James M. Anderson Center
for Health Systems Excellence
Leveraging the
Recent Advances in
Improvement Science
to Eradicate AKI
Omni Netherlands, Downtown Cincinnati
September 28, 2012
Uma Kotagal, MBBS, MSc
SVP, Quality, Safety and Transformation
Executive Director, James M. Anderson Center
for Health Systems Excellence
James M. Anderson Center
for Health Systems Excellence
523 Bed Medical Center
Admissions/Year – 32,981
900,000 outpatient visits
$143 million externally funded research
$ 1.3 billion dollar endowment
12,000+ employees
Surgical Procedures – 31,000 cases (20% Inpt)
17% average annual growth over past decade
National /International partnerships and affiliates
James M. Anderson Center
for Health Systems Excellence
Core Business strategy at Cincinnati Children’s
• Research-Conduct research to generate new
knowledge that changes the paradigm• Quality Improvement-Reliably apply new and
past knowledge ( evidence) to transform
outcomes
Knowledge for Improvement
James M. Anderson Center
for Health Systems Excellence
Improvement: Learn to combine subject matter knowledge
and profound knowledge in creative ways to develop effective
changes for improvement.
Subject Matter
Knowledge
Profound Knowledge
Improvement
Deming’s System of Profound
James M. Anderson Center
for Health Systems Excellence
Knowledge
Appreciation
of a system
Theory of
Knowledge
Psychology
Understanding
Variation
5
Profound Knowledge: Theory of Knowledge
James M. Anderson Center
for Health Systems Excellence
Appreciation
of a System
Theory of
Knowledge
Psychology
Understanding
Variation
James M. Anderson Center
for Health Systems Excellence
Being the Best at Getting Better
• Focus on the outcomes
• Patients and families as Partners
• Integration and alignment
• Theory of knowledge, Building a learning system
• Respecting the science
• Capacity and capability
• Transparency and Trust
• Learning from other industries
• Prediction and management
• Executing with a sense of urgency
James M. Anderson Center
for Health Systems Excellence
James M. Anderson Center
for Health Systems Excellence
This document is part of the quality assessment activities of Cincinnati Children’s Hospital Medical Center and, as such, it is a confidential document not
subject to discovery pursuant to Ohio Revised Code Section 2305.25 and 2305.251. Any committees involved in the review of this document, as well as
those individuals preparing and submitting information to such committees, claim all privileges and protection afforded by ORC Sections 2305.25,
2305.251 and 2305.28 and any subsequent legislation. The information contained is solely for the use of the individual or entity intended. If you are not
the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information are prohibited.
Chart Updated APR 16 2012 by Tracey Bracke, AC
Source: Chart Review of Random Sample (20 Charts)
James M. Anderson Center
for Health Systems Excellence
Managing by Prediction:
Patient Safety
James M. Anderson Center
for Health Systems Excellence
The Elements of Prediction
•
MEASURABILITY OF OUTCOME – Will it be clear
if the outcome happens or not?
•
COMPARABALE EVENTS – Is it possible to study
outcomes similar to the one being predicted?
•
VANTAGE – Is the person making the prediction
in a position to observe the predictions and
context?
•
OBJECTIVITY – Is the person who is predicting
objective enough to believe either outcome is
possible?
•
IMMINENCE – Is the event to occur in the next
week or years away? Is the prediction before the
event?
•
INVESTMENT – To what degree is the person
predicting invested in the outcome?
•
REPLICABILITY – Is it practical to test the exact
issue being predicted in another situation?
•
KNOWLEDGE – Does the person making the
prediction have accurate knowledge of the
topic? Is the knowledge relevant and accurate?
•
CONTEXT – Is the context clear to the person
predicting?
•
PRE-INCIDENT INDICATORS (PINs) – Are there
detectable pre-incident indicators that will
reliably occur before the outcome?
•
EXPERIENCE – Does the predictor have
experience with the specific topic involved?
The Gift of Fear and Other Survival Signals that Protect Us from Violence:
Gavin De Becker, Dell Publishing, 1997
James M. Anderson Center
for Health Systems Excellence
James M. Anderson Center
for Health Systems Excellence
Sensitivity to Operations
Beyond reducing harm:
Moving toward
Eliminating Harm
James M. Anderson Center
for Health Systems Excellence
Eliminating Events of Harm
Multiple Barriers
- technology, processes, and people - designed to stop
active errors (our “defense in depth”)
EVENTS of
HARM
Active Errors
by individuals
result in initiating
action(s)
Latent Weaknesses
in barriers
PREVENT
DETECT & CORRECT
The Errors
The System Weaknesses
Adapted from James Reason, Managing the Risks of Organizational Accidents, 1997
Variation from standard of care
that results in:
SEC
James M. Anderson Center
Safety
for Health Systems
Excellence
Event
SM
Classification
Serious Safety Event
Event that reaches the patient and results in death,
life-threatening consequences, or serious physical or
psychological injury
Cause Analysis Level: RCA
Precursor Safety Event
Event that reaches the patient and results in
minimal to no harm
Cause Analysis Level: ACA or RCA
Serious
Safety
Events
Precursor
Safety
Events
Near Miss
Event that almost happened - the
error was caught by one last detection
barrier
Cause Analysis Level: Trend, ACA
Near Miss
© 2006, HPI, LLC
Serious Safety Event Reduction
Key Driver Analysis
Outcomes
Reduce
Serious Safety
Events
0.2/10,000 Adjusted
Patient Days by
6/30/10
Key Drivers
James M. Anderson Center
Intervention/Change
for Health
Systems Excellence
Concepts
Lessons Learned
Program
•Safety Stories
•Transparency
•Reinforce Culture Change
•Spread story beyond
organization
•Patient Safety blog
•Share all Action plans
Improved Safety
Governance
•Patient Safety Oversight Group
•Cabinet Leadership
•CSI annual goals
•CCHMC Board focus
Error Prevention System
Cause Analysis Program
Specific Tactical
Interventions
• Error Prevention Training
•Adoption of Behaviors
•Safety Coaches
•Procedural Safety
•Simulation training
•Leadership Behaviors
•Situation Awareness
•Family Engagement
•RCA- continuous improvement
•Transition to Action
•Common Cause data to drive
Strategy
•Effective Action Plans
• 100% UP in OR
•UP for all procedures
•IV infiltrate reduction
•Monitor reliability pilot
•Announce and Count
Outcome
Key Drivers
Error Prevention training
Effective
Error
Prevention
System
Safety Coach program
James M. Anderson
Center
Interventions
for Health Systems Excellence
•Leadership training*
•Staff training*
•Community MD training
•New staff training (achieve
95%)
•Initial pilot units*
•Spread to all units*
•Monthly Safety Coach support
•Focused Safety Coach enhancements
•Unit Level Plans
Procedural Safety
•UP in OR*
•UP throughout system
Simulation Training
•Initial focus in ED*
•Expand capability of Sim Center
•Pilot expansion*
•In-situ across IP
Leadership Behaviors
Situation
Awareness
•Increased event reporting
•Use of Lessons Learned in microsystem
•Support safety Coaches
•Unit level Safety outcomes
•Patient SA across IP
•Microsystem SA spread
•Organization SA pilot
Family Engagement
•Family Engagement Bundle spread
•MRT Activation: revise
James M. Anderson Center
for Health Systems Excellence
James M. Anderson Center
for Health Systems Excellence
Serious Safety Events per 10,000 Adj. Patient Days
Rolling 12-Month Average
Error Prevention Training
Simulation Training Expands
1.8
Events per 10,000 Adj. Patient Days
1.6
Patient
Safety
Tracker
1.4
Desired Direction
of Change
Safety Coach Program
1.2
1.0
0.8
0.6
Surgical
Safety Begins
0.4
aSSERT Began
July 2006
Tenants of
Surgical Safety
aSSERT begins
0.2
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
0.0
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010
** Each point reflects the previous 12 months. Threshold line denotes significant difference from baseline for those 12 months (p=0.05).
** The narrowing thresholds in FY2005-FY2007 reflect increasing census. Adjusted patient days for FY07 were 27% higher than for FY05.
SSEs per 10,000 Adj. Patient Days
Baseline [ 1.0 (FY05-06) ]
Fiscal Year Goals (FY07=0.75 / FY08=0.50 / FY09=0.20)
Threshold for Significant Change
Chart Updated Through 28Feb10 by Bob Carpenter, Legal Dept.
Source: Legal Dept.
James M. Anderson Center
for Health Systems Excellence
Root Cause Analyses
SSE COMMON CAUSES
Total Number of Times each Safety Element Failed
(FY07 – Jan. 2010)
Failure Type
Count
% of times this failure
occurred
Coordination of Care
13
45%
Situation
Awareness
13
45%
Reliable Escalation
7
24%
Family Engagement
6
21%
None of the 4 above
11
38%
James M. Anderson Center
for Health Systems Excellence
Identifying, Mitigating, and
Escalating Patients at Risk
Background
James M. Anderson Center
for Health Systems Excellence
Journey to High Reliability: HROs
•
Preoccupation with Failure
•
Reluctance to Simplify Interpretations
•
Commitment to Resilience
•
Deference to Expertise
•
Sensitivity to Operations
– Find loopholes in system’s defenses, barriers and
safeguards on the frontline.
Maintain Situation Awareness
James M. Anderson Center
for Health Systems Excellence
James M. Anderson Center
for Health Systems Excellence
Situation Awareness?
James M. Anderson Center
for Health Systems Excellence
What is Situation Awareness (SA)?
• Simple Definition:
– Knowing what is going on around you.
– Having a notion of what is important.
– Anticipation of possible future consequences
of the current situation.
Dr. Mica Endsley (1995)
James M. Anderson Center
for Health Systems Excellence
Identifying, Mitigating, and Escalating Patients at Risk
So how do we improve SA at CCHMC?
• Identify patients at risk.
• Mitigate risk with team on unit.
• Escalate risk that is not fully addressed.
James M. Anderson Center
for Health Systems Excellence
Situation Awareness Process
Situation Awareness
1. Gather
Information
“Perception”
↑HR, ↑diarrhea,
parent concern
2. Recognize &
Understand
“Comprehension”
Recognize
dehydration
Progress to
shock if
untreated
3. Anticipate
“Projection”
Decide
Act
James M. Anderson Center
for Health Systems Excellence
Hypotheses to Improve SA
Situation Awareness
1. Gather
Information
“Perception”
Miss Important Systematically Identify
Information
High Risk Patients
2. Recognize &
Understand
“Comprehension”
Miss Context as
Info Not Integrated
3. Anticipate
“Projection”
Wrong
Right
Decision!
Wrong
Prediction
Decide
Communicate Each
Risk to Watchstander
Predict/Mitigate/
Escalate as Team
Act
James M. Anderson Center
for Health Systems Excellence
Prediction:
Patients at Immediate Risk
•
•
•
•
•
PEWS >5
Family raises a concern
Therapy unusual for this team
“Watcher patient”
Communication amongst team not
adequate
James M. Anderson Center
for Health Systems Excellence
Situation Awareness Model
Family
concerns
High risk
therapies
Bedside
Team
Microsystem
Team
Organization
Team
Intern
Watchstander
Senior Resident
MRT
Bedside
nurse
Watchstander
PCF/Manager
Safety Team
(MPS and SOD)
at 800, 1600 & 100
PEWS>5
Watcher
Reliable escalation of risk
Communication
concern
Attending
Rapid assessment and
communication with
primary team
James M. Anderson Center
for Health Systems Excellence
Situation Awareness Algorithm. Illustrates the tool used during education and early
phases and the specific questions and communication pathways.
James M. Anderson Plan
Center
Identify the Patient, Make a Specific
for Health Systems Excellence
Robust Planning Tool
• Elements of “Robust Plan”
– Identifying the problem or
concern
– Making responsible parties
aware
– Forming a plan
– Predicting an expected
outcome within a fixed
amount of time
– Deciding on an escalation
and contingency plan if
outcome is not met in time
James M. Anderson Center
for Health Systems Excellence
Process Measure Run Charts illustrating the percentage of units by week that escalate risk
on ≥90% of shifts.
James M. Anderson Center
for Health Systems Excellence
Process Measure Run Charts illustrating the percentage of units by week that identify
≥90% of patients at risk each shift.
Escalations
Average Weekly Escalations
Week Ending Date
Control Limits
09/18/10
09/11/10
09/04/10
08/28/10
08/21/10
08/14/10
08/07/10
07/31/10
07/24/10
07/17/10
07/10/10
07/03/10
06/26/10
06/19/10
06/12/10
06/05/10
05/29/10
05/22/10
05/15/10
05/08/10
05/01/10
04/24/10
04/17/10
80
04/10/10
04/03/10
03/27/10
Escalations
James M. Anderson Center
for Health Systems Excellence
Not Fully Addressed SA Bundle Concerns
120
100
5/2/10 Change in data
collection process
60
40
20
0
0
Rate
Median
Updated through August 31 2012 by K. Simon
James M. Anderson Center for Health Systme s Excellence
Goal
Aug 12 n=6192
Jul 12 n=7024
Jun 12 n=7314
May 12 n=7354
Apr 12 n=7374
Mar 12 n=7954
Feb 12 n=7401
Jan 12 n=7400
Dec 11 n=6662
Nov 11 n=6767
Oct 11 n=7275
Sep 11 n=6721
Aug 11 n=6794
Jul 11 n=6501
Jun 11 n=6528
May 11 n=6998
Apr 11 n=6864
Mar 11 n=7356
Feb 11 n=6793
Jan-11 n=6544
Dec-10 n=6075
Nov-10 n=6443
Oct-10 n=6983
Sep-10 n=6742
Aug-10 n=6850
Jul-10 n=6356
Jun-10 n=6361
May-10 n=6689
Apr-10 n=6599
Mar-10 n=7067
Feb-10 n=6671
Jan-10 n=7040
Rate per 10,000 Non-ICU Base Inpatient Days
James M. Anderson Center
for Health Systems Excellence
Rate of UNSAFE Transfers
UNrecognized Situation Awareness Failure events
Per 10,000 Non-ICU Base Inpatient Days
10
9
8
7
6
5
4
3
2
1
James M. Anderson Center
for Health Systems Excellence
Hospital Wide System for Safety
3 Times - Every Day
Individual Room / Floor / System Predictions – Capacity and Safety
Floor Huddles
PeriOp Huddle
ED Huddle
ICU Huddles
Institutional Wide Bed Huddle – Capacity Management
Pharmacy
Pt. Transport
Security
Institutional Wide Safety Call
Housekeeping
System Prediction – Mitigation Strategy
Pt
Experience
Facilities
Leadership Outcomes and Prediction Meeting
CEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Hospital Wide System for Safety
3 Times - Every Day
Individual Room / Floor / System Predictions – Capacity and Safety
Floor Huddles
PeriOp Huddle
ED Huddle
ICU Huddles
Institutional Wide Bed Huddle – Capacity Management
Pharmacy
Pt. Transport
Security
Institutional Wide Safety Call
Housekeeping
System Prediction – Mitigation Strategy
Pt
Experience
Facilities
Leadership Outcomes and Prediction Meeting
CEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Hospital Wide System for Safety
3 Times - Every Day
Individual Room / Floor / System Predictions – Capacity and Safety
Floor Huddles
PeriOp Huddle
ED Huddle
ICU Huddles
Institutional Wide Bed Huddle – Capacity Management
Pharmacy
Pt. Transport
Security
Institutional Wide Safety Call
Housekeeping
System Prediction – Mitigation Strategy
Pt
Experience
Facilities
Leadership Outcomes and Prediction Meeting
CEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Hospital Wide System for Safety
3 Times - Every Day
Individual Room / Floor / System Predictions – Capacity and Safety
Floor Huddles
PeriOp Huddle
ED Huddle
ICU Huddles
Institutional Wide Bed Huddle – Capacity Management
Pharmacy
Pt. Transport
Security
Institutional Wide Safety Call
Housekeeping
System Prediction – Mitigation Strategy
Pt
Experience
Facilities
Leadership Outcomes and Prediction Meeting
CEO, CFO, CMO, CNO, SIC, Sr VP’s, Safety Director
Systematically & Reliably
Identify
patients at risk
Mitigate risk on
unit
Escalate risk
that is not fully
addressed
Predict course
of most at risk
patients
Learn from
each event
James M. Anderson Center
for Health Systems Excellence
BEING THE BEST AT
GETTING BETTER
James M. Anderson Center
for Health Systems Excellence
To learn more about our work visit:
www.cincinnatichildrens.org/andersoncenter