Title: Patient safety across the continuum of care: provocations and considerations
1Patient safety across the continuum of care
provocations and considerations
- Joseph S. Bujak, MD, FACP
- WHIN Patient Safety Conference
- Richmond, BC
- June 8, 2006
2Industry Considerations
3How can you simultaneously specialize and
integrate?
4Who has a vested interest in storing, assessing,
interpreting, and advising about healthcare data?
5Who has a vested interest in patient safety?
- Patient
- Payer
- Provider (liability, ethics, at-risk
reimbursement) - Entrepreneur
6Three Drivers for Hospitals to Improve
Quality Reinertsen
7Digitalization frees individuals to seek advice
beyond current limitations of licensure, and
geography
8The Overdosing of America
9The solution
- Software
- Individual
- Entrepreneur
- Data management, technology that empowers the
individual (at home diagnostics)
10Cultural Considerations
11Errors and MishapsViolationsSabotage
12Three barriers to quality improvement
- Knowing is doing
- No harm no foul
- The provider culture
13Patient Safety - Human ErrorProcess Design
- Process Design
- Reduce Reliance on Memory Vigilance
- Simplify
- Standardize
- Checklists
- Forcing Functions
- Eliminate Look and Sound-alikes
- Bagian
14Systematic
- Human Error Must Have Preceding Cause
- Failure to Follow Procedure By Itself Is NOT a
Root Cause - Negative Descriptors Arent Actionable
- Bagian
15Jarmans 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
17Levels of Reliability in Health Care (Amalberti,
Nolan) (from Reinertsen)
18The focus on maintaining individual physician
autonomy is sacrificing physician group autonomy
19How 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
20Question 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
21Medication Safety
- High risk meds (anticoagulants, pain, insulin)
- Allergies, weight based dosing
- IV medsgtPO
22Major areas of medication risk
- Insulin
- Pain management
- Anticoagulation
- antibiotics
23What are the major areas of risk?
- Medication errors
- Nosocomial errors (sensitivity and specificity
-Bayes theorem)
24Time, complexity, busyness, task orientation,
overwhelmed with the trees-cant see the forest
25The science of medicine versus the art of
medicine a polarity to be managed, not a problem
to be solved
264 areas that challenge the appropriateness of
standardization
271. Inherently conflicting goals
- Pain management
- End of life care
- The Technical vs the Complex (Can do vs Should do)
282. Advancing clinical medicine
- Excellence is a manifestation of deviant behavior
293. Appropriately individualizing care
- Depersonalization of care (The patient has become
incidental to the practice of medicine) - Efficiency should never apply to human
relationships
304. 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
31The substitution of technology for caretaking
threatens the soul of medicine.
32Too 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.
34Hopefully 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.