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Systems based practice Andrew G. Lee, MDProfessor of Ophthalmology, Neurology, andNeurosurgery, Weill Cornell Medical CollegeChair, Dept. Ophthalmology, The Methodist HospitalAdjunct Professor of Ophthalmology: U. Iowa Hospitals& Clinics and Baylor College of MedicineClinical Professor : UTMB Galveston, UTMDACC

I have no relevant financial interest inthe contents of this talkDisclosuresPI: American GeriatricsSociety GSIPI: Lilly NAION studyStock: Credential ProtectionAdvisory Board: Alcon,Cataract education in ChinaReviewer: NASA, VIIPstudy sectionHonorarium: NoneSpeakers bureau: None

Relevant Disclosures Dr. Lee is a member of the Residency ReviewCommittee (RRC(RRC)) for OphthalmologyACGME Ophthalmology Milestones Working GroupExaminer/prop writer for the American Board ofOphthalmology (ABO(ABO)) & OKAP test writing committeeResidency Education Committee (REC(REC)) for theAmerican Academy of Ophthalmology (AAO(AAO))Association of University Professors of Ophthalmology(AUPOAUPO)) Fellowship Compliance CommitteeThe views expressed here do not reflect those ofRRC, ACGME, OKAP, ABO, REC, AAO, or AUPO

Start with a philosophical question Why are you here .?

These talks contain information of a graphic nature and some materialmay be inappropriate for unengaged learners.You will be asked tomake a behavior change at the end. Viewer discretion is advised.

Women in audience close your eyes .Men:What do you see (keep it to yourself for now)?

OK, now men cover your eyes. Women: Whatdo you see (keep to yourself for now)?

What did you see?Men? Women?How much would you bet that the other person is wrong?How strongly would you argue the point?

Remember this the next time youget in a fight with .

Objectives Definesystems based practice (SBP) Describe your system(s) of care Encourage you to commit to usingsystems based practice & learning End with a practical real worldrecommendation

Defining Systems based competency:ACGME perspective Systems--Based PracticeSystemsAwareness of and responsiveness to larger context &system of health care Ability to effectively call on system resources toprovide care that optimal i.e., Work within the health care system

Systems based care Micro-system of care (your clinic, your office, the O.R.)MicroSmall macromacro-system (your hospital, your state)Large macromacro-system (Medicare, US health care system, Payfor Performance)

Which part of system are you on?WeightlossFUONAIONTMJPMRHeadache

The artery on the side of my headhurtsI have GCA

Initial symptoms in GCA (n 100)PMRFUOTVL

Why do we still miss GCA?

The elephant in the room

How many systems can you find? sTeamwork with nursing, labs, radiologyPharmacyReferring & primary care doctors

Systems based practice patientsafety

It takes a village Parking attendantRegistrationEmergency roomNurseTechnicianResident or fellowLabRadiologyReferring doctorSocial workerPATIENT

Systems--based practice team workSystems

When I was a resident .Our busy operating room inophthalmology Cataract surgery day Two patients Mary Smith (not real names) Mary K. Smith Mary L. Smith Wrong intraocular lens in BOTH patients

Maria Garcia is a super commonname at Ben Taub Hospital HCHD patients database:3,428,925 2 pts same last & first names: 249,213 4 share same last & first names: 76,354 2 same last & first name & dob: 69,807Maria GarciasGarcias::2,488Maria Garcias with same date of birth: 231

Challenge question Whatshould we do with our nextMaria Garza patient? What is your system for avoidingwrong patient, wrong name, samename, wrong medication, wrong sitesurgery ?

United flight 232 United flight 232 Denver to ChicagoJuly 19, 1989Captain Al Haynes: 30,000 hour pilotFirst Officer Records & Engineer DvorakEight flight attendants285 passengers on board DCDC-10

Uh Oh Somewhere over IowaFan broke apart, lost #2 engineNo hydraulicsPlane can not fly withouthydraulicsSioux City had an open runwayCapt. Haynes kept his coolCapt. Haynes formed a team

Team building Passenger on board: Dennis Fitch, a Unitedtraining & check pilot3,000 hours on DCDC-10They could only turn rightThey had no controlsThey used the engine thrust to steerThis had been done once before in Japan (Fitchhad studied it)

Capt Fitch meet Capt Haynes Transcript of meeting of Captains in cockpitHaynes: “My name's Al Haynes”Fitch: “Hi, Al. Denny Fitch”Haynes: “How do you do, Denny?”Fitch: “I'll tell you what. We'll have a beer whenthis is all done”Haynes: “Well, I don't drink, but I'll sure as hellhave one.”

Transcript for the approach Sioux City Approach: United two thirtythirty-two You're cleared to land on any runway.Haynes: [Laughter] Roger. [Laughter] You wantto be particular and make it a runway, huh?

Initially pointed to Des Moines thenSioux City, Iowa

The plane crash landed but landed 111 diedBut 185 survivedIncluding Captain Haynes

After the accident 57 flight crews could not replicate the landing inthe simulator

Challenge question: What shouldwe do now?1.2.3.4.Congratulate Captain HaynesMake a charitable donation in his nameAvoid flyingPerform a root cause analysis

Root cause analysis Fracture of fan diskFailure of maintenance process to detect crackMetal 'inclusion' in diskDefect traced back to metal processing plantDefect in elimination of gaseous anomaliesduring purifying of (molten) titanium disk ingotNewer batches used a 'triple vacuum' process toeliminate these impurities.

The fan failed

Fan reconstructed

Examples: Quality Assurance Systems based carePatient safetyReduce medical errorsReduce medication errorsEliminate wrong site surgeryCompetency ToolsNear miss analysisRoot cause analysisResident porfolio projectsSelf--reflection exercisesSelf

Reason’s Swiss cheese

Active failures vs. latent conditions

Alignment of the holes leads tooutcome of error

Culture change: Don’t blame the lastslice of cheeseMiddle of night ER visitNo formalVisual fieldsat nightRadiologyOrder formDiscuss withradiologyStroke patientDischarged with“normal CT”Look at filmsResidentFacultyRadiologyresident

We are all responsible for patientsafety

Jesica Santillan

Jesica Santillan’s story Congenital restrictive cardiomyopathyTransplant was her only hope of survivalFather was a truck driver near Guadalajara,Mexico (illegal immigrants to USA)North Carolina businessman adopted her cause

Feb 6, 2003 Carolina Donor Services (CDS) offers transplantableheart to Duke (middle of night)First potential recipient was not ready for transplantDoctors asked if organs might be available for JesicaOrgan procurement coordinator offers to check thisand call back, and when they did .Doctors assumed that CDS wouldn't have called backand released the organs unless they were a matchThis was a wrong assumption

The rest of the story Organs brought to Duke (Known Type A)Following implantation of organs(approximately 10:00 p.m.), surgical teamreceived a call from Duke's Clinical TransplantImmunology Laboratory reporting organs wereincompatible with Jesica's blood type (Type O)Despite aggressive treatment & a secondtransplant, Jesica died

Multiple holes in the Swiss Cheese Organ Procurement didn’t ask if matchedHarvesting surgeon knew Type was A butassumed it was a matchDr. Jaggers knew patient was Type O butassumed donor was a match12 doctors came into contact with this chart butnone noticed the mismatch

It isn’t about bad hospitals 2001: Johns Hopkins All 2,400 federallyfinanced experiments shut down because EllenRoche died after inhaling hexamethonium in anasthma experiment1995 Memorial SloanSloan-Kettering: chiefneurosurgeon operated on wrong side1994 Dana Farber Cancer Ctr: Overdose ofchemotherapy for breast cancer

Human errors in the ICU Crit Care Med 1995;23:2941995;23:294-300. Donchin et al.4 months observation timeAverage of 178 activities per patient per dayEstimated 1.7 errors per patient per daySevere or potentially detrimental error occurredon average twice a dayPhysicians and nurses were about equalcontributors to the number of errors

Translation: Not good enough ICU function 99% level of proficiencyA 99.9% proficiency rating2 unsafe landings at O'Hare airport everyday 16,000 pieces of lost mail every hour 32,000 bank checks directed from the wrong bankaccount every hour Error in Medicine, JAMA, 272:1851,1994.

A true story of my own . 65 y/o WM with optic neuropathyMRI, labs, chest xx-ray orderedScheduled follow up in 3 weeksPatient did not return for follow upMRI reviewed and normal on reportLabs in electronic record report (IPR) negative

3 months later Chest xx-ray report appears in my electronicmailbox (months later): “Right upper lungnodule”Patient had moved to New JerseyOld number & address were disconnectedNo forwarding number or address in EMR

Now what .

Name the system errors Resident ordering study did not get chest xray toreview at roundsFaculty did not review x ray (did not know itexisted!)Electronic reporting did not put report in in boxRadiologist did not callThree month delay was not flagged

The rest of the story Found patient’s brother in IowaCalled patient in New JerseyDisclosed situation by phoneCalled patient’s new primary doctor in NJRepeat chest film showed .No change, benignnoduleWhew!.

System improvements Work rounds listLetter to no showsLook up dictation for no showsRadiology instructed to call for lung nodulesIPR back log flags

What is your system for tracking labs andradiographs? When you have a sentinelevent do you do a root cause analysis?

"Every system is perfectly designedto achieve the results it does."Don Berwick: Institute for Health Care Improvement

The story of Patrick Patrick Reynolds is an antianti-smoking advocateFoundation for a smoke free AmericaPatrick’s father died from smoking related COPDPatrick’s brother died from smoking related COPDPatrick’s aunt died from stomach cancerPatrick’s grandfather died of pancreatic cancerAll were tobacco usersThat’s not the interesting part

Patrick is antismokingbecause . Patrick’s brother was R.J. Reynolds IIIPatrick’s father was R.J. Reynolds, Jr.Patrick’s grandfather was R.J. ReynoldsReynold’s (Camel, Kool, Doral, Winston, Salem)2 billion smokers worldwide200 million will die from tobacco related illnesses

Smoking is bad for you, Patrick wants you to know thisand he knows from experience

Evidence shows MD telling them toquit DOES make a difference 1972-2003: 39 different trials on effects of1972doctors telling 31,000 people to quit smokingBeing hounded to quit smoking by their doctormade people almost twice as likely to quit!Extra 2.5% of tobacco addicts did quitWhat is our system for smoking cessation inthe eye clinic?

Smoking related eye disease CataractAge related macular degenerationDiabetic retinopathyIschemic optic neuropathyThyroid ophthalmopathy

Smoking cessation and interventions do work

The challenge question: What isyour system based practice forsmoking cessation?

Teamwork training MedTeams (Department of Defense)43% of errors in ER teamwork coordination79% deemed preventableEmergency Team Coordination Course (ETCC)67% increase in error averting behavior after ETCC &58% reduction in observable errorsRisser et al. Ann Emerg Med 1999;34:373.Morey et al. Health Serv Res 2002;37:1553.

Creating a culture of safety Old paradigmCulture of blame NameBlameShameBarriers to disclosureLast person in line causeNew paradigmCulture of safety No namesNo blameNo shameNo barriers to disclosureof errorRoot cause analysisSystems improvement

Not communicating

Root cause?

ComplexityTMIToo muchinformation

Does TMI remind you of anywhere?

TransitionsBroken dialsMaintenanceMisreading signs

Milestones Focus on transitions

Milestones & PDSA cycles (QA)

Practical adviceResident Quality ImprovementProject Checklist for compliance All residents participate (not just one)Scheduled (not ad hoc) & protected timeStructured not random, meetings & discussionFaculty supervision, oversight, mentorshipWritten documentation in portfolioBackground, Methods, Results, Outcome (PDSA(PDSA))Linkage to downstream improvement in patientsafety, quality, or cost reducation