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HAP735 Risk Management/Patient Safety (Fall 2013)

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Elaine Wong

on 8 October 2013

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Transcript of HAP735 Risk Management/Patient Safety (Fall 2013)

How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out
by : Peter Pronovost, PhD, MD; Eric Vohr

TRIP & CUSP Model for
Michigan Health Care System

Where are we now?
44 states Participated in the program
Safe Patients, Smart Hospitals:
Words of
Dr. Pronovost ....

What caused Josie's death?

Checklist at Adult ICU
Checklist Evolution
The Real Culprit....
Weinberg 4C unit
Staff turnover was high (20%/ year)

Moral was low

Conflict between physicians and nurses.

Poor communication

Problem 1
- Patients were cared for by different teams.
Solution 1
Group patients for specific service together in one unit.

number of pages physicians get per day.

From 64/day to 2/day!

Problem 2
Dead zones where pages can not
be sent or received.

Solution 2
Dead zone were difficult to fix.
wireless monitors.

- Staff turnover went to nearly 0.

- Culture and teamwork

-Staff satisfaction increased.

- Patient length of stay reduced.

Problem 1
Central line maintenance.

Infection rates reduced but not eliminated.

Solution 1
Labeling the tube the expiry date.

Color code the stickers.

Infection rate dropped to
nearly zero.

Problem 2
Solution 2
Handoff form

Improved teamwork & communication
Improved the general atmosphere of
the unit.

- Named one of the times magazine’s 100 most influential people in 2008.

- Received the coveted MAcArthur Fellowship.
How & where to get
- AHRQ budget is only $300 million

- Obama Care

- donation of 2.4 million

- AHRQ money
- work with 28 states.

- Partnership with Leapfrog group

- The Joint Commission

- The Center for Disease Control and Prevention (CDC)

- A provision within the senate’s national health care reform bill

Introduction to other states
and countries

Lack of communication between
and among key medical staff
Failure to response to Josie's mother when she voiced her concern on Josie's decline.
1st Trial
Comprehensive unit-
based safety program (CUSP)
GOAL : Central line infection prevention

Year 2000 : median of infections was
19/1000 catheter days.
Inspired from the aviation industry.
Tested the checklist theory in the SICU (Surgical ICU).
A tool that is :
Simple & Easy-to-follow protocol
Contains the most essential information needed to protect patients from harm
Work closely with Epidemiology & Infection Control Specialist.
Sifted through CDC Guideline
Talk to nurses & doctors
Observe how central line were placed
- No team work.

- Difficult communication.
Patient Safety....How?
Central Line* Issue Back Then
Problem :
Lack of standardized procedure for placing central lines.
Question :
How to solve this problem to reduce the risk of using catheter in patients?
Rhode Island
BELIEVE : The healthcare system is capable of giving patients far better care.
Work with Sorrel King to promote patient safety awareness among clinical staff not only at Johns Hopkins but throughout the America.
1,100 hospitals and 1,800 CUSP teams
Physician Ego
Low compliance to the
Checklist Protocol
Factors contributing to .......
Time consuming to locate all items in the checklist which was located all over the ICU unit.
Physicians Feedback
Fail to locate equipment, staff made risk-benefit decision against complying with the checklist.
Nurses Feedback
Did not understand the purpose of the checklist.
Thought merely following physician orders.
Educate nurses on the science and patients' benefits from the use of checklist.
Compliance Rate:
Doctors ego & over confidence-refuse to obey the checklist steps.
"Medicine operates like a private club of self-styled deities where the entrance requirement is an MD.'
Nurses as the independent party to monitor with authority to force doctors to comply with the checklist.
A year later.....
SICU infections rate dropped to nearly 0.
Saved 8 lives & $2 million
Result :
Compliance rate
New Jersey
Incomplete data collection
(Translating Research into Practice)
Implement checklist across various department to REDUCE medical error and INCREASE patient safety.
1. Summarize evidence into checklist.
2. Identify & mitigate local barriers to
3. Measure Performance.
4. Ensure all patients reliably receive the
Identify a diagnosis, treatment/procedure that is putting patient at risk.
Ventilator-associated pneumonia
Create a checklist
(by a team of interdisciplinary members)
VAP Checklist
1. Elevate the head of the bed so that it is at or above 30 degrees.

2. Limit the sedation of patients so that they are able to follow
commands at least once a day.

3. Test everyday whether the patient still needs the ventilator.

4. Provide medication for stomach ulcers.

5. Provide medication for blood clots.

Identify barriers that could prevent patient from receiving the items on the checklist.
VAP Checklist Barriers
TRIP Model
1st Experiment
Measure outcome/performance
VAP Checklist Compliance Rate
TRIP in the Operating Room
- Surgical Site Infections (SSI)
TRIP Model failure in the OR.
Intense Culture Dynamic.
Lack of Communication, Respect, Cooperation and Teamwork.
GOAL : Improve communication, teamwork and culture in the individual units of the hospital.
Build a CUSP Team
Senior Executive
Associate Staff (e.g. Pharmacist, respiratory therapist)
Safety Attitudes Questionnaire (SAQ) Survey
Baseline used to judge improvement
1. Educate staff about CUSP.
2. Clinicians identify defect.
Unit people complete a survey on safety issue they think need addressing.
3. CUSP Team review all the defects.
greatest chance of harming patient
highest severity of harm
highest frequency of occurence
4. Brainstorm on solution to the selected problems.
5. Performance measurement
WICU Test Run
Problem 1 :
Safely moving patients to other parts of the hospital
Problem 2 :
Create a form - list medication taken
arrival at WICU,
in WICU and
leaving WICU
Solution :
Medication Reconciliation
Problem 3 :
Establishing clear communication of physician's order
Solution :
Daily Goal Form
Attending physician announces the patient's treatment, head resident scribbles it down.
Patient nurse is not present.
Require patient's nurse be present during rounds.
Clear-to-read care form for resident to fill in.
Nurse reads back to confirm
CUSP Success in WICU
Safety Culture Scores (SAQ Survey) went up by 50%
Length of Stay dropped by half to just over 1 day
Medication Errors dropped from 94% to 0
Nursing turnover decrease from 9% to 2%
Quote from Rhonda Wyskiel (then Chief Nurse)
'We were part of the change. It wasn't like someone asking us to do this or that. We played the role in making those decisions. It was fun to come to work just to find out in what new ways we could make our unit safer for patients'
Dr. Provonost & his team collaborated with Michigan Hospital Association
3 months after the study in Michigan :
MHA received a 2 year grant from AHRQ to reduce bloodstream infections in the ICUs across Michigan using the TRIP and CUSP model.
Infection rates dropped to nearly zero and stayed there.
Saving an estimated 2000 lives
Saved $200 million a year
Josie King
August 1999-February 2001
HAP 735 (Fall 2013)
Norah AlRayes
Ping Chet Wong

Problem 1
: No clear way of telling when the bed was situated correctly i.e. at or above 30 degrees.
: Put a gauge on the side of the bed - measure & visually remind nurse/ doctors.

Problem 2
: Order to do the VAP checklist had to be initiated by a physician.
: Made VAP checklist an automatic order and equipment would automatically get delivered to the unit.

Problem 3
: VAP checklist was given to family members of WICU patients

: Explained how it works and encourage them to ask questions.

Checklist in SICU
Compliance Rate :
38 %
2 out of 3 patients are at greater risk of infection and death !
What is wrong here??
Inexperience nurse and resident
Special Transport Team
* This is a long tube (catheter) that goes into a vein in your chest or arm and ends at your heart. Your central line will carry nutrients and medicine into your body.
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