Patient safety across the continuum of care: provocations and considerations

1
Patient safety across the continuum of care
provocations and considerations

• Joseph S. Bujak, MD, FACP
• WHIN Patient Safety Conference
• Richmond, BC
• June 8, 2006

2
Industry Considerations
3
How can you simultaneously specialize and
integrate?
4
Who has a vested interest in storing, assessing,
interpreting, and advising about healthcare data?
5
Who has a vested interest in patient safety?

• Patient
• Payer
• Provider (liability, ethics, at-risk
  reimbursement)
• Entrepreneur

6
Three Drivers for Hospitals to Improve
Quality Reinertsen
7
Digitalization frees individuals to seek advice
beyond current limitations of licensure, and
geography
8
The Overdosing of America
9
The solution

• Software
• Individual
• Entrepreneur
• Data management, technology that empowers the
  individual (at home diagnostics)

10
Cultural Considerations
11
Errors and MishapsViolationsSabotage
12
Three barriers to quality improvement

• Knowing is doing
• No harm no foul
• The provider culture

13
Patient Safety - Human ErrorProcess Design

• Process Design
• Reduce Reliance on Memory Vigilance
• Simplify
• Standardize
• Checklists
• Forcing Functions
• Eliminate Look and Sound-alikes
• Bagian

14
Systematic

• Human Error Must Have Preceding Cause
• Failure to Follow Procedure By Itself Is NOT a
  Root Cause
• Negative Descriptors Arent Actionable
• Bagian

15
Jarmans Hospital Standardized Mortality Rate

• Compares your hospitals death rate for each
  diagnostic cell by age/sex/admission type and
  source what the national experience for that
  cell
• Is adjusted for community features such as
  socioeconomic status, availability of hospice
• Eliminates all deaths within 24 hours of
  admission
• Is a systemic property of a hospitalnot a
  function of one or two diseases that the hospital
  treats, or a few bad doctors.

J.M. Reinertsen, MD
16

• Holding physicians accountable
• Discredit the data
• Justify the data
• Shoot the messenger

17
Levels of Reliability in Health Care (Amalberti,
Nolan) (from Reinertsen)
18
The focus on maintaining individual physician
autonomy is sacrificing physician group autonomy
19
How can we hope to regain/maintain trust and
confidence if we cant demonstrate that we
practice state of the art, evidence-based
medicine?Average time to widespread adoption of
new knowledge is 18 years
20
Question for your Medical Staff

• Beyond sterile technique in the OR, could you
  agree on evidence-based practices that should be
  done for a particular diagnosis or procedure for
  every patient, even if a doctor doesnt order
  them?
• If you reached agreement on a list of these
  operating systems how would you make sure that
  they are done, reliably?

J.M. Reinertsen, MD
21
Medication Safety

• High risk meds (anticoagulants, pain, insulin)
• Allergies, weight based dosing
• IV medsgtPO

22
Major areas of medication risk

• Insulin
• Pain management
• Anticoagulation
• antibiotics

23
What are the major areas of risk?

• Medication errors
• Nosocomial errors (sensitivity and specificity
  -Bayes theorem)

24
Time, complexity, busyness, task orientation,
overwhelmed with the trees-cant see the forest
25
The science of medicine versus the art of
medicine a polarity to be managed, not a problem
to be solved
26
4 areas that challenge the appropriateness of
standardization
27
1. Inherently conflicting goals

• Pain management
• End of life care
• The Technical vs the Complex (Can do vs Should do)

28
2. Advancing clinical medicine

• Excellence is a manifestation of deviant behavior

29
3. Appropriately individualizing care

• Depersonalization of care (The patient has become
  incidental to the practice of medicine)
• Efficiency should never apply to human
  relationships

30
4. Maintaining the doctors presence in the
health care equation

• The private encounter between the sufferer and
  the healer (The art of the history and physical
  examination) The power to heal-the source of the
  joy. Healing versus curing, wisdom versus
  knowledge

31
The substitution of technology for caretaking
threatens the soul of medicine.
32
Too often we even practice medicine this way.
Side by side, patient and physician focus on the
disease, the symptoms, the treatments, never
seeing or knowing each other. The problem gets in
the way and we are each alone. Rachel Remen
33
Our argument is for the steady advance and
application of science (but not its deification)
in a context that equally values and respects
individualized human needs. It is the distinction
between curing and healing.
34
Hopefully the push toward emphasis on
evidence-based medicine, public reporting of
performance data, and pay for performance wont
serve to extinguish the art of medicine, devalue
transformational doctor-patient relationships or
penalize creativity. Those aspects of the
physicians role are intrinsic to the joy and
privilege that attend this unique profession, and
live, always in some tension with our obligation
to make rigorous use of best science.