The Lessons of Bristol (Models for the Future)

1. The Lessons of Bristol(Models for the Future) Associate Professor Stephen Bolsin Department of Perioperative Medicine The Geelong Hospital Barwon Health

2. The Lessons of Bristol • Other examples • Manitoba Paediatric Cardiac Surgery Inquest (Canada) • Dr Harold Shipman Inquiry (UK) • Dr Michael Swango (USA) • Bristol Royal Infirmary Inquiry (UK) • 40 deaths in private clinic 2000 (France) • Dr Reimers charged with manslaughter 2001 (Aus)

3. Safety in Health Care Stimulus to change • 1995 ‘Quality in Australian healthcare study’ • 1999 ‘To err is human’ Institute of Medicine, USA • 44-98K patients die through error in US hospitals • 3-6K patients die through error in Australian care • Bristol Inquiry 2001 “could be happening now in NHS” • Public demand for change

4. Safety in Health Care Quality in Australian Health Care Study 1992 Wilson RMcL, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. • 16.6% of admissions had iatrogenic injury • 14,000 admissions to 28 hospitals (NSW & SA) • Extrapolate <230,00 preventable adverse events • Extrapolate <14,000 preventable deaths

5. Safety in Health Care Causes of Adverse Events (50% preventable) 34.6% complication/failure of technical performance 15.8% decision/action failure 11.8% failure to arrange procedure/investigate/consult 10.9% lack of care/attention An analysis of the causes of adverse events from theQuality in Australian Health Care Study Ross McL Wilson, Bernadette T Harrison, Robert W Gibberd and John D Hamilton MJA 1999; 170: 411-415

6. Safety in Health Care Limited adverse occurrence screening: using medical record review to reduce hospital adverse patient events Alan M Wolff MJA 1996; 164: 458

7. Safety in Health Care Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program Alan M Wolff, Jo Bourke, Ian A Campbell and David W Leembruggen MJA 2001; 174: 621-625

8. Safety in Health Care Wolff M A. MJA 1996; 164: 458 General patient outcome criteria used for screening of medical records • Death. • Return to operating theatre within 7 days. • Transfer from general ward to intensive care unit. • Unplanned readmission within 28 days of discharge. • Cardiac arrest. • Transfer to another acute-care facility. • Length of stay greater than 35 days (reduced to 21 days in 1993-1994). • Theatre booking cancelled.

9. Safety in Health Care Wolff M A. MJA 1996; 164: 458 15,912 patients screened 1,465 (9.21%) screened positive for criteria 155 (0.97%) screened positive for AO 110 major 45 minor 88 (56.8%) cases minor or not preventable 67 recommendations to patient care committee 66 recommendations for changes in policy Changes in policy clinical & administrative

10. Safety in Health Care Wolff M A. MJA 1996; 164: 458 • Reasonable rate of detection on screening by clerks • Reasonable rate of confirmation by clinicians • LAOS will detect circa 50% of adverse events • Requires 10% review of medical records • Fast & accurate • Costs <0.1% of total hospital budget • Reduction in adverse events by >50% in 3 years

11. Safety in Health Care Wolff AM et al. MJA 2001; 174: 621-625 49,834 inpatients screened 20,050 EMD patients screened Inpatient record review EMD record review Clinical incident reporting GP reporting

12. Safety in Health Care Inpatient adverse events down from 1.35% - 0.74% (Reduction from 69-49 events in 8 years p<0.001) EMD adverse events decreased from 3.26% - 0.48% (Reduction from 84-12 events in 8 quarters p<0.001) “Adverse events can be detected...” “...and their frequency reduced using…detection methods and clinical improvement strategies...

13. Safety in Health Care Causes of Adverse Events (50% preventable) 34.6% complication/failure of technical performance 15.8% decision/action failure 11.8% failure to arrange procedure/investigate/consult 10.9% lack of care/attention An analysis of the causes of adverse events from theQuality in Australian Health Care Study Ross McL Wilson, Bernadette T Harrison, Robert W Gibberd and John D Hamilton MJA 1999; 170: 411-415

14. ANZCAPersonal Professional Monitoring Project • Pietroni 1993 Ann RCS;75:200-2. • de Leval et al. 1994 J Thorac Cardiovasc Surg;107:914. • Kestin 1995 BJA;75:805-9. • Ellis 1995 BJA;75:673-4. • Day & Bolsin 1998 Short Practice of Anaesthesia. • Bolsin 2000 Int J Qual Health Care;12:367-369. • Bolsin & Colson Int J Qual Health Care;12:433-8. • Bolsin 2001 Aust Health Review;24:1-4.

15. ANZCAPersonal Professional Monitoring Project

16. ANZCAPersonal Professional Monitoring Project

17. ANZCAPersonal Professional Monitoring Project

18. ANZCAPersonal Professional Monitoring Project

19. ANZCAPersonal Professional Monitoring Project • Recruits • 1st year Anaesthetic Registrars • Supervisors of Training • Collects Electronically • Log Book data on procedures • Data on procedural performance • Data on adverse incidents

20. ANZCA Personal Professional Monitoring Project • Sponsors • ANZCA (Australian & New Zealand College of Anaesthetists) • United Medical Protection • PALM Corporation of Australasia • VMIA • Sync International

21. ANZCA Personal Professional Monitoring Project Procedures monitored • IV line insertion • IA line insertion • CVP line insertion • Epidural insertion • Spinal anaesthetic • Brachial Plexus block • Other blocks

22. ANZCA Personal Professional Monitoring Project • PALM III handheld computers • Personal log book • Customised synchronising programmes • Electronic data collection • Electronic data retrieval • Secure electronic data transmission • Remote Analysis • Secure return of analysed data

23. ANZCA Personal Professional Monitoring Project • Data collection in <1 minute • Cultural change has been achieved • Enthusiasm is palpable • Other Specialities are interested • Other Professions are interested • Registrars are Specialists of the Future • Data from any procedures collectable

24. ANZCA Personal Professional Monitoring Project

25. ANZCA Personal Professional Monitoring Project

26. ANZCA Personal Professional Monitoring Project

27. ANZCA Personal Professional Monitoring Project

28. ANZCA Personal Professional Monitoring Project

29. ANZCA Personal Professional Monitoring Project

30. ANZCA Personal Professional Monitoring Project

31. ANZCA Personal Professional Monitoring Project Anaesth. College Palm Secure Server Desktop APSF

32. ANZCA Personal Professional Monitoring Project Phase 1 Project • Six 1st or 2nd year registrars recruited • 3 Centres in Australia & New Zealand • 4-7 month data collection • 1690 Cases collected • All collected data analysed • Some data lost (batteries & breakages)

33. ANZCA Personal Professional Monitoring Project Phase 1 Project • Supervision • 62% level 1; 22% level 2 • 27% out of hours • 11% remote locations • Operative Speciality • 480 procedures logged for Cusum analysis

34. ANZCA Personal Professional Monitoring Project Phase 1 Project • 42 critical incidents • 2.5% of total anaesthetics logged • 19 uneventful; 8 minor;14 major; 1 death • 64% “near miss” reporting • cf 50% event reporting by LAOS • 21 airway respy events; 17 cardiovascular

35. ANZCA Personal Professional Monitoring Project Phase 2 Project • 715 anaesthetics recorded • 17 critical incidents • 2.4% of total anaesthetics logged • 7 uneventful; 8 minor;2 major • 88% “near miss” reporting • 7 airway; 4 procedure; 2 cardiovascular

36. ANZCA Personal Professional Monitoring Project • Relatively objective. • Easy and quick to collect. • Provides early feedback. • Provokes specific action early. • Consistent with the “continuing quality improvement” paradigm. • Allows for ongoing, self directed learning • Phase 2 better than Phase 1

37. ANZCA Personal Professional Monitoring Project “The Future Now” • Personal Professional Monitoring • Real Time Prospective Reporting • Numerator Data & Denominator Data • “Near Miss” Reporting • Critical Incident Analysis • Targeted Incident Reporting • Immediate Feedback of generic data • Policy & Procedural change as a result

38. ANZCA Personal Professional Monitoring Project The Vision • Reduction in Adverse Events • Elimination of attributable Adverse Events • Improved Health Care Practice • Reduced Health Care Costs (Au$4-6 billion) • Improved Patient Outcomes • Reduced Legal Costs • Safest Hospital status

39. www.ppm.com.au Articles on CUSUM Product details Program tour www.syncint.com Look under what’s new ANZCA Personal Professional Monitoring Project

41. Professional Monitoring & Cultural Change A/Prof Stephen Bolsin, Dr Mark Colson, Dr Peter Stow, Dr Peter Tolley, Mr Morteza Mohajeri, Mr James Kenny, Dr Rory Wolff Depts Perioperative Medicine, Cardiac Surgery & ICU The Geelong Hospital Barwon Health Dept Epidemiology & Preventive Medicine Monash University

42. Professional Monitoring & Cultural Change Inexplicable change in performance

43. Professional Monitoring & Cultural Change Review Meeting Protocol Changes Xmas Holidays New Surgeon

44. Professional Monitoring & Cultural Change • Overall bleeding rate 5.5% • Important variables on univariate analysis • Emergency category • Renal failure (Pre-op creatinine >120mol/L) • Cardiopulmonary bypass time (10% : 10 min) • Surgeon

45. Professional Monitoring & Cultural Change Xmas holidays Protocol Changes Review Meeting New Staff Changed Performance

46. Professional Monitoring & Cultural Change • Further analysis required • Renal failure implicated • Bypass time implicated • Emergency surgery implicated • Surgeon in part explanatory • Surgeon effect remediable • Decrements in performance explicable • Increments in performance inexplicable

47. Professional Monitoring & Cultural Change • We are being expected to do better • We could do better • We should do better • Our patients would want us to do better • Our patients would benefit • We would benefit • “All Win” Medical Management