Temple University Hospital House Staff Orientation

1. Temple University HospitalHouse Staff Orientation High Value Care Susan L. Freeman, MD, MS Chief Medical Officer Temple University Health System June/July, 2013

2. PART ONEHigh Value Care What is it?

3. The Triple Aim Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)

4. Value Proposition High value health care = high quality outcomes / low cost High value can only occur if: • The culture supports communication, collaboration and consistently safe care • Frontline employees and physicians (including house staff) are engaged at every level • The entities of the health system are aligned from Board to bedside

5. TUHS Value Construct Quality Construct High Value Care, Every Patient, Every Day Engineering And Design Execution And Diffusion Culture Infrastructure: Integrated Care Across The Continuum Electronic Communication and Health Information Adopted from the Mayo Clinic Value Construct Model, 2012

6. High Value Care Are we consistently delivering it?

7. Wrapping Your Head Around the Problem of Medical Errors • To Err is Human – the landmark report of the IOM in 1999 – up to 98,000 people die each year in the U.S. from medical errors.

8. The Numbers are Staggering • Every day and a half a fully loaded 747 would have to fall from the sky before the airline passenger loss of life would surpass that of hospitals

9. Adverse Events at TUH • Wrong site surgery • Retained sponge • Medication errors • Falls • Infections • Death SERIOUSLY?

10. Healthcare QUALITY begins with PATIENT SAFETY Kenneth Kaiser, MD, MPH National Quality Forum Freedom from injury Consistent care 24 x 7 x 365 Seamless transitions/handoffs Informed, satisfied patients Transparency in care and data Open, honest, non- punitive reporting A culture obsessed with safety

11. Defining Quality No needless deaths No needless pain or suffering No unwanted waits No helplessness No waste For Anyone…. Institute for Healthcare Improvement

12. The Six Dimensions of Quality Patient Safety Patient Centeredness Timeliness Effectiveness Efficiency Equity From the IOM: Crossing the Quality Chasm (2001)

13. Why So Many Errors? • Why are hospitals unsafe? • Why are errors made? • Can they be prevented?

14. Humans Make Errors You are sitting on the unit entering orders after rounds There are a series of orders for different patients Midway through, your cell phone goes off. You take the call. You turn back to the ordering tasks and pull up Mr. Jones. You order 100mg of methadone orally. The medication is administered to Mr. Jones. Two hours later you get a call from the nurse, that Mr. Smith wants to know where his methadone is. You realize at that point that you ordered methadone on the wrong patient. Distraction Human Error

15. Human Factors • Human information processing is influenced by multiple factors: • Attention – may be limited in duration or focus • Memory constraints – working memory is limited • Automaticity – consistent, over-learned responses may become automatic, and completed without conscious thought • Situation awareness – a person’s perception of elements in the environment may affect their processing of information (Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science 1974; 185:1124-31)

16. Human Factors and Bias • Pattern matching instead of careful reasoning • What has worked before is used when there is uncertainty • Availability heuristic – giving undue weight to facts that come readily to mind, and ignoring that which is not immediately present • Confirmation bias – once a decision is reached, there is a tendency to seek evidence to support it • Selectivity – focus of attention on what is logically important vs. what is psychologically salient • Frequency gambling – betting on the condition that occurs most frequently

17. Human Error • An unsafe act is “an error or a violation committed in the presence of a potential hazard” • Two categories: errors and violations (James Reason, Human Error, 1990)

18. Errors and Violations Errors Violations A deliberate deviation from an operating procedure, standard or rule An action does not go as intended An action goes as intended, but it’s the wrong action Lapse Slip Mistake (James Reason, Human Error, 1990)

19. Human Factors • Humans will always make mistakes regardless of training, experience and determination • Human infallibility is impossible • Those who build systems that depend on the absence of human error will fail John Nance. Why Hospitals Should Fly. 2008, page 45

20. Systems are Designed to Prevent Errors from Reaching the Patient • What is a system? • A series of actions that, when followed, provides for the delivery of safe care to every patient, every time • Codified in policies, procedures, standard order sets, check lists • A series of redundancies that provides multiple check points • An order is written, checked by the pharmacy, checked by the nurse, reconciled with the medication list

21. Redundant Processes (James Reason) Each layer is a defense against potential error impacting the outcome

22. Failure at Every Level Circumstances in which planned actions fail to achieve the desired outcomes

23. Culture of Safety • Shared perceptions and actions around what is good, right, important, valued, supported, rewarded and expected • Culture is shaped by the alignment of people and systems; attitudes; knowledge; practices; leadership; trust; accountabilities; and a commitment to safety • Culture is linked to outcomes – strong culture decreases medication errors, hospital acquired UTI’s, nurse turnover and absenteeism, nurse satisfaction, malpractice claims, back injuries, patient satisfaction, needle sticks Halligan, M. and A. Zecevic. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. QualSaf Health Care/. 2011. doi:101136/bmjqs.2010.040964.

24. High Value Care Evidence-Based care delivered efficiently, at the highest standard in the absence of error or adverse event by a team that has created a culture to support superior outcomes.

25. High Value Care How is this accomplished? KNOW THE SYSTEM

26. High Value Care Communication Care Delivery Hospital Acquired Conditions Risk Management

27. Breakout Sessions • 319A Risk Management • 319B Care Delivery • 319C Quality and Hospital Acquired Conditions • 319D Communication

28. PART TWOHigh Value Care THE TOP TEN

29. House Staff Orientation:TOP TEN • Patient safety and quality of care are the top priorities • Humans make errors • Systems are designed to prevent those errors from reaching the patient (processes, policies, best practices) • Systems only work in the presence of individual accountability • The majority of errors occur because of lack of communication • Teamwork is vital – it takes a village - use the resources and expertise available (Nurses, CM, RM, PT, Pharmacy, etc.) • Basic medication safety rules, consent, documentation • Universal protocol • Infection prevention • The patient and the patient’s well being must be at the center of everything you do – it’s about the patient experience and the clinical outcomes Adopted from: Tsilimingras, et.al. The Challenge of Developing a Patient Safety Curriculum for Medical School. Med Sci Edu2012;22(2):65-72.

30. Keep the Patient at the Center of Everything You Do

31. The National Agenda: The Triple Aim Berwick, et.al. The Triple Aim: Care, Health and Cost. Health Affairs. 2008;27:3(759-69)

32. Get Involved in Quality and Safety RESIDENT INTEGRATION INTO QUALITY

33. PATIENT SAFETY You Are The Key to Preventing Medical Errors AND Providing Safe, Quality Patient Care