Slide Presentation from the AHRQ 2009 Annual Conference
On September 14, 2009, John M. Morton made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (5.92 MB) (Plugin Software Help).
Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience
John M. Morton, MD, MPH, FACS
Director of Surgical Quality
"To Err is Human"
A number of images are shown.
- Measuring Patient Safety cover
- The Joint Commission logo,
- AHRQ - Agency for Healthcare Research and Quality logo
- U.s. Department of Health and Human Services logo
- Clinical Input
- " You search where there is light"
Department of Surgery Quality Plan Preview
- Imperative from SHC Board
- Areas of Focus
Clinicians in Quality Improvement - A New Career Pathway in Academic Medicine
A table of the types of Health Care Quality Activities and Their Potential Academic Merit is shown.
Screen Shot of Stanford Hospital and Clinics
PSIs: Quality Diagnostic Tool
2007 Quality Improvement and Patient Safety Scorecard
Top Priority PI Action Plans
DVT/PE: Reduce the rate of DVT & PE by 25% by December 2008.
- Increase Monitoring
- Provide Feedback to Physicians
- Improve Compliance to order sets
Sepsis: Reduce hospital mortality of severe sepsis & septic shock from 50% to 40% by Jan 09
- Update Sepsis Guidelines
- Implement processes for early identification of sepsis and aggressive treatment
- Establish ICU/ED task force and spread learning
IAP: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08
- Promote ultrasound-guided internal jugular (IJ) catheterization as the method of choice for CVC
- Require all medical & surgical interns to complete CVC Website Curriculum & Simulation Program during orientation
- Require that the first 5 CVCs by a house staff member be supervised by a more senior physician who has successfully inserted & documented the placement of 5 CVCs
UHC DVT/PE Measure
A graph of the Post Operative DVT or PE is shown.
Incidence of DVT/PE by DRG
A graph of the Incidence of DVT/PE by DRG is shown
Concurrent Surgical Audit
- Concurrent audit started in Feb 08; conducted by Quality Specialist 24 hours after surgery on:
- Orthopedic surgery
- General surgery patients
- "Risk level" of patient is assessed by Quality Specialist & compliance determined based on current order
- Surgical DVT Prophylaxis must be ordered and 1st drug dose given within 24 hours after surgery
- If no order or inadequate order, a "fix-it" ticket is placed in medical record so MD can order or revise prophylaxis
Radiology DVT/PE Report
An image of the Radiology DVT/PE Report is shown.
DVT/PE Risk Assessment in Epic
A screen shot of the DVT/PE Risk Assessment in Epic is shown.
Retrospective Surgical Audit (? radiology test)
Accordance of Ordered Drug Agent, Dose & Frequency to Patients Risk Level and SHC Guidelines (N=17) (Aug-Oct 08)
- Drug Agent: 0.88
- Drug Dose: 0.88
- Drug Administration Frequency: 0.88
Retrospective Surgical Audit
MD Order for Postoperative Drug Prophylaxis and Receipt of 1st Drug Dose within 24 Hours of Surgery (N=17)
- MD Order w/in 24 hrs of Surgery 0.71
- Receipt of 1st dose w/in 24 hrs of Surgery 0.53
Action Plan for DVT/PE
Monitor concurrent MD ordering practices of DVT prophylaxis & educate/reinforce Epic order sets.
Quality Specialist to audit 10 charts/wk of General & Ortho Surgery pts & educate MDs.
Begin Feb 1
Review concurrent DVT/PE cases for adherence to DVT prophylaxis guidelines monthly.
Quality Specialist to perform audit based on monthly report of + radiology tests.
Examine & present results from concurrent monitoring & audit & NSQIP data to providers.
P. Pilotin & K. Bashaw to discuss results with Chairs of General & Orthopedic Surgery.
Educate physicians to DVT guidelines and order sets.
P. Pilotin to develop/distribute materials of DVT guidelines & screen shots of Epic DVT order set.
Establish rules & rates for DVT/PE cases for individual MD profiles.
Quality Dept to establish rules & rates in Midas.
Refine DVT prophylaxis guidelines for medical patients.
K. Posley to review/revise guidelines.
DVT/PE Concurrent Review By Action Team
DVT/PE Rates with SCIP VTE Compliance Comparison by Quarter
Incidence of Medical and Surgical Cases
A graph of the Incidence of Medical and Surgical Cases is shown.
ANALYSIS: The incidence of hospital-acquired DVT/PE of both medical and surgical cases decreased in Qtr 3 2008.
- First quarter 2008 rate 8.37/1000
- Second quarter 2008 rate 14.28/1000
- Third quarter 2008 rate 8.59/1000
ACTION: Retrospective auditing of cases identified by? radiology test is being conducted to assess adherence to guidelines. Process for this is under consideration to move to a concurrent audit to improve patient care and outcomes.
UHC Benchmark: IAP
A graph of the UHC Benchmark: IAP is shown.
CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases
A graph of the CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases is shown.
- Next steps: focus on other causes of IAP: thorascopic lung biopsy, feeding tube placement and EP procedures
CVC Insertion Site
Two graphs are shown.
- Insertion Site of CVC-Related latrogenic Pneumothoraces in Medical Patients
- Insertion Site of CVC-Related latrogenic Pneumothoraces in Surgical Patients
GOAL: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08.
|Promote ultrasound-guided internal jugular (IJ) catheterization as the method of choice for CVC
Limit use of subclavian approach to:
- Access to the neck is limited (e.g., trauma/code resuscitations)
- Patients with suspected neck injuries
- Lack of other available sites
- L. Shieh to revise CVC Website Curriculum & Simulation Program to further promote IJ approach
- Drs. Maggio, Williams, Mihm & Lee to educate ED, OR & General Surgery. Drs. Mihm, Riskin and Daniels to educate ICU. Dr. Shieh to educate B2 & D1.
- I. Tokareva to develop & distribute educational materials to reinforce
Start Jan 22 & ongoing
Require all medical & surgical interns to complete CVC Website Curriculum & Simulation Program during orientation (“Bootcamp” for surgical interns)
- Drs. Shieh, Maggio, Williams, Mihm & Lee
- Monitor quarterly IAP rates for impact
Two publications are shown.
- Prevention of latrogenic Pheumothorax from Central Line Insertion
- Documenting the CVC Procedure Note is Required
PSI: Surviving Sepsis Guidelines
- The evidence
- Early Goal-Directed Therapy
- Initiation of Appropriate Antimicrobial Therapy
- Treatment with Hydrocortisone
- Activated Protein C
- Glucose Control
- Lung Protective Strategies
Performance Improvement Initiative: Severe Sepsis and Septic Shock
- Goal of 2008 SHC Quality Initiative on Severe Sepsis and Septic Shock: Reduce hospital mortality by 10% from Jan 08 to Jan 09
- May 2008: Initial education of ICU Guidelines for Severe Sepsis & Septic Shock
- December 2008:Epic order sets revised to reflect changes in guidelines.
Two publications are shown.
- SHC Critical Care Management Guidlines for Severe Sepsis and Septic Shock
- Critical Care Management Guidlines for Severe Sepsis and Septic Shock
Screen shot - Order Set
Audit of Process Indicators
ANALYSIS: .25% of cases received antibiotics within one hour of identification. Appropriate antibiotics were given in nearly all of the cases. In 40% of the cases, antibiotic were given >120 minutes, in 60% antibiotics were given within 64 minutes on average.
ACTION: Measure process indicators in context of when SS/SS management guideline algorithm started. Map process to determine areas for improvement.
Audit of Process Measures
ANALYSIS: Poor compliance in ordering steroids for cases failing therapy. Steroids were given only 25% of the time. Glucose control was reached in 65% of the cases. Of the 35% of cases with BG > 150, mean BG was 176
ACTION: Educate physicians to document rationale for not giving steroids in next quarterly audit. Work with ICU team, nursing groups to determine root causes for elevated BG>150 after 24 hrs.
Two photos are show. One of a building and the other is 5 Doctors in an operating room.
An image of a chart labeled "Departmental Quality Structure" is shown
An image of "Specific Responsibilities the PPEC is designated to" is shown.
PPEC: Accountable Outcomes
An image of "PPEC: Accountable Outcomes" is shown.
PPEC: Accountable Outcomes SCIP
An image of "PPEC: Accountable Outcomes SCIP" is shown.
PPEC: Accountable Outcomes PSIs
An image of "PPEC: Accountable Outcomes PSIs" is shown.
Use of PSI in PPEC: Post-op Hematoma
An image of "Use of PSI in PPEC: Post-op Hematoma" is shown.
Use of PSI in PPEC: Accidental Puncture or Laceration
An image of "Use of PSI in PPEC: Accidental Puncture or Laceration" is shown.
Persistent Pursuit of Excellence
- Dedicated Monthly Grand Rounds on Quality
- NSQIP based Morbidity and Mortality Conference
- Resident Award for Quality Improvement
- Novel Quality Improvement/Patient Safety Resident Curriculum
- Documentation Improvement Program
- Peer Review
- Surgery Quality Council
- Quality Initiatives: DVT, Sepsis, Iatrogenic Pneumothorax,Vent >48 hours, Colo-rectal Wound Infection
- Rounding Policy
- OR Checklist
An image of a character with text saying "He's Watching you" is shown.
National PSI Rates Morton 2009
A graph Decubitus, Sepsis, Postop Resp, PE/DVT
Clinical Outcomes Report: Product Line Mortality Comparison October 2006 - September 2007
175 Surgical Deaths, Dept of Surgery 71, 2.1%
An image of the "Clinical Outcomes Report" is shown.
||July 2007 to June 2008
|General Surgery Product Line
An image of a building is shown.
Current as of December 2009
Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/Morton.htm