Enhancing Patient Safety and Quality: Evidence-based Design Meets Patient Safety

Slide Presentation from the AHRQ 2009 Conference

On September 16, 2009, John G. Reiling made this presentation at the 2009 Annual Conference.

Select to access the PowerPoint® presentation (2.3 MB).


Slide 1


 

Enhancing Patient Safety and Quality: Evidence-based design meets patient safety

September 2009

John G. Reiling
President/CEO

 

Slide 2


 

Image: A comic is displayed that says "I was making $100,000 a year, I had 75 people under me, a condo in Aspen, and was being considered for the Senate, and then I switched to Decaf.

 

Slide 3


 

Image: Book Cover titled "To Err is Human".

 

Slide 4


 

Background - IOM Report

  • The risk of dying as a result of medical error far surpasses the risk of dying in an airline accident.
  • Death on domestic flights: 1 in 8,000,000 flights.

 

Slide 5


 

Background - IOM Report (continued)

  • Death in hospitals from medical errors:
    1 in 343 admits to 1 in 764 admits.
  • Adverse Events in Hospitals
    1 in 27 admits to 1 in 34 admits.

 

Slide 6


 

Image: Book Cover titled "Managing the Risks of Organizational Accidents - James Reason".

 

Slide 7


 

The National Learning Lab

The participants:

  • AHA
  • AMA
  • AphA
  • ASQ
  • Center for Patient
  • Safety at VA
  • IHI
  • ISMP
  • JCAHO
  • MGMA
  • NPSF
  • PSI
  • WHA
  • UW-Milwaukee
  • University of MN
  • VHA

 

Slide 8


 

National Advisory Committee (Invitees)

Jim Adams, Exec. Director & Fellow, IBM Center of Healthcare Management
Frank T. Brogan, President, Florida Atlantic University
Carolyn Clancy, MD, MPH, Director of Agency for Healthcare Research & Quality
William F. Coyne, PhD., Former Senior VP for R&D for 3M, Healthcare for 3M, and 3M Canada
Tim Flaherty, M.D., Past Chairman, NPSF & Past Chair of American Medical Association
Lillee Smith Gelinas, RN, BSN, MSN, FAAN, Vice President & Chief Nursing Officer of VHA, Inc.
Pascal Goldschmidt, MD, Senior Vice President & Dean, University of Miami Miller School of Medicine
Donald Holmquest, M.D., Ph.D., J.D., President & CEO of California Regional Health Information Org
Beverly Johnson, President & CEO, Institute for Family Centered Healthcare
Lucian L. Leape, MD, Adjunct Professor, Harvard Univ. School of Public Health
Kathy Malloch, PhD., MBA, RN, FAAN, Pres of Malloch & Assoc & Director of the MHI Program at ASU
David Marx, J.D., President of Outcome Engineering, LLC
David Nash, M.D., M.B.A., FACP, Chairman, Jefferson Medical College, Thomas Jefferson University
Richard Norling, Chief Executive Officer and Director of Premier, Inc.
Dennis O'Leary, President Emeritus of Joint Commission
Paul O'Neill, Former Secretary of the U.S. Treasury
Mary A. Pittman, Ph.D., American Hospital Association & Current President of the Public Health Institute & Past President of the Health Research and Educational Trust
William Rupp, MD, Past President of Luther Midelfort & Immanuel St. Joseph's-Mayo Health Systems & Institute for Healthcare Improvement
Donna E. Shalala, Ph.D, President, University of Miami
Gail Warden, President Emeritus, Henry Ford Health Systems
Bennet Waters, D.H.A., Chief of Staff for the US Dept. of Homeland Security, Office of Chief Medi Officer

 

Slide 9


 

Human Factors/Safety in Healthcare

  • The environment affects performance. (facilities, equipment, technology)
  • The processes affect performance.
  • The culture affects performance.

 

Slide 10


 

Human Factors/Safety in Healthcare

  • You can design environments, culture, and processes.

 

Slide 11


 

Human Factors/Safety in Healthcare

  • Focus environments, processes, and culture on safety and quality by:
    • Minimizing risk of failure
    • Evidence-based medicine.

 

Slide 12


 

What Practices Will Most Improve Safety?

  • Evidence-based medicine meets patient safety.

 

Slide 13


 

Design Recommendations

  • Latent Conditions:
    • Noise Reduction
    • Scalability, Adaptability, Flexibility
    • Visibility of Patients to Staff
    • Patients Involved with Their Care
    • Standardization
    • Automate Where Possible
    • Minimize Fatigue
    • Immediate Accessibility of Information, Close to the Point of Service
    • Minimize Handoffs
    • Minimize Patient Movement
    • Communication

 

Slide 14


 

Lean Principles

  • Continuous Flow
  • Pull vs. Push
  • Standardize Work
  • Visual Control
  • Proven Technology
  • Culture of Stopping to Fix Problems
  • Get Quality Right the First Time

 

Slide 15


 

Design Recommendations

  • Active Failures
    • Operative/Post-Op Complications/Infections
    • Events Relating to Medication Errors
    • Deaths of Patients in Restraints
    • Inpatient Suicides
    • Transfusion Related Events
    • Correct Tube-Correct Connector-Correct Hole
    • Patient Falls
    • Deaths Related to Surgery at Wrong Site
    • MRI Hazards

 

Slide 16


 

Process Recommendations

 

Slide 17


 

Creating a Culture of Safety

  • Matrix Development (Post Learning Lab)
  • FMEA at Each Stage of Design
  • Patients/Families Involved in Design Process
  • Equipment Planning Day 1
  • Mock-ups Day 1
  • Design for the Vulnerable Patient
  • Articulate a Set of Principles for Measurement
  • Establish a Checklist for Current/Future Design

 

Slide 18


 

Results of the AHRQ Grant #UC1 HS15384

All latent conditions studied improved with the exception of fatigue:

  • Noise Reduction
  • Scalability, Adaptability, Flexibility
  • Visibility of Patients to Staff
  • Patients Involved with Their Care
  • Standardization
  • Automate Where Possible
  • Minimize Fatigue
  • Immediate Accessibility of Information, Close to the Point of Service
  • Minimize Handoffs
  • Minimize Patient Movement

 

Slide 19


 

Results of the AHRQ Grant #UC1 HS15384

Medication Errors Observation Study 2004 (pre) - 2009 (post)

Department W/out Wrong Technique W/Wrong Technique
ER -58% +51%
Medical/Surgical -21.2% -16.5%
ICU -63.0% -26.0%

 

Slide 20


 

Results of the AHRQ Grant #UC1 HS15384

Adverse Drug Events 

Department 2004 (pre) 2007 (post) % Decline
Medical/Surgical 17.9% 2.8% 84%
ICU 12.9% .5% 96%
Preventable Adverse Drug Events
Department 2004 (pre) 2007 (post) % Decline
Medical/Surgical 13.1% .4% 97%
ICU 6.9% 0% 100%

 

Slide 21


 

Results of the AHRQ Grant #UC1 HS15384

Incidence Report for ADEs

Department Preventable All ADEs
Medical/Surgical -97.0% -84.0%
ICU -100% -96%

 

Slide 22


 

Results of the AHRQ Grant #UC1 HS15384

Graph: Medication Safety Reports Greater than Category "D" Tallies (not including ADR's)

 

Slide 23


 

Results of the AHRQ Grant #UC1 HS15384

  • Infections: The only consistent data recorded for infections during the 5 years of this study were for ventilator pneumonia and surgical site infections.

Infections - Surgical Site

Department 2002 (pre) 2009 (post) % Decline
Surgical Site Infections (procedures) 3.6% .5% 76.2%

 

Slide 24


 

Results of the AHRQ Grant #UC1 HS15384

Graph: Surgical Site Infection Percentage by Year

 

Slide 25


 

Results of the AHRQ Grant #UC1 HS15384

  • Infections: The only consistent data recorded for infections during the 5 years of this study were for ventilator pneumonia and surgical site infections.

Infections - Ventilator Pneumonia

Site 2002 2003 2004 2005 2006 2007 2008
Ventilator Pneumonia (days) 5.6% 10.9% 5.6% 11.5% 0.0% 2.6% 3.9%

 

Slide 26


 

Results of the AHRQ Grant #UC1 HS15384

Graph: Ventilator Pneumonia Rate 2002 through 2008

 

Slide 27


 

Results of the AHRQ Grant #UC1 HS15384

Patient Falls
The number of patient falls steadily declined during the study period, from 149 to 31 (almost 80%), with one spike in 2006 of 115 falls (the new hospital opened in 2005).

 

Slide 28


 

Results of the AHRQ Grant #UC1 HS15384

Graph: # of Patient Falls Reported per Year 2002 - 2008

 

Slide 29


 

Results of the AHRQ Grant #UC1 HS15384

Transfusion Related Events
The number of transfusion events stayed consistent throughout the study period, at .3%. Almost all of these were considered not preventable.

 

Slide 30


 

Results of the AHRQ Grant #UC1 HS15384

Graph: # of Transfusion related events

 

Slide 31


 

Results of the AHRQ Grant #UC1 HS15384

Graph: # of Transfusion related events

 

Slide 32


 

Results of the AHRQ Grant #UC1 HS15384

  • Deaths of Patients in Restraints
  • Inpatient Suicides
  • Correct Tube-Correct Connector-Correct Hole
  • Deaths Related to Surgery at Wrong Site
  • MRI Hazards

These adverse events had Zero occurrences in 2002 and the incidence rate stayed at Zero during the study period ending 2008.

 

Slide 33


 

Results of the AHRQ Grant #UC1 HS15384

Lean/Six Sigma Process Redesign

  • Continuous Flow
  • Pull vs. Push
  • Standardize Work
  • Visual Control
  • Proven Technology
  • Culture of stopping to fix problems
  • Get quality right the first time

 

Slide 34


 

Results of the AHRQ Grant #UC1 HS15384

Safety Culture

  • Shared Values/Beliefs about Safety within the Organization
  • Always Anticipating Precarious Events
  • Informed Employees and Medical Staff
  • Culture of Reporting
  • Learning Culture
  • "Just" Culture
  • Blame-Free Environment Recognizing Human Infallibility
  • Physician Team Work
  • Culture of Continuous Improvement
  • Empowering Families to Participate in Care of Patients
  • Informed & Activated Patient
Current as of December 2009
Internet Citation: Enhancing Patient Safety and Quality: Evidence-based Design Meets Patient Safety: Slide Presentation from the AHRQ 2009 Conference. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/reiling/index.html