FOLLOW THE STORY OF THE INTERVENTION (A NEW PROCEDURE ABOUT TO BE DONE AT YOUR HOSPITAL) -
FROM DISCOVERY THROUGH IMPLEMENTATION.....        
 

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Item number and issue:
Reported by:                  

External to the Hospital

Learning Goal

  
  1. Literature provides evidence that the intervention is effective (improves mortality, morbidity, safety etc).  However many years pass...

Demonstrate that there is a translational gap.  It takes years for advances published in the literature to filter to the bedside.

 Chrissy Lauro:  What are the three stages of Translating Research into Practice
  1. Eventually it becomes the new standard of care and multiple organizations create guidelines regarding the intervention

Demonstrate that there is a repository of guidelines.  The key is how organizations and individuals use these

 Robert Giannini:  Print out a guideline related to an issues that is pertinent to one of the Hospital related goals
  1. AHRQ may set up research on the intervention (if a safety intervention)

AHRQ Conducts safety and quality related research.  They are key in creating the science of safety and disseminating finding

 Nancy McMann – What is the mission of AHRQ?
  1. The Institute of Medicine releases a statement about the intervention

This organization helps advise the government on quality issues.  They help set standards and future vision and help set policy

 Susan Vemuri – What does the IOM do? What is their mission
  1. National Quality Forum creates consensus around the intervention and thus establishing the use of this intervention as a marker of quality

This organization of organizations establishes consensus about what IS quality.  These measures are then used by other s (payors, accreditation bodies etc)

 Susan Radick –What does the NQF do?  Who has membership in the NQF
  1. The Joint Commission decides to mandate its use in organizations as part of its accreditation process

TJC will accredit hospitals.  Hospitals who receive funds from the CMS Medicare) need to be accredited.   TJC ensures that standards set by

Linda Mimm – What does the Joint Commission Do?   What does our data look like on theirwebiste
  1. The Leapfrog Group decides to put additional incentive for hospitals to create change as purchasers will steer patients to hospitals  that have the intervention.  Your hospital is unfamiliar with this so they watch a video describing the initiative.  Watch a video overview of the Leapfrog groups survey utilizing the NQF 30 Safe Practices and watch another on how to score it.

The Leapfrog Group allows  employers to preferentially send employees (patients) to hospitals of high quality.  The Leapfrog Group uses the NQF 30 Safe Practices as part of the Hospital Self Assessment

 Doron Schneider – What is the Leapfrog Group.  How do their surveys help patients and employers
  1. The IHI sets up a learning community to assist hospitals with ensuring this intervention is done safely and effectively

The IHI is an organization established to promote best practices.  Organizations sign up for programs and share successes and barriers.

Maureen Frye – What is the IHI?  What is the 5 million lives and 100K lives programs?
  1. Local state agencies (PHC4) begin to publicly report performance around the intervention

This state agency was established to provide cost and quality oversight for Pennsylvania Hospitals

 Doron Schnider – What is the mission of PHC4?  How does AMH look on the most recent reports?

 

 

  

In the Hospital

 

  
  1. At your hospital a teams reviews the intervention to determine if they should do it at the hospital.

 

  
  1. An FMEA is commissioned to proactively address the risks of performing the new intervention.  The hospital recognizes that safety is one of the IOM elements of quality

This prospective exercise is a critical look at all of the steps on a process.  It is done before the process is rolled out.  Design changes are implemented as a reult which will mitigate the risks

 Kelly Cummings – Do a small FMEA (on the IHI website).  Pick a topic related to a process that residents are involved in.
  1. Voice of the customer is obtained in initial design

 

 Press Gainey
  1. Hospital begins to perform drills and simulations

 

  
  1. Hospital staff undergo team training (watch video) to ensure that a high functioning team will be in place

Team training introduces tools to providers intended to lessen communication breakdown between providers (the most common cause of errors)

 Linda Mimm – Provide an example of how a team STEPPS tool was used well.  Provide and example of a situation where a STEPPS tool should have been used but was not.
  1. New equipment is purchased for the intervention. Human factors are greatly considered when making the purchases

The study of how humans interact with machines.  Good design lessen the likelihood for error

 Diane Humbrecht – Provide an example of a device in our workplace that has a bad design
  1. Procedure begins to be performed

 

  
  1. Local data is generated through audits to see the quality/performance gap

 

  
  1. Quality improvement team is established to improve performance (a gap in your hospital performance and best practice is present).  The team understand the basics of quality improvement.  They take a post test and receive CME credit

The Quality Improvement basics

  
  1. The quality improvement team looks to other sources for help.  The team is excited to learn more about safety and they sign up for an E-newsletter from AHRQ. 

AHRQ has excellent resources.  Having them pushed to the end user will increase use.

  
  1. Team utilizes PDSA cycles to enhance performance

A cornerstone of improvement science.  Plan - Do - Study - Act.  Please read all links off of this main page.

 Doron Schneider- Consider a process that needs improvement.  Prepare a PDSA cycle relative to that process
  1. Team utilizes reliable design mechanisms to enhance delivery         

Reliable designs are built in safeguards that allow systems to perform with minimal variability and likelihood for error

 Nancy McMann – provide an example of one design at AMH that leverages reliability science (uses one of the tools you have learned about)
  1. During routine care common errors are noted ( that may not be directly related to intervention).  Staff report the errors to internal department (Patient Advocacy/Risk).  Internal department then submits to a state (see details) or national database.

ACT 13 requires that hospitals report errors to a state database (PAPSR).  The PA PSA then analyzes these errors for trends and creates interventions (programs, education campaigns etc) to decrease likelihood of recurrence around the state.

 Cindy Koeneman -  What is ACT 13?  Fill out a PEMINIC form for an event or near miss that you observed this month
  1. Common errors are analyzed by type and interventions are implemented to reduce recurrence

Understand how 1) Communication 2) Human Factors and 3) Cognitive errors lead to unsafe situations.  Understand the basics about Medication Erorrs

 Donna Fine – What is the ISMP? Review the most recent Newsletter – Medication Safety Alert. What are your impressions of AMHs vulnerabilities relative to the issues raised

1.                  Decision support

 

  

2.                  Cognitive aids / software

 

  
  1. Now an error occurs during performing the ‘intervention’.  An RCA is performed using the VA tool. 

Understand the basics of Root Cause Analysis - a tool used to investigate events/near misses with an eye to find causal factors (and hence allow systems redesign as appropriate)

  
  1. The RCA team decides to learn more about designing a safer system so they look at AHRQ PSNet

A nice resource that compiles the safety/quality literature in an easy to manage way

 Sign up for the PSNet newlsetter
  1. Now turning back to the review of the overall performance of the intervention the team generates run charts to analyze performance  to display and share data and understand.

Understand the basics of how run charts are more effective in uncovering learnings about performance than tabular data

  
  1. Patients voice is captured through CAHPS as they try to practice patient centered care

Understand how the CAHPS survey is being used nationally.  This publicly reported survey is the gold standard tool for measuring patient centered care

 Doron Schneider – what is CAHPS.  How does AMH look on this survey overall? How do AMH physicians look on this survey.  What can residents do to make our score look better?
  1. Patients voice is captured through Patient Family Councils (see summary of evidence)

Understand the roll of Patient Family Councils in capturing the 'Voice of the Customer'.  This allows systems to be designed in a more patient centered way.

  
  1. Culture of all staff is audited to ensure high reliability.  To do this the hospital administers a yearly survey

Understand that the most important contribution to the safety of patients is for organizations to have a culture of safety.  Review tools that measure safety culture.

  
  1. Hospital negotiates a Pay for Performance contract with third party payer regarding the intervention

      Understand the basics of P4P.  Understand the limitations of P4P in  
      improving care.

  
  1. Hospital reviews it utilization of resource to ensure they are efficient in delivery of care for the intervention

Understand the IOM definition of efficiency.

 Doron Schneider – How can residents help us be effective stewards of our financial resources