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Leadership Council for Clinical Quality,Safety and Service GoalsQuality Improvement:Engaging the TeamReduce Potential Preventable Quality & Safety EventsQuality &SafetyAchieve top decile status for health system riskadjusted inpatient mortality rate (0.67).Enhance educational programs for Quality & SafetySusan Moffatt-Bruce, MD, PhDChief Quality and Patient Safety OfficerExpand performance transparency and accountabilityas it related to quality, safety & service outcomesacross the Health SystemProductivity &EfficiencyService &ReputationAgendaReduce Health System ALOS to 6.03 days.Achieve top decile status by 2012 for patientsatisfaction(2009 Health System target 87.9)Quality and Safety ScorecardType of Event Leadership Quality & Patient Safety Goals Just Culture Quality Processes and Ongoing Evaluation Importance of Checklists Using data to improve performanceRetained Foreign BodiesWrong Site EventsMedication Events with Harm (Severity E-I)Medication Events with Intervention to Prevent Harm (Severity D)Severe Injury Falls (Resulting in change in patient outcome)Hospital Acquired Decubitus UlcerHospital Acquired MRSAHospital Acquired VREHospital Acquired Central Line Blood Stream InfectionsVentilator Associated PneumoniaHospital Acquired Surgical Site InfectionsHospital Acquired Clostridium difficile InfectionOther Sentinel EventsDeath in Low Mortality DRGCodes Outside of ICU1

“JustAccountabilityJust CultureCulture” – Balance system and processTo guide organizations when making fair decisions,decision algorithms have been developed. Thesealgorithms typically ask a series of questions:issues with accountability for expected behaviors The just culture is not a blame-free culture. Itmerely tries to provide a consistent guide todetermine:1) When a person is truly at fault for a specific act2) Reasonable consequences that will best servethe individual’s and the organization’s interests Were the actions intended?Was the person under the influence of unauthorizedsubstances?Did the person knowingly violate existing policies,procedures, or expectations?Would another person in the same situation perform inthe same manner?Does this person have a history of unsafe acts?Just CultureThe four key categories of fault in a justculture are: Human error: Unintended slips, lapses, andmistakes Negligent conduct: Failure to exercise careexpected of a prudent worker Reckless conduct: Conscious disregard fora known risk Knowing violations: conscious disregardfor known rulesReason, J: Managing the Risk of Organizational Accidents2

Practitioner PerformanceEvaluationQuality Processes andOngoing Review Partnership between9 Department Chairs9 Quality Department9 Credentialing Department9 Chief Quality and Patient Safety Officer9 Chief Medical Officer To evaluate the competency andprofessional performance of anindividual practitioner9Initial applicant -FPPE9New privilege request-FPPE9Concern has been identified-FPPE9Ongoing basis-OPPEQuality Review ProcessesQuality Review ProcessOPPE (Profile)Global/SSI outlieror trendsMorbidity &MortalityReview outcome (s)Mortality Review(single egregious ortrends in highseverity outcome)Insurance/ ManagedCare QualityNoticeTriggers forfurther review1PEC ChairreviewsPEC Chair notifiesDept Chair,that case goingto PECPractitioner notifiedPhysician Executive Council Role (PEC)1.Review determinations from prior levels of review,including OPPE & FPPE2.Obtain additional clinical expertise frominternal/external physician3.Notify practitioner of any preliminaryissues/concerns & request input prior to finaldisposition4.Final disposition to DMA/CMO as appropriateCase reviewedat PECPEC PotentialRecommendationsNo action –continue OPPEDept Chair –processimprovementplanEvent Report((singlei l egregiousi[sentinel]or trends)Dept Chair –observationProfessionalismCouncilFPPE (new privilege/new practitioner)indicator outlieror trendsDept ChairreferralTerry Zang, RNQuality & Operations 06.11.10Contact: Susan Moffatt-BruceNoDept Chair –proctoringCommittee forLIHP HealthNotify practitioner &Dept. Chairof findingsRequiresrecommendationto CMO/DMA/Chair?Close caseYesDept Chair –simulationProfessionalismCouncilCMO initiates formalpeer review processas outlined in BylawsEngageDMA/CMO1Triggercases follow determined processes &are peer reviewed prior to forwarding to ChiefQuality & Pt. Safety OfficerPractitioner PerformanceEvaluation Six core competencies that wereoriginally developed for the GraduateMedical Education:1) Patient care2) Medical knowledge3) Practice-based learning andimprovement4) Interpersonal and communicationskills5) Systems-based practice3

FPPE – Initial Privilege(New Applicant) Initial privilege request – new Applicant Requires evidence of competency in 10 clinicalencounters (outpatient or inpatient; office visit) Initial period of FPPE is 6 months (provisionalperiod) Must be pertinent to the privileges requested Evidence is reviewed by the Chief Quality &Safety Officer and Credentials Committee prior tomoving to full active appointmentFPPE – New Privilege Current members of the medical staff or licensedhealthcare professional staff with specificallydelineated clinical privileges who are requestinga new privilege will be granted the new privilegeon a Provisional basisbasis. The review criteria may vary, but the review mustbe specifically relevant to the privilege granted Evidence is reviewed by the Chief Quality &Safety Officer and Credentials Committee prior toapproving new privilegeFPPE – For Cause Appropriate when questions arise regarding acurrently privileged practitioner’s ability toprovide safe, high quality patient care Triggers include but are not limited to:999999Event Reporting trends or single egregious casePatient/Family complaintReferral from the Department ChairUnprofessional behaviorOutliers identified in FPPE for applicant or privilegeOutliers identified during OPPEOngoing PractitionerPerformance Evaluation Biannual evaluation of each Department member with theDepartment Chair Aligns with reappointment and data are used todetermine:9 Maintenance of privileges9 Modification of privileges9 Termination of privileges Global indicators (mortality, LOS, readmission) Service-specific indicators as approved by the Divisionand Department Low volume faculty- 23 / 2 years4

Quality Review ProcessesQuality Review ProcessOPPE (Profile)Global/SSI outlieror trendsMorbidity &MortalityReview outcome (s)Mortality Review(single egregious ortrends in highseverity outcome)Insurance/ ManagedCare QualityNoticeTriggers forfurther review1PEC ChairreviewsPEC Chair notifiesDept Chair,that case goingto PECPractitioner notifiedPhysician Executive Council Role (PEC)1.Review determinations from prior levels of review,including OPPE & FPPE2.Obtain additional clinical expertise frominternal/external physician3.Notify practitioner of any preliminaryissues/concerns & request input prior to finaldisposition4.Final disposition to DMA/CMO as appropriateCase reviewedat PECPEC PotentialRecommendationsNo action –continue OPPEDept Chair –processimprovementplanEvent Report((singlei l egregiousi[sentinel]or trends)Dept Chair –observationProfessionalismCouncilFPPE (new privilege/new practitioner)indicator outlieror trendsDept ChairreferralTerry Zang, RNQuality & Operations 06.11.10Contact: Susan Moffatt-BruceNoDept Chair –proctoringCommittee forLIHP HealthNotify practitioner &Dept. Chairof findingsRequiresrecommendationto CMO/DMA/Chair?Close caseYesDept Chair –simulationProfessionalismCouncilCMO initiates formalpeer review processas outlined in Bylaws“ Check lists help achieve that balance theysupply a set of checks to ensure the stupid butcritical stuff is not overlooked, and they supplyanother set of checks to ensure people talk andcoordinate and accept responsibility whilenonetheless being left the power to manage thenuances and unpredictabilities the best theyknow how.”Gawande “The Checklist Manifesto”EngageDMA/CMO1Triggercases follow determined processes &are peer reviewed prior to forwarding to ChiefQuality & Pt. Safety OfficerCheck Lists:Achieving “Zero Defects” Commitment to improving the process. Using “source check” and “sequential check” toeliminate defects.9 “Source check” is where the operatorimmediately checks his or her work to see ifthere is an error.9 “Sequential check” is a redundant checkwhere every worker checks to see that theprevious step has been performed correctly.OSUMC’s SafeSurgicalSi l ChecklistCh kli t Using systems that do not rely on memory.Checklists, prompts or forcing functions areneeded.5

Surgical Safety is a SeriousPublic Health IssueOSU Surgical Team Safety ChecklistSign In (Before Induction)Performed by Nursing andAnesthesiaTime Out (Before Skin Incision)Initiated/Led by SurgeonSign Out (Procedure Completed)Performed by OR TeamTeam Members IntroduceThemselves if Different TeamTeam Members IntroduceThemselvesPerformed Procedure RecordedBody Cavity Search PerformedOperation to be Performed Patient Identification About 234 million operations are done globallyeach year Procedure Site Confirmed Consent Blood Band AllergiesUninterrupted CountAnticipated Operative Course Sponges Sharps InstrumentsSite of ProcedurePatient PositioningCounts Correct Sponges Sharps InstrumentsAllergies A rate of 0.4-0.8% deaths and 3-16%complications means that at least 1 milliondeaths and 7 million disabling complicationsoccur each year worldwideConfirmation of Site Marking,when applicableAntibiotics Given Anesthesia AssessmentTimeSpecimens LabeledImaging Displayed Anesthesia Machine Check Monitors functional? Difficult Airway? Suction available? Patient’s ASA statusTeam DebriefingEvent Report FiledBlood Available Anticipated Blood Loss RiskEquipment AvailableThank YouAdapted from World Health OrganizationSeptember -0990%Q1-09100%Q4-08SCIP Measure:Prophylactic Antibiotic within 1 Hour of Incision:A surrogate for 4-07Q3-07Q2-07Q1-07Q4-060%Q3-0610%Q2-06World Health Organization(WHO) Surgical Safe Checklist6

WHO Safe Surgical Checklist wasfound to reduce the rate ofpostoperative complications and deathby more than one-third .Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a GlobalPopulation. New England Journal of Medicine 360:491-9. (2009)OSUMC’s Video:mms://media.twomd.ohiostate.edu/medical center/Safety Checklist.wmvBedside ProceduresAll other deep, percutaneous procedures(e.g. biopsies, drainage)Infusion of drugs to middle earArthrocentesisLumbar punctureBone marrow aspiration or biopsyPacenthesisBracytherapyAll procedures in the Radiation OncologyDepartmentCentral venous catheter insertionPeripheral arterial lines (A-line) insertionChChesttubeb placementlPlPlacementoff regionalil anesthesiah i blocksbl kCircumcisions (Neonatal)Regional and local nerve blockplacementElectro-convulsive therapy (ECT)Swan-Ganz amma knifeTraction pin placementICP drains and pressure monitorplacementWound debridement as a plannedprocedure, does not include minordebridement during a routine dressingchangeThree StepsUniversal Protocol –Three Step Checklist1. Conduct a PreProcedureVerification2. Mark theProcedure Site3. Perform a “TimeOut”7