WebEx Quick Reference

Transcription

1 Gordon Gordy Schiff, MD Kathy Duncan, RN These presenters have nothing to disclose WebEx Quick Reference Welcome to today s session! Please use Chat to All Raise your hand Participants for questions For technology issues only, please Chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Select Chat recipient Enter Text 2 1

2 When Chatting Please send your message to All Participants 3 Agenda Welcome and Introductions The Expedition Process Overview of Critical Values Communication Assignment & Planning for Next Session Final Questions & Close 2

3 Chat Time! What is your goal for participating in this Expedition? 5 Join Passport to: Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements. Train your middle managers to effectively lead quality improvement initiatives. Enhance your strategic planning with customized whole systems data and selected benchmarking information.... and much, much more for $5,000 per year! Visit for details. To enroll, call or improvementmap@ihi.org. 3

4 What is an Expedition? ex pe di tion (noun) 1. an excursion, journey, or voyage made for some specific purpose 2. the group of persons engaged in such an activity 3. promptness or speed in accomplishing something Where are you joining from? 4

5 Our Expedition Director Kathy D. Duncan, RN, Faculty, Institute for Healthcare Improvement (IHI), is co-leader of IHI's National Learning Network and coordinates the Improvement Map support care processes. Previously she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. Ms. Duncan was responsible for the Prevention of Pressure Ulcers and Deployment of Rapid Response Teams content areas for the 5 Million Lives Campaign. She is a member of the Scientific Advisory Board for the AHA NRCPR, NQF's Coordination of Care Advisory Panel, and NDNQI's Pressure Ulcer Advisory Committee. She has served in a variety of staff and management positions, including director of critical care for a large community hospital, where she led an initiative to decrease ICU mortality and morbidity by reducing ventilator-associated pneumonia and ICU length of stay. What We Expect of You All Teach, All Learn philosophy Join and participate on all calls Participate in the listserv discussion Test, test, test Share what you ve learned (challenges as well as successes and insights) 5

6 Overall Program Aim The overall goal of the Expedition is for participants to build the foundation of an efficient process for communicating critical tests results consistently and promptly. 11 Objectives Upon completion of this expedition, participants will be able to: Identify opportunities to improve their current process of communicating critical test results Identify safe practice recommendations for communicating critical test results Develop a reliable process for communicating critical test results 12 6

7 Gordon Gordy Schiff, MD 13 Gordon Gordy Schiff, MD, Associate Director, Center for Patient Safety Research and Practice, Brigham and Women s Hospital, is also Associate Professor of Medicine at Harvard Medical School. He is a founding member and past president of Physicians for a National Health Program (PHNP), and he is author of PNHP s JAMA paper on quality health care reform. Dr. Schiff was previously professor of medicine at Rush University and senior attending physician at Cook County Hospital, where he worked for more than 30 years as director of clinical quality research and improvement for the department of medicine. During the 1990s he was director of Cook County s large general medical clinic. He is clinical director of the recently awarded TOP-MED (Tools for Optimizing Prescribing, Monitoring and Education) CERT (Center for Education and Research in Therapeutics) based at the UIC College of Pharmacy. Outline Personal introduction 3 studies Theophylline Potassium TSH Review of selected literature Methods Studies Reliability science Key concepts for results management 6 requirements to reliable test result f/up 7

8 Abnormal Lab Belatedly Discovered -67 y.o. woman w/ hx of HBP, COPD, asymptomatic gallstone -Presents acute MI -Develops CHF, treated w/ usual meds including digoxin, diuretic, theophylline -Acute nausea vomiting abdom pain, rushed to operating room for cholecystectomy -Chart review 1 yr later--theophylline level Schiff Ann Intern Med 1990 ERROR (N=40) # % Delay (>10 hrs) toxic level draw to MD action 20 50% Excessively high (>1.5) doses CHF, liver dis 17 43% Miss obvious GI,CNS,cardiac sx/signs toxicity 16 40% Recurrent toxicity: unaware; failure adjust dose 11 28% Dosing errors for non CHF pts 9 23% ED rx despite pretreatment level already toxic 6 15% Inadvertent overlap of i.v. and p.o. rx 6 15% Interacting drugs (w/ failure to adjust dose) 5 13% Discharged on same dose came in toxic 5 13% Discharged w/ no noted MD awareness of toxicty 4 10% Theophylline Toxicity, Schiff, Ann Internal Med

9 Schiff, Am J Med 2000 Potassium Prescriptions N = 32,563 (12,825 unique patients) Potassium Levels 5.3 N = 9,790 (4,188 patients) Positive Screen = Match Found in Both Databases N=1,781 Prescriptions (701 Unique Patients) Detailed Review all Potassium Levels Last K 5.3 N= % Same Day K 5.3 N= % No Error N=1107 NAME UNITNO DATE RESULT GENERIC_NM QUANTITY JEFFERSON, RUTH /06/ JEFFERSON,RUTH /11/95 POTASSIUM CHLORIDE 100 JONES, BILL /11/ JONES, BILL /20/95 POTASSIUM CHLORIDE 60 SMITH, MARY /16/ SMITH, MARY /16/95 POTASSIUM CHLORIDE 30 SMITH, MARY /19/ STOKES,WILL /03/95 POTASSIUM CHLORIDE 30 STOKES,WILL /03/ CULLEN, CORA /30/ CULLEN, CORA /01/95 POTASSIUM CHLORIDE 14 CULLEN, CORA /12/95 POTASSIUM CHLORIDE 60 CULLEN, CORA /14/95 POTASSIUM CHLORIDE 30 PABST, POLLY /11/ PABST, POLLY /12/95 POTASSIUM CHLORIDE 240 KENNEDY,JOE /22/ KENNEDY,JOE /06/95 POTASSIUM CHLORIDE 240 KENNEDY,JOE /05/ KENNEDY,JOE /09/ KENNEDY,JOE /10/95 POTASSIUM CHLORIDE 20 KENNEDY,JOE /23/ KENNEDY,JOE /24/95 POTASSIUM CHLORIDE 30 9

10 SMITH, MARY /16/95 POTASSIUM CHLO SMITH, MARY /19/ STOKES,WILL /03/95 POTASSIUM CHLO STOKES,WILL /03/ CULLEN, CORA /30/ CULLEN, CORA /01/95 POTASSIUM CHLO CULLEN, CORA /12/95 POTASSIUM CHLO CULLEN, CORA /14/95 POTASSIUM CHLO PABST, POLLY /11/ PABST, POLLY /12/95 POTASSIUM CHLO KENNEDY,JOE /22/ KENNEDY,JOE /06/95 POTASSIUM CHLO KENNEDY,JOE /05/ KENNEDY,JOE /09/ KENNEDY,JOE /10/95 POTASSIUM CHLO KENNEDY,JOE /23/ KENNEDY,JOE /24/95 POTASSIUM CHLO Potassium Level Most Recent Value High Same Day High Total % N % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % > % % Total % = or > K+ Level 10

11 TSH > Schiff Arch Intern Med 2005 On Thyroxine 390 No Thyroxine 80 Hyperthyroid Rx 17 Hypothyroid 63 Rx Outside Pharmacy 17 Baby 3 No Rx 19 Missed Dx Hypothyroidism 12 (2.6%) Lost F/up; Died (5.7%) 27 +/-Awareness (0.9%) 4 Year N % N % Total TSH done 22,076 24,524 Unique patients 17,467 19,293 TSH levels > 20 1, TSH > 20 unique patients On thyroxine No thyroxine % % Hyperthyroid Rx % % Rx outside pharmacy % % No Rx % % Lost F/up or died % % Babies 3 3 Awareness but failed F/up 4 2 Missed Dx hypothyroidism % % 11

12 Year N % N % Total TSH done 22,076 24,524 Unique patients 17,467 19,293 TSH levels > 20 1, TSH > 20 unique patients On thyroxine No thyroxine % % Hyperthyroid Rx % % Rx outside pharmacy % % No Rx % % Lost F/up or died % % Babies 3 3 Awareness but failed F/up 4 2 Missed Dx hypothyroidism % % Every system is perfectly designed to deliver the results it does Don Berwick IHI Perfectly designed system to miss 12 patients a year (and lose another 27 follow-up) 12

13 Poon Arch Intern Med

14 150,000 Missed Tests/Yr 2.5 Missed Results per MD = 25,000 Harvard CRICO MD s Poon Arch Intern Med 2004 Methods to Measure Failed Test Result Follow-up MD survey- how often missing results Chart review: failure, delay in documenting result Patient survey- whether aware of result Failure follow-up action as signal Tracer studies-working backward from dx Action suggesting unaware of result Linking pharmacy data Malpractice studies PRO Citations Lab Frustrations 14

15 Methodologic Issues Time frame; abnormal criteria Type of result (Lab, x-ray, other) Inpatient vs. outpatient vs. ED Labs at discharge Failure to document vs. failure to act MD notification by lab vs. Pt notification by MD Recall biases Generalizability: VA, academic centers Denominators Notification vs. Action Lost letters; unopened electronic messages Follow-up action in future Casalino Arch Intern Med

16 Singh Arch Intern Med 2009 Acknowledged Alerts for Abnormal Imaging Exams No Better in Timely Follow-up Lack of Timely f/up N=92 (7.7%) Timely F/up N=1104 (92.3%) Acknowledged 71 (77.2) 908 (82.2) Not Acknowledged 21 (22.8) 196 (17.8) Singh Arch Intern Med

17 Gordon Ann Intern Med

18 Reliability Science 10 Key Improvement Concepts 1. Situational awareness and anticipation of needs 2. Need for closed-loop 3. Attention to hand-offs and teamwork 4. Continuous flow systems w/out batching 5. Doing everything just-in-time 6. Culture of stopping to fix problems 7. Forcing functions, simplification, standardization 8. Visual cues- facilitate work, ensure probs not hidden 9. Use only reliable thoroughly tested technology 10.Go see for self to thoroughly understand (Genchi Genbutsu) Schiff, JAMA

19 High Reliability Results Management 1. Track tests from ordering to completion to receipt/acknowledgement and action on results. 2. Standardized approach for all test areas to define and flag clinically significant abnormal results 3. Eliminate ambiguities regarding how to return a result or who to contact High Reliability Results Management 4. Patients should be informed about all test results, even normals 5. Importance of tracking and system oversight monitoring 6. Advanced systems to support clinicians in result management activities 19

20 Questions? Raise your hand or Use the chat box The Model for Improvement Critical Values Reporting and Communication July 26,

21 Fundamental Questions for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Langley, G.J., Nolan, K.M., Nolan, T.W, Norman, C.L., & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd Ed.). San Francisco: Jossey-Bass. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do From:: Associates in Process Improvement 21

22 The PDSA Cycle for Learning and Improvement Source: Improvement Guide p 60 Act - What changes are to be made? - Next cycle? Study - Complete the analysis of the data - Compare data to predictions - Summarize what was learned Plan - Objective - Questions and predictions (Why?) - Plan to carry out the cycle (who, what, where, when) - Plan for Data collection Do - Carry out the plan - Document problems and unexpected observations - Begin analysis of the data Repeated Use of the Cycle Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? A P S D Changes That Result in Improvement A P S D Hunches Theories Ideas Source: Improvement Guide, p 10 22

23 Successful Cycles to Test Changes Plan multiple cycles for a test of a change Think a couple of cycles ahead Initially, scale down size of test (# of patients, clinicians, locations) Test with volunteers Do not try to get buy-in or consensus for test cycles Be innovative to make test feasible Collect useful data during each test In latter cycles, test over a wide range of conditions Question #1: What are we trying to accomplish? Developing the team s Aim Statement 23

24 What are we trying to accomplish? Defines the aim of the improvement effort. Time specific and measureable. Aim Example Reduce adverse drug events (ADEs) in critical care by 75% within 1 year. Increase the number of surgical cases between cases with a surgical site infection by 50% within 1 year. Reduce the average length of stay for Medical ICU patients by 50% within 9 months. 24

25 Tips for Creating Aim Statements State the aims clearly (What do you want to accomplish? How good, by when?) Define location or population Set stretch goals Include numerical goals/targets 49 Homework: Due Next week Assess Current work State your Aim Simple What, Where, By when State 2 measures How do you know you have made an improvement? 25

26 Things to Consider in Aim Setting What happens to results that return after patient discharged? Who is responsible and what is process for incidental finding on pre-op CXR? What happens when the ordering MD does not answer page for panic result? How are cross coverage test result issues handled? When is the PCP vs. specialist responsible for results of tests specialist orders? What does it mean to have a test acknowledged? How are patients informed of test results; how documented? 51 Things to Consider in Aim Setting How do you insure that proper follow-up occurs ( repeat in 6 mos )? What happens when test result is returned to an MD and he/says this is not my patient? Are there ways to know when a normal result (e.g. INR) is not normal? Are there ways to link test results to drugs (elevated CPK on statin)? How easy do you make it for your clinicians, in and outpatient, to manage results? How do you handle results that return to the ED for a patient who has been admitted? 26

27 Volunteers Upcoming Sessions Session 2: August 2, 2:00 PM 3:00 PM ET Topic: Getting Started Session 3: August 23, 2:00 PM 3:00 PM ET Topic: Developing Your Aim Statement Session 4: September 6, 2:00 PM 3:00 PM ET Topic: Testing Process Changes Session 5: September 20, 2:00 PM 3:00 PM ET Topic: Safe Practice Recommendations Session 6: October 4, 2:00 PM 3:00 PM ET Topic: Participant Report-outs and Continuing Your Work 54 27