Improving Perioperative Care in Michigan

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Improving Perioperative Care in Michigan

• Johns Hopkins University
• Quality and Safety Research Group
• January 29, 2008

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Why Surgery?

• Important public health issue
• Focus of many national improvement efforts
• WHO, CMS SCIP, ACS NSQIP, BCBSM MSQC
• National Quality Forum (NQF) never events
• Magnitude of preventable harm unknown

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Central Mandate
x
Scientifically Sound
Feasible
Local Wisdom
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(No Transcript)
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How do we need to learn?
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Strategy

• Who are we?
• Where are we going?
• How will we get there?

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Who are we?

• 75 participating hospitals
• 48 hospitals completed readiness survey
• 27 urban, 21 rural (including 10 critical access)
• 45 community, 16 w/ residents, 3 academic
• Median bed size 172 (14 - 1000)
• Median annual surgical volume
• In-patient 2148 (34 21,500)
• Out-patient 4442 (469 15,269)

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Keystone SurgeryCollaborative Goals

• Develop a safety scorecard
• Eliminate surgical site infections, by ensuring
  that 90 of patients receive evidence-based
  interventions for preventing surgical site
  infections
• Eliminate mislabeled specimens
• Learn from our mistakes, in particular focusing
  on the National Quality Forums Never events
  (wrong site surgery and retained foreign bodies)
• Have 80 of your staff reporting positive safety
  and teamwork climate using a measurement
  instrument that is psychometrically sound.

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How will be get there?

• Use collaborative model to learn together
• Central support from MHA for technical work
  (evidence and measures)
• Local leadership to execute
• Ohana

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Michigan Keystone ICU
N Engl J Med 20063552725-32
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"Needs Improvement Statewide Michigan CUSP ICU
Results

• Less than 60 of respondents reporting good
  safety climate needs improvement
• Statewide in 2004 84 needed improvement, in 2006
  41
• Non-teaching and Faith-based ICUs improved the
  most
• Safety Climate item that drives improvement I
  am encouraged by my colleagues to report any
  patient safety concerns I may have

 
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Lessons Learned

• Harm is preventable
• Need to overcome prior beliefs that constrain
• Collaborative social network
• Ohana
• Hard to learn within single institution
• Learning network
• Culture is important
• Couple with clinical focus
• Can be improved

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Potential Challenges

• Surgical teams are complex
• Diffusion of innovation in ORs challenging
• Data collection burdensome

Your hospitals have done it before Surgery and
Anesthesia long history of learning and
improvement
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How does this collaborative compare to other
efforts?

• CMS SCIP
• ACS NSQIP
• BCBSM MSQC

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How do we organize safety work

• Evaluate progress in Safety
• Translate evidence into practice
• SSI and DVT
• Improve Culture and Communication
• CUSP
• Identify and learn from mistakes
• Wrong site/sided surgery
• Organize for patient safety

Pronovost Circulation (in press)
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Perioperative Safety Scorecard

• How often do we harm patients?
• Eliminate surgical site infections
• How often do we do what we should?
• gt 90 compliance with SSI prevention process
  measures
• How often do we learn from defects?
• Learn from one per month- NQF never events
• How well do we improve culture?
• CUSP with quantitative assessment of culture

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Draft Timeline

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Proposed Hospital Organizational Structure
Intervention Specific Subgroups CUSP (culture,
mistakes) SSI Mislabeled specimens Wrong Site
surgery DVT Retained foreign bodies
K-Surgery Committee Executive Sponsor PI
Director Nursing Director Anesthesia
Chair Surgery Chair Hospital Epidemiologist Safety
Nurse Physician and nurse from each team
Clinical Area Team A (ie neurosurgery) RN
Champion Surgeon Champion Anesthesiologist
Champion Executive Champion
Clinical Area Team B (ie ortho) RN
Champion Surgeon Champion Anesthesiologist
Champion Executive Champion
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What do you need to do?

• Discuss the project with OR and hospital leaders
• Decide what ORs or OR teams you want to start
  with
• Create a project team that includes surgeon,
  anesthesiologists, nurses, administrator
• Select project manager

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Data Collection Plan

• Consider initial focus on 2 surgical specialties
  (ie neuro, ortho etc)
• Minimize data collection burden
• Intercept subset of data from SCIP, MSQC, NSQIP
• Balance quantity vs quality
• Focus on complete data collection

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How Will Teams Be Supported?

• This is complicated work in a complex setting --
  OHANA
• Communication across and within teams is critical
  for rapid dissemination of content, evolution of
  knowledge and improvement of outcomes
• Several mechanisms designed to support the groups
  and will refine these with your input- recorded
  coaching calls, content calls, podcasts,
  face-to-face workshops

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Ongoing Project Management

• Periodic newsletters, aggregate project
  updates etc to make your own
• Web based audio presentations
• Project powerpoint presentations that you may
  personalize for use in your own organization
• Toolkits for all interventions
• Training and tools for measurement

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Next Steps

• Summarize and provide feedback from readiness
  survey (MHA/QSRG)
• Distribute conference call schedule and workshop
  information (MHA/QSRG)
• Complete the readiness survey (YOU)
• Establish your team and meet to develop internal
  infrastructure (YOU)
• who should be included?
• start with all ORs or pick specialty areas?

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Mark Your Calendars

• Keystone Surgery workshop is being held 4/28 and
  4/29 in Dearborn, MI.
• We will be starting at 12 noon on 4/28 and
  concluding by 3pm on 4/29.
• There will be a reception in the evening of 4/28.
• Bring as many team members as you can

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Discussion