Hot Topics in Quality and Safety: A GME Perspective

1. Hot Topics in Quality and Safety:A GME Perspective Arpana R. Vidyarthi, MD Director, Quality and Safety Programs, GME

2. In the beginning… It may seem a strange principle to enunciate, as the very first requirement in a hospital that it should do the sick no harm Florence Nightingale, 1859

3. Today… Objectives Agenda • Understand the current climate involving Q/S • Gain insight into specific topics that affect housestaff • Discover current local improvement efforts • Changing landscape • Edith’s experience • Q/S and education • GME Q/S programs • Next on the horizon

4. The Institute of Medicine: 44,000 – 98,000 preventable adverse events yearly Exceeds those who die from highway accidents, breast cancer, and aids

5. Patient safety publications before and after the “IOM Report” Stelfox, H T et al. Qual Saf Health Care 2006;15:174-178

6. Regulators and Regulations Leapfrog Joint commission AHQR IHI CMS NQF

7. Safety and Quality Today… Safety Quality • Freedom from accidental injury due to medical care, or medical errors • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Priority for providers, organizations, and educators

8. Agenda • Changing landscape • Edith’s experience • Q/S and Education • UCSF efforts • Next on the horizon

9. Edith presents with SOB TimeLine 12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM Shortness of Breath Sent for CXR & Labs Admit Settled Ward Edith in ED ED MD Shift Change ED MD Overnight MD Daytime MD

10. Day 2 TimeLine 10AM 2PM 6PM 10PM 2AM 6AM 10AM 2 PM 6PM Decompen-sates Edith in ICU Edith in ICU Edith Stable Edith Stable Transfer to ICU Admitting ICU MD MD goes to clinic Cross coverage MD MD returns Overnight MD Daytime MD

11. Day 2 TimeLine 10PM 2AM 6AM 10AM 2PM 6PM 8PM 12 AM 4AM Edith in ICU Shortness of Breath/ Intubated Intubated & Stable Extubated Overnight MD Daytime MD Daytime MD

12. The first 48 hours of Edith’s stay…. ICU MD: “Do you remember us Edith, we are the doctors taking care of you?” Edith: “Uh….no?” ICU MD to self: “Poor Edith, she has suffered a change of mental status” Total MD in Charge of Care: 9 Total Signouts: 10

13. Why So Many Handoffs Today? • ACGME duty hour limitations • 80 hours per week • 30 hours continuous • 24 hours off per month • Practicing physicians • Group practices: cross-coverage • Hospitalists 4000 Handoffs Daily, 1.5 Million Handoffs per Year

14. handoff Handoffs Represent Gaps Practioner Practioner signout Gap Patient vulnerability Cook, BMJ,2000

15. Housestaff Experiences Perceptions Impacts • “handoffs are dangerous” • A common suboptimal care practice • 59% report patient harm • Increased errors from discontinuity • Clinical • Delayed test ordering • Increased in-hospital complications • Increased medication errors • Presumed increase in length of stay Vidyarthi, JGIM, 2006;Kitch, Jt Comm J Qual Patient Safe,2008; Irani, Surgery, 2005

16. Evaluate factors associated with hospital based medical preventable adverse events Most significant risk for an adverse event: cross-covering MD Discontinuity and Patient Harm Petersen, Ann Intern Med 1994

17. Emergency Medicine Handoff is the “gray zone” Errors due to communication failures Incomplete information cultural professional conflicts, high workload pending data ambiguity Surgery Information transfer lapses Blurred boundaries of responsibility Decreased familiarity with patients Diversion f attention Distorted or inhibited communication And Other Analysis Shows Apker, Acad Emerg Med, 2007;Horwitz, Annals Emerg Med, 2009;Reed, Annals of Surg, 2007

18. University Health Consortium Position Papers IM, ER, Surgery, Hospital Medicine Society of Hospital Medicine Joint Commission Effective Handoff: Signout must include Written Verbal + Handoff Best Practices Best Practice Guidelines Do it…well Standardize UHC,2006; Solet, Academic Med, 2005; Kemp, Arch Surg, 2008; Vidyarthi, JHM 2006; Arora, JHM pending; Joint Commission, 2009

19. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety And the IOM says… The Charge Recommendations • Work hours • Maintain 80 limit • Decrease extended shifts • Need for clear and effective handoffs • Education • Overlap time • Cross-coverage clarity • Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety • 2007 • Input from everywhere Institute of Medicine, 2009

20. In the ICU… TimeLine 12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM In ICU Getting ready for transfer D/C Central Line Acute Desat Air Embolus Nurse eval Orders Written Resident? On High-Flow 02

21. Air Embolus: Never Event • NQF---CMS---DHS • Represents an evolution of understanding • Reportable to the state • Investigation • Remuneration • Fines • Report • Incident reporting system • Your attending • Your QI coordinator • Your Program Director • me

22. The Summons Dear Colleagues, The Clinical Event Oversight Committee (CEOC) has convened a Root Cause Analysis meeting on Wednesday, January 28th @ 10-11:00am, in MUE506/7, regarding a patient who had an acute onset shortness of breath after a central line removal A root cause analysis is a multidisciplinary process that allows us to analyze an event and identify opportunities for improvement. Your attendance is imperative, as we need your input to assist in the analysis. If you are not able to attend, it must be cleared by your immediate supervisor or service chief so that appropriate alternate representation can be arranged. Please RSVP to Sharon Talbott @ sharon.talbott@ucsfmedctr.org as soon as possible.  In addition to the CEOC Members, the following is a list of necessary participants: Resident Med Icine Program Director QI Director ICU nurses and attendings Dr. Arpana Vidyarthi • T  Thanks, Adrienne Adrienne Green, MD Associate Chief Medical Officer Co-Interim Chief Medical Officer UCSF Medical Center 415-353-2823

23. Scary…but Not Scary Not Scary • Lots of important people • Dark wood room • no food provided • Folks you know • You are an honored guest • Great learning opportunity • Huge impact to improve care

24. Case Review: To Fix the System… Root Cause Analysis Case Review-Peer Review • Medical center level • Multi-disciplinary • Clinical Events Oversight Committee • Systematic review of the events including participants with actions • Department/division based • Single discipline • M and M/Peer Review/Case Review • Discussion and review by peers

25. What Happens Next… • Go to the meeting! • You are the one with the knowledge: events • clinical • Operational • Systems • You are the one with knowledge: solutions • Experience • Feasibility • Culturally applicable

26. Edith Goes Home… Your Press-Ganey Survey How likely are you to recommend UCSF…?

27. Who is Press Ganey? • National patient satisfaction expert • Manage10,000 healthcare organizations • Majority of those in University Health Consortium • Design survey • Well researched • Administer the survey • Provide analysis • Compare us to others “benchmarking”

28. Why Should You Care? Housestaff Healthcare organization • Cuz you should…and do • You are the front line • You set the tone for the experience • At ease and confident • Anxiety and discomfort • Our mission • Patient referrals • Publically reported

29. Public Reporting CHART: California Hospital Assessment and Reporting Taskforce www.chcf.org

30. HCAHPS and Hospital Compare

31. Foodies to MDs…

32. Not just for restaurants anymore

33. Likelihood of Recommending: 2001-2009 Our mean score has continuously improved over time

34. Physician Survey QuestionsOct-Dec 09 • Combined Physician section: 74th percentile as compared to other UHC hospitals nationwide • Resident rating question: 75th percentile in the UHC peer group

35. Resident Rating Question: Oct08-Dec09

36. Resident Comments from Patient Surveys Positive Feedback Areas for improvement • Much attention from interns and med team • The doctor and residents, interns were very caring • Very good, found the residents especially informative, nurturing and kind • Very professional and competent resident doctors • I feel very comfortable around my physician; was timely to answer all my questions and very friendly; skill is very impressive; residents and interns are all amazing • Had great experience with the interns and residents; residents were very knowledgeable and friendly • Was not clear on who was an experienced doctor and who was a resident • I had an intern administer a test that should have been 2 minute – she stood with her back to me for 45 minutes, I had to explain to her how to do it and then requested she get her superior • Having contact only with residents was not a good experience – especially because I was not prepared for it

37. Priority Index Items • Priority Index • statistical analysis of survey data that combines two factors: low mean score, and high correlation to overall satisfaction • Delineates areas of import for focused improvement • The top 5 items for Inpatient • Staff addressed emotional needs • Staff response to concerns and complaints • Staff sensitivity to inconvenience • Staff sensitivity to special needs • Extent informed about medications received

38. Edith’s Inpatient Doctor Gets an Email… Congratulations, your patient satisfaction ratings are above 90.2 And you get $400!

39. Pay For Performance • US far behind • United Kingdom National Health Service • European Union • Central America • South America • Common P4P Programs • Veterans Affairs Healthcare System • Private Insurers (Blue Shield of California) • Independent Physician Association • Centers for Medicare and Medicaid Services • Hospital Systems • Individual Organization

40. $$, Motivating, Results? Lindenauer P et al. N Engl J Med 2007;356:486-96

41. UCSFMC Housestaff Incentive Program • Overall Purpose: • Link all everyone to organizational mission, vision, values, and goals • Housestaff Purpose: • Engage housestaff in the organizational mission, vision, value, and goals, and motivate performance improvement in quality measures

42. Incentive: All Housestaff • Patient Satisfaction • Score of 91% • Quality Improvement • Hand Hygiene • Flu vaccination (or declination) • Infection control module • Lab Utilization • CBC/Dif down 5% • Eligible: • 12 week a year at moffitt • $400/element

43. How are we doing?

44. Program Specific Incentives • Anesthesia • Increase rate of prophactic antibiotics • Dermatology • Decrease clinic wait times • EM • Increase PCP communication • Peds • Asthma action plans • Neuro • Improve swallow exams on stroke pts • Medicine • Increase PCP communication • Neurosurgery • Ontime start in the OR • ObGyn • Improve DM orders • Radiology • Critical results reported

45. Resident Experience: quotes • Harder than I thought…data, keeping it up • Fantastic—learned a lot • Never thought this was exciting…but it really is • Now I am looking at doing QI for my first job • We have to do it….it is the right thing to do.

46. Why Teach QI • Training must reflect future practice • ACGME Core Competencies • Patient Care • Medical Knowledge • Professionalism • Interpersonal Skills and Communication • Practice-Based Learning • Systems-Based Practice

47. GME Quality and Safety Programs • Incentive Program • Chief Resident Engagement • Med Ctr Collaboration • Program Collaboration • Education • Resident driven projects • Research IOM, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001.

48. On the Horizon… • Resident supervision? • Further Reduction in Duty Hours? • Board Certification • Medical knowledge vs system knowledge? autonomy supervision Duty hour handoffs educ

49. Conclusion • Quality and safety issues are here to stay • Housestaff affect and are affected by challenges and solutions • Remember Edith: • Handoffs, Case Review, Patient Satisfaction and P4P • UCSF is engaged • Next…controversy Stay Informed and Engaged

50. More information • Arpana Vidyarthi, Director, Quality and Safety Programs GME arpana@medicine.ucsf.edu