SaferPatients

Allstate Insurance had a great ad during the Super Bowl - showing all the mayhem that has happened throughout history after Eve ate the apple in the Garden. Watch the video here.

Mayhem does happen. Even if we don’t want it to. Just look at the amount of patient harm in our nation’s hospitals.

Allstate won’t prevent that harm. But you can - with a really great system of care that has high reliability processes and a culture of safety that holds everyone accountable to use those standard processes.

Mayhem happens. You have the tools to stop it. Time to get busy.

At the Weill Cornell College of Medicine, new doctors-in-training are learning communication and teamwork skills right alongside their medical skills. Cornell has integrated simulated practice and role-plays into their medical education and training. Students learn to effectively use human factor skills when communicating with patients because numerous studies have shown that the better physicians can create rapport with patients, the more effectively the patient will follow their medical advice.

In the learning center where simulations occur, a central observation area is outfitted so that faculty can observe students practicing with the actor-patients; there are one-way mirrors and the technology to support wireless headsets so that instructors can change the audio channels to observe several rooms simultaneously. Rooms are also outfitted with AV equipment and microphones so that every interaction is recorded. This creates a longitudinal database so that students and professors can track their progress and ensure that practice has a positive outcome on student performance in medical school and beyond. This is an important point - practice sessions are taped for study and learning.

Football coaches have long analyzed game tape, but taping practice is actually more important. Part of building a culture of practice is videotaping practice; it sends the message that improvement through practice matters.

Cornell uses the lens of practice and feedback for all aspects of their program.

After each training session the actor-patient breaks out of the role and, using a detailed checklist, gives the medical student three pieces of very explicit feedback. Following feedback from the actor-patient, each student debriefs with faculty for more performance feedback. Finally, the students go through the very painful process fo watching their own video tape. (I know this is painful because this is the exact process we followed when learning how to present new material when I was an instructor at TOPGUN. Fellow instructors played the role of students in a classroom listening to our presentation, and after getting their feedback we received feedback from our instructor on the new material, and finally, we had to watch a video tape of the whole presentation.)

What these new medical students are learning is priceless for success in the new world of health care:

1. Medical skill is not enough. Every clinician must know how to be an expert communicator and how to operate as part of a highly functional team.
2. Practicing together and exchanging feedback builds isolated individuals into an expert collaborative team.

Children’s Healthcare of Atlanta saved $23 million on hospital costs by slashing central-line infections by nearly 80 percent.

Altogether, the hospital avoided 550 bloodstream infections since it launched the initiative in 2006, an overall reduction of 77 percent, according to the article. Two of the hospital’s units have had more than 1,000 days and more than 800 days, respectively, without a central-line infection.

Hospital officials embraced a variety of infection-avoidance tools, including checklists for inserting and maintaining central lines, and teamwork training for the improvement of communication between physicians and hospital staff.

The tools used by the Children’s were first introduced to health care by LifeWings in 2001. The methodology was refined, studied, published, and made poplar by work done at Johns Hopkins. “Real change rarely occurs overnight. It requires sustained effort and unwavering focus, day after day, month after month, year after year,” Michael Rinke, lead author of the Johns Hopkins study, said in a statement. “It’s a slow, arduous process, but the payoff can be dramatic.”

The $23 million in savings are further proof that patient safety and quality initiatives, when executed successfully, have a significant Return on Investment. it is projected that up to 15% of hospitals will go out of business by 2019. Results like Children’s was able to realize are critical to economic survival.

Urgent care clinics: It seems like everywhere you turn, there’s a new retail clinic like CareNow, Patient First and CVS’ Minute Clinic. These clinics allow people to get the care they need without having to make a doctor’s appointment or wait for hours in the emergency department.

A new Harris Interactive/HealthDay survey reports the number of people who use retail health clinics has jumped from 7 percent in 2008 to 27 percent.

Why?

Convenience.

People are looking for ways to fit health and wellness into their busy schedules. Hospitals that develop efficient, reliable, fool-proof processes and services with this in mind will build their brand and customer loyalty.

The others will go out of business.

On the bottom of the World Health Organization Safe Surgery Checklist are these two sentences: “This checklist is not intended to be comprehensive. Modifications to fit local practice are encouraged.”

This item on the checklist is the most important because ignorance of this advice from the WHO is the source of almost 90% of checklist implementation failures. Successful checklists are created by the physicians, nurses, and staff that actually use them. Ineffective checklists are imposed from above by administrators without regard to local practice or input from end-users.

For example, at the University of California, San Francisco Medical Center, the Neurosurgery unit just created its own Time Out checklist.  Because of its proven record in reducing surgical morbidity and mortality, relative ease of use, and focus on improving interdisciplinary team communication practices, the WHO Surgical Safety Checklist was used as a major point of reference in the design of their checklist.

An interdisciplinary taskforce modified the checklist and inserted neurosurgery-specific language and concerns to make the WHO Surgical Safety Checklist and its communication practices more applicable to neurosurgical procedures in their institution. In addition, the taskforce consolidated the timeouts before induction of anesthesia and before skin incision on the WHO checklist for 2 reasons.

1. It is often challenging to have all multidisciplinary operating room team members congregate on 2 separate occasions to conduct 2 timeout checks.
2. Moreover, the WHO checklist before the induction of anesthesia places heavy emphasis on addressing airway concerns and verifying the functionality of equipment. Anesthesiologists at UCSF institution already routinely perform their own separate equipment checks and assess the patient’s airway prior to anesthesia induction.

These are two great examples of the type of modifications that must be done to create a checklist that staff will actually use in a sustainable way.

To view a video of the completed checklist at UCSF, use these links. Click here to view with Media Player. Click here to view with Quicktime.

By now almost everyone involved in health care quality improvement has heard of the checklist used to insert central lines that was developed Peter Pronovost, MD, professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine. The checklist has made Dr. Pronovost famous.

That checklist has long been known to reduce bloodstream infections when used correctly. It has now been proven to reduce patient deaths in Michigan hospitals by 10%.

The British Medical Journal (BMJ) studied the use of the checklist and discovered  a drop in patient mortality in Michigan hospitals. Though previous studies found a reduction in infections, this is the first to link the checklist program with reduced mortality.

“It’s breathtaking,” Pronovost told The Baltimore Sun. “With our program, patients are alive who wouldn’t be if they were outside Michigan.”

The results are so dramatic that the average ICU in Michigan now has better infection numbers than 95% of the ICUs in the remainder of the country.

While checklists must be well-designed, and getting staff to use them correctly can be tricky, with results like these, why isn’t every hospital using the same checklist program?

Watch a three-minute movie about LifeWings

HealthLeaders recently surveyed health care leaders around the country about their thoughts on improving patient safety. Here’s a recap of what they found:

• 91% of health care leaders rank patient safety among their top 5 priorities

(Which means if you are involved in patient safety your boss thinks the work you do is really important - so important it is one of the top five things on his/her plate. So right now I would be pretty bold with my goals and my actions to reach those goals. If I was ever going to be supported in my work to improve the safety of my patients, now is the time. If I was ever going to get resources and mind share from my boss to make it happen - NOW IS THE TIME.)

• 69% say that important patient care information is sometimes, often, or always lost during shift changes

(If I really wanted support and resources for my work from my boss, I’d be focusing on teamwork and communication training around patient hand-offs between care givers during the course of care and during shift changes. I’d also make sure I had great checklists or briefing guides to standardize the way hand-offs are accomplished. My boss has recognized this is an area of weakness and an area of emphasis. Now is the time to get it fixed.) 

• 73% say improved infection control practices are among the new initiatives designed to improve patient safety

(Why is my boss saying this? Because infection rates will affect our reimbursements, and because we can’t give great care if we are giving our patients infections. Again, I’d make sure we have the communications training and standardized processes in place to prevent infections. If I needed to understand how to do this I would look to the Keystone Project in Michigan for guidance.)

• 53% are devoting more financial resources to patient safety program

(If I was ever going to get a piece of the budget to fund my safety projects, now is the time. I’d get really good at showing my boss why the initiative I want to do will result in a permanent improvement in safety so I could earn a big part of the financial resources my boss is willing to invest. NOW IS THE TIME TO DREAM BIG.)

• 49% say that lack of communication skills poses the greatest risk to patient safety during handoffs or transition of care

(I now know why my boss thinks we are at risk during transitions and handoffs. I would make sure I had identified the very best communication training available and had a plan to make sure my staff was trained. Selling my boss on this training should be a lot easier than ever before.) 

Bottom line: If I was in charge of patient safety in your organization, I’d realize that my work was a high priority for my boss and take advantage of that fact to dream big, act big, ask for big resources, and make it happen now in a big way.

A recent study of surgical procedures in Colorado hospitals and health care facilities turned up an alarming number of cases where a surgery was performed on the wrong patient or on the wrong body part. The study, reported in the October issue of the medical journal Archives of Surgery, analyzed a database of over 27,000 adverse occurrences reported by physicians between 2002 and 2008. The findings reported 132 wrong surgeries.

The root cause of these errors was communication problems in all of the wrong-patient cases and 48.6% of the wrong-site cases.

In 72% of the cases, the physician did not participate in the Time Out.

Two things we can learn from these facts:

1. If you are using your surgical safety checklist as a glorified form of a grocery list or as an audit tool, doing a Time Out with a checklist will not fix the communication problems that lead to wrong surgeries. A properly formatted and executed checklist is a trigger to have a scripted conversation among the surgical team about the upcoming procedure. To have a scripted conversation you must have multiple speaking parts for different members of the team. If your idea of a speaking part is for them to say, “I agree,” in response the the information rattled off by the circulator  - you are missing the boat. That is not a scripted conversation.

2. If you want to ramp up your chance of having a wrong surgery even though you are using a checklist-driven Time Out, continue to accept the refusal of physicians to get involved in your checklist. In the airlines, the effective and complete use of checklists are the responsibility of the team leader - the Captain. He calls for and leads most of the checklists used in the cockpit. Checklists are his tool to manage the workflow and lead the team. The most effective checklist-driven Time Outs are surgeon-led. The science is settled - more surgeon involvement leads to fewer wrong surgeries. Less surgeon involvement leads to more wrong surgeries.

Bottom line? Effective surgical checklists are led by the surgeon in such a way as to have a scripted conversation with the team about the impending procedure. Anything less that that target exposes your surgical team to more risk of a wrong surgery.

This week’s post comes from the monthly CRM Newletter produced by Memorial Healthcare System in Hollywood, FL. Memorial is ranked as the 6th best place to work in health care by Modern Healthcare magazine. The article, reproduced here in it entirety was written by Dr. William Perryman, Chief of Cardiac Surgical Services at MHS. Dr. Perryman’s article will give you a sense of why Memorial is such a great place to work.

“Performing pediatric cardiac surgery in a foreign country with a support team from a variety of centers can sometimes be challenging to get everyone on the same page. This is a similar situation to that often faced by airline crews and was the genesis for the development of Crew Resource Management (CRM).

On a recent trip to the University of the West Indies (UWI) Hospital in Jamaica, we had the opportunity to use CRM during surgery for 7 children having complex cardiac surgery. The OR team had surgeons, anesthesiologists, perfusionists, OR nurses, residents and students from Joe DiMaggio Children’s Hospital, Jackson Memorial Hospital, University of Florida Shands Hospital and host UWI Hospital.

The equipment that we used was, at times, different from case to case and different from MRH (Memorial Regional Hospital). The perfusionists were using whatever cannulae they could find and anesthesia was using drugs, sometimes, with different names than they were used to in US. I was operating with a different faculty member each day or a resident.

As you can imagine, this is a very similar scenario to airline crews who arrive for a flight on equipment that may vary, with a flight crew who have never flown together before and a cabin crew who face the same challenge.

CRM allowed all present to understand each component of the operation, what adaptation might be needed and what specific “stuff” would be required for that particular child. CRM proved to be an excellent solution to an ever-changing operating room scenario and allowed us to leave with all children safely managed through their operations and returned to delighted and grateful parents. CRM also provided a template that could be continued after our departure.”

Dr. Perryman is correct. Airline pilots frequently fly with other pilots and flight attendants whom they have never met before, and with aircraft mechanics, dispatchers, and air traffic controllers whom they have never worked with before.

The Captain of the flight has just a few moments to create an effective team that utilizes expert communication and collaboration skills to detect, catch, and correct the inevitable small mistakes and errors humans make before those mistakes become serious or fatal. The blueprint for creating this expert team from a group of aviation experts is crew resource management (CRM).

As Dr. Perryman’s experience clearly shows, CRM is the blueprint for even widely disparate, international medical experts to creat an expert medical team. If CRM can work in that environment, it can work anywhere.

In addition to my work with LifeWings, I am an international Captain on the MD-11 aircraft for FedEx Express. I’ve been flying professionally for 33 years. Every year for 33 years I have had to undergo a competency check, either in the real airplane or in a simulator. For 24 of those 33 years I have had two competency checks per year in a simulator - for a total of 48 checks.

This week I just completed my annual competency check in the MD-11 simulator, and it was one of the most challenging tests I have ever had in aviation.

What was interesting about this check is that the basic strategy for testing my competency as a captain was completely different from anything I had ever experienced before. For years the approach to testing aviation skills was much like batting practice. Get in a simulator and demonstrate to the check pilot that you could handle a long list of potential malfunctions and emergencies. The list never varied from year to year - engine failures, electrical problems, hydraulic malfunctions, wind shear recoveries, and landings in bad weather - all accomplished at the same simulated airport. 

The disconnect with the real world is that the inability to fly the maneuvers and handle the emergencies tested annually in the simulator are rarely the cause of accidents. Prior to the advent of teamwork training for airline crews, almost 80% of airline accidents were caused primarily by a breakdown in the teamwork and communication skills of the flight crew.

Thus, the check ride for this year had a totally different approach. During the briefing for the test, the company check pilot was very clear the purpose of the event was to check my ability to operate the airplane safely by using both a high level of technical competence and effective teamwork and communication skills (CRM) with my co-pilot. Could we solve complex problems in a challenging scenario by working together effectively while simulating a regular flight from Point A to Point B? No batting practice this time.

In short, could I manage the human factors?

When you think about what really causes airline accidents this evaluation emphasis makes sense.

Our test involved a simulated flight from Taipei, Taiwan to another airport in Taiwan just 30 minutes away. The scenario tested our ability to respond to a potentially deadly wind shear, thunderstorms, an unexpectedly closed airport, holding patterns, a divert to Hong Kong, gusty winds, poor visibility, difficult to understand controller language, an engine failure, another minor engine malfunction, another divert from Hong Kong to an airport in mainland China, low fuel, and an approach and landing in bad weather conditions.

After two and a half hours of intense concentration I was totally spent. Without a technically competent co-pilot, and exceptionally effective teamwork and communication, we couldn’t have carried the flight off safely. Had I not listened to the co-pilot’s inputs and suggestions I would have made a couple of serious mistakes. Had she not listened to me she would have made a few too. 

Together, we crosschecked everything, detected and corrected our small mistakes before they became serious or potentially fatal, and eliminated the human factor of fallibility as a source of undetected deadly error.

We demonstrated how two technical experts could also function as an expert team.

My experience this week makes me think of the application to health care. The data on why medical mistakes happen is almost identical to that of aviation. Seventy to 80% of preventable medical errors have some sort of communication error as the main cause. Almost 70% of sentinel events have a breakdown in teamwork and communication as a primary cause.

If the causes are the same for both professions - the cure might be similar too. A commitment to more and better designed simulation training, and effective teamwork training and checklist usage for everyone will go a long way for improving patient safety and quality outcomes.