interval from result available to an follow‐up action (min) 113 102.9 85 17.9
Interventions s ince following audits C lose supervis ion
HMS /manual from J un 08
Hospital–wide HMS wef Oct
Dash board introduced at Lab to
* All cases of which the time of doctors’ notification was 10 minutes earlier than time of results availability were excluded** Cases of which the action had been taken prior to the critical results were excluded.
supervis ion from J un 08 08 monitor HMS calls
Communication of Outpatient CLRsCommunication of Outpatient CLRs19–25/11/ 07 14 –20/4/ 08 4 –10/8/08 9 ‐15/2/09
OUTPATIE NT Audit 1 Audit 2 Audit 3 Audit 4Number of critical results 41 44 64 70
b f S / S l/ lNumber of HMS /HMS ‐Manual/Manual calls (EMD) 9 / 29 / 26 13 / 27 / 30
% of direct communication of C LR s 73.2% 84.1% 95.3% 91.4%% of indirect communication 26.8% 15.9% 4.7% 8.6%% of c ommunic ation within 120 mins * 70.7% 97.7% 95.3% 100.0%% of C LR s acknowledged by doctors (with/without time/date) 97.6% 100.0% 98.4% 100.0%
% of C LR s without date/time of doctors '% of C LR s without date/time of doctors notification 26.8% 2.3% 3.1% 1.4%
% of C L R s with documented ac tion** 71.1% 97.7% 98.1% 82.8%% documented ac tion with no time 23.1% 33.3%Median time interval from result available to doctors ' notification (min) 14 16.7 14 5
Mean time interval from result to dr notification (min) 27.4 18.1 18.6 10.3notification (min)Median time interval from result available to follow up action (min) 286 113.9 30 19
I t ti i f ll i dit C lose HMS /manual Hospital–wide HMS f O t
Dash board i t d d t L b t
* All cases of which the time of doctors’ notification was 10 minutes earlier than time of results availability were excluded** Cases of which the action had been taken prior to the critical results were excluded.
Interventions s ince following audits supervis ion/
from J un 08 HMS wef Oct 08
introduced at Lab to monitor HMS calls
Art and Science
1 Science- Design simple no extra work1. Science Design simple, no extra work
2 No alternatives bury old ways2. No alternatives bury old ways
3. Art - Better the design less behaviour change
4. New challenges always arise. New Tests
PREVENTING WRONG PATIENTPREVENTING WRONG PATIENTWRONG SITEWRONG PROCEDUREWRONG PROCEDURE
Clinical Care
Research
Education
DesignDesign‐USE OF INTELLIGENT DASHBOARD SYSTEM
PERFORMANCE OF CHECKLIST TIED TO BILLING SYSTEM
USE OF SYSTEM ENCOURAGED BY USEFULNESS– FOR CALLING BLOOD /EQUIPMENTUSE OF SYSTEM ENCOURAGED BY USEFULNESS– FOR CALLING BLOOD /EQUIPMENT
The Campaign : OT com/ Surgeons/Nursep g / g /
Patients and Shared Equipmentare RFID tagged
Dashboard in Recovery RoomDashboard in Recovery Room
Tea Room / Waiting room of relativesTea Room / Waiting room of relatives( ID only first 4 numbers and letters)
C t h lComputer on wheels
i h tiin each operating room
Staff present
Pat Info
TimingTiming
Checklists
S i t
Checklists
Service request
Communication with the wardCommunication with OT staff ( AU nurse and attendants )Communication with blood bankChecklists safe surgery / equip prep /patient highlights/ High 5 for WHOTiming of surgery
Sign InFinal Time Out (Pre‐Induction)
should be completed with the Staff presents during the verification prior to Anesthesia Induction
Time Out and Who was Present-- AccountabilityFinal Time Out (Pre‐Indcision)
should be completed with the Staff presents during the verification prior to Anesthesia Induction
Select the present Staffs to complete the Staff Checklist for Surgery Team
during Pre‐Induction
Click Staff Checklist to display the Staff Checklist popup
Post‐Op ChecklistSign OutPost‐Op checklist should be completed to indicate any special requisite for the patient after surgery
Prompt Occurs When Wrong Patient Brought to Wrong OTP t ti tPrevent wrong patient surgery
Service RequestService Request
• Automatically trigger a notification to service provider to render specific requests via text messaging
• Eg: drugs, blood bank, X-Ray, equipment setup task, surgical material, patient fetching
Pull System - Live Tracking of Blood Request by Touch Screen
Request for Drugs by AnesthetistRequest for Drugs by Anesthetist
Team Member Touch Screen SMSTeam Member Touch Screen SMS
Outcomes
Patient Safety
EfficiencyEfficiency
Compliance in Pre‐op Verification, Site Marking & Time Out
(OT Dashboard & Observational Audit Data)
CS-1 Complete Pre-op Verification
98%
100%
ance
CS-2 Properly Marked Surgical Site
98%
100%
nce
92%
94%
96%
cent
age
of C
ompl
ia
94%
96%
ntag
e of
Com
plia
n
88%
90%
Feb-
12M
ar-1
2Ap
r-12
May
-12
Jun-
12Ju
l-12
Aug-
12Se
p-12
Oct-1
2No
v-12
Dec-
12Ja
n-13
Feb-
13M
ar-1
3Ap
r-13
May
-13
Jun-
13Ju
l-13
Aug-
13Se
p-13
Oct-1
3No
v-13
Dec-
13Ja
n-14
Feb-
14M
ar-1
4Ap
r-14
May
-14
Jun-
14
Perc
OT Dashboard Observational Audits
90%
92%
Feb-
12M
ar-1
2Ap
r-12
May
-12
Jun-
12Ju
l-12
Aug-
12Se
p-12
Oct-1
2No
v-12
Dec-
12Ja
n-13
Feb-
13M
ar-1
3Ap
r-13
May
-13
Jun-
13Ju
l-13
Aug-
13Se
p-13
Oct-1
3No
v-13
Dec-
13Ja
n-14
Feb-
14M
ar-1
4Ap
r-14
May
-14
Jun-
14
Perc
e
OT Dashboard Observational AuditsOT Dashboard Observational Audits OT Dashboard Observational Audits
CS-3 Complete Final Time Out • Compliance in pre‐op ifi ti h d
97%
98%
99%
100%
of C
ompl
ianc
e
verification has approved steadily after interventions were put in place
94%
95%
96%
b-12 -12
r-12
-12
-12
l-12
-12
-12
t-12
v-12 -12
-13
b-13 -13
r-13
-13
-13
l-13
-13
-13
t-13
v-13 -13
-14
b-14 -14
r-14
-14
-14
Perc
enta
ge o
• Full compliances for both site marking and time out since Aug 2012
Feb-
Mar
-1Ap
r-M
ay-
Jun- Jul-
Aug-
Sep-
Oct-
Nov-
Dec-
Jan-
Feb-
Mar
-1Ap
r-M
ay-
Jun- Jul-
Aug-
Sep-
Oct-
Nov-
Dec-
Jan-
Feb-
Mar
-1Ap
r-M
ay-
Jun-
OT Dashboard Observational Audits
Aug 2012
Near Miss Patient--- Brought to Wrong OT Flag Detected
By RFID Tracking.y g
Patient listed in 1 OT brought to Another OT and brought back to Listed OT
000CCC771FC7 81981 MOR12 MOR13 MOR13 2000CCC77204A 83410 MOR14 MOR02 MOR02 2000CCC772111 85367 MOR12 MOR07 MOR07 2
OperatedListedWrongOT?
000CCC772111 85367 MOR12 MOR07 MOR07 2000CCC771A80 87003 MOR12 MOR10 MOR10 2000CCC772006 87928 MOR07 MOR04 MOR04 2000CCC771EEC 90238 MOR01 MOR03 MOR03 2000CCC7720C6 91614 MOR12 MOR15 MOR03 MOR03 3000CCC771EDB 87111 MOR12 MOR02 MOR02 2000CCC7720C6 97061 MOR12 MOR10 MOR10 2000CCC771F32 99988 MOR12 MOR01 MOR01 2000CCC772069 102820 MOR14 MOR02 MOR02 2000CCC772069 107725 MOR14 MOR07 MOR07 2000CCC771ED8 108361 MOR15 MOR07 MOR07 2000CCC771EDB 107547 MOR12 MOR04 MOR04 2000CCC77203A 108922 MOR10 MOR01 MOR01 2000CCC77210B 104521 MOR12 MOR05 MOR05 2000CCC7721B5 110817 MOR12 MOR10 MOR10 2000CCC7721B5 110817 MOR12 MOR10 MOR10 2000CCC771FE8 99406 MOR12 MOR15 MOR15 2000CCC77210B 112945 MOR12 MOR13 MOR13 2
T t l 19 CTotal 19 Cases
19 Potential Cases 1 Year ( out of 20 000 major OT cases)
Types of Human ErrorsTypes of Human Errors
Summary of Effect Size of 10 Types of Accident Prevention ProgrammesProgrammes
T f P N b f St di Eff t %Type of Programme Number of Studies Effect %1. Personnel 26 3.7
2 Technology 4 292. Technology 4 293. Behaviour 6 38.64 Poster campaign 2 144.Poster campaign 2 145. Quality Circle 1 206. Exercise after Stress 2 157.Near miss reporting 2 178.International safety rating 4 17
9 . Comprehensive ergonomics
3 51.6
Helander- guide to human
Always a New ChallengeAlways a New Challenge
• 2009 to 2014 no wrong site, wrong procedure or wrong patient.p g p
• 2015- 1 wrong implant from miscommunication upstream of themiscommunication upstream of the consent
• 2015- wrong level spine surgery/wrong side spine injection– distraction byside spine injection distraction by technology and issue of multiple spine levels Localization by xray no guaranteelevels. Localization by xray no guarantee
• Out Patient and Ambulatory areas , DDI.
Art + ScienceArt + Science
• Design- part of workflow, few steps as possible, scalable.
• Better Designed less Campaign and Behaviour change needed
• Be prepared to stand firm to the principlesfor at least 2 years.
• Continuous attention needed.