IHI Expedition Improving Safety and Reliability for Surgical - - PDF document

11/14/2013 1

IHI Expedition

Improving Safety and Reliability for Surgical Procedures Session 1

Thursday, November 14, 2013

These presenters have nothing to disclose

Anthony DiGioia, MD Kathy Duncan, RN

Expedition Coordinator

Chris Chue, Project Coordinator at the Institute for Healthcare Improvement. Chris has worked on

• rganizing any care transition related activities

through the STate Action on Avoidable Rehospitalizations (STAAR) Initiative. He has also supported several webinars such as the Primary Care Coach Program: Wave 3, IHI’s Expedition on Reducing Readmissions, and many others. In addition, he is an avid Boston Celtics fan, go Celtics!

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WebEx Quick Reference

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Let’s Practice Using “Chat”

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• rganization name and the number of people
• n the call with you.
• Ex. “Institute for Healthcare Improvement – 2”

Get unlimited access to Expeditions, two- to four- month, interactive, web-based programs designed to help front-line teams make rapid improvements. Train your middle managers to effectively lead quality improvement initiatives. Enhance your strategic planning with customized whole systems data and selected benchmarking information. . . . and much, much more for $5,000 per year! Visit www.IHI.org/passport for details To enroll, call 617-301-4800 or email info@ihi.org

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What Is an Expedition?

Ex•pe•di•tion (noun)

• 1. an excursion, journey, or voyage made for some

specific purpose

• 2. the group of persons engaged in such an

activity

• 3. promptness or speed in accomplishing

something

Expedition Support

All sessions are recorded Materials are sent one day in advance Listserv address for session communications: surgeryexpedition@ls.ihi.org

– To add colleagues, email us at info@ihi.org

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Where are you joining from?

Expedition Director

Kathy D. Duncan, RN, Faculty, Institute for Healthcare Improvement (IHI), oversees multiple areas of content and is the clinical lead for IHI’s National Learning Network. Ms. Duncan also directs content development and provides spread expertise for IHI’s Project JOINTS as well as additional content direction for the Hospital Portfolio, directs a number of virtual learning webinar series, and manages IHI’s work in rural settings. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation

• Community. In addition to her leadership on the field team during the

Campaign, Ms. Duncan was the content lead for several interventions in IHI’s 100,000 Lives and 5 Million Lives Campaigns. She also serves as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care for a large community hospital.

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Today’s Agenda

Ground Rules & Introductions Safer Surgery from Start to Finish IHI’s Model for Improvement

Ground Rules

We learn from one another – “All teach, all learn” Why reinvent the wheel? – Steal shamelessly This is a transparent learning environment All ideas/feedback are welcome and encouraged!

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Expedition Objectives

By the end of this Expedition, participants will be able to: Identify specific opportunities to improve safety and reliability during the patient’s surgical experience Improve reliability of key processes identified during each step of the surgical suite Identify and test strategies to decrease risk of surgical site infection Describe strategies to identify failures during the surgical process

Expedition Schedule

Session Date/Time Lead Faculty: Summary

Session 2: Pre-Operative Processes Thursday, 12/5 @ 1:00 – 2:00 PM ET Thomas Varghese, MD, University of Washington Strong for Surgery Program Engaging patients long before scheduled surgery Session 3: Innovative Strategies for Hip and Knee Surgery Thursday, 12/19 @ 1:00 – 2:00 PM ET Deborah Yokoe, MD, Brigham and Women’s Hospital Pre-Op screening/decolonization process Pre-Op process for CHG bathing Session 4: Pre-Operative Processes Post-Admission Thursday, 1/9 @ 1:00 – 2:00 PM ET Gerald Healy, MD, Harvard University Medical School Sheila Barnett, MD, Beth Israel Deaconess Medical Center Standardize patient experience immediate pre-op BIDMC team discusses their best practices Session 5: Perioperative Processes Thursday, 1/23 @ 1:00 – 2:00 PM ET William Berry, MD Harvard School of Public Health Team work and communication Standardize immediate post-op process Session 6: Post-Operative Processes Thursday, 2/6 @ 1:00 – 2:00 PM ET William Berry, MD Harvard School of Public Health Post-op procedures Standardizing the end of the surgical process

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Faculty

Anthony M. DiGioia III, MD is a practicing orthopaedic surgeon and an engineer by

• training. He developed the Patient and Family Centered Care Methodology and

Practice (PFCC M/P), which is based on the “third” science for health care called the Design Sciences and builds upon traditional clinical research and process improvement efforts. PFCC M/P requires Care Givers to view all care through the eyes

• f patients and their families and transforms the delivery of care because care is

designed for the end user. PFCC M/P is an experienced based tool that co-designs services, interactions, processes and environments by partnering with patients and families as well as health care providers. This approach improves care delivery through a full cycle of care without the need for additional resources and most importantly, develops the culture to achieve outstanding outcomes, safety, quality and waste reduction. The PFCC M/P has been adopted in over sixty different care experiences at UPMC in Pittsburgh with great success and is now being adopted

• nationally. Dr. DiGioia collaborates with care givers and health care leaders to export

the PFCC Methodology and Practice for any care experience and any organization and is helping to develop a national PFCC Community of Practice. He is board certified in

• rthopaedic surgery and a Fellow of the American Academy of Orthopaedic Surgeons

and the American College of Surgeons and a Faculty Member for the Institute for Healthcare Improvement (IHI). He has received numerous professional awards including the Pittsburgh History Makers Award in the area of medicine and health.

Anthony M. DiGioia III, MD November 14, 2013 Tony@pfcusa.org www.pfcc.org/IHIExpedition

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Learning Objectives

• Deliver value and volume by

building your own Patient Focused Care Center

• Use performance and process

improvement tools that will improve outcomes, safety and experiences while reducing costs

Value = Outcomes Value in Health Care Cost

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Deliver Value by Developing a Patient Focused Care Center

• Deliver care for a specific medical

condition (or health) but viewed from the patient’s and family’s perspective

• Treatment for a full cycle of care by

design

• Reorganize and manage all resources to

meet the needs of patients and families

• Accountability for all outcomes and costs

Free Standing Subspecialty Hospital Inside an Existing Hospital Developing a Hospital within a Hospital

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• 1,600+ surgeries per year, only 2 OR’s a day

and 3 FT surgeons

• Over 88% of patients are discharged to

home…and with lowest length of stay

• Best outcomes as measured by

readmission rates, transfusion rates, infection rates and SCIP compliance and functional outcomes

• Lowest cost per case (real costs)

Our Journey in Developing the Bone and Joint Center

BJC Annual Report and Outcomes: http://www.pfcc.org/annual-reports/

3 Keys

• 1. View All Care as

an Experience Through the Eyes

• f Patients and

Families

• 2. Co-Design
• 3. Implementation

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• One month post-op f/u surveys

for every patient and family

• Determine your Current State, care

pathway and the true Touchpoints and Care Givers

• Start a Patient and Family

Advisory Council

How We Got Started…

Patient and Family Centered Care Methodology and Practice Amazingly simple… simply amazing www.pfcc.org

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• 1. Define Care Experience
• 2. Guiding Council
• 3. Shadow, Current State, Urgency
• 4. Working Group thru Touchpoints
• 5. Shared Vision of the Ideal
• 6. PFCC Project Teams

to Close the Gap

The PFCC Methodology and Practice Provides the Steps to Success

Ideal Experience Current State

Why a “Care Experience”?

• Defined through the eyes of patients

and families and includes everything that impacts their journey toward wellness.

• Examples include outcomes,

interactions with and among care providers, transitions in care, safety, costs, and everyone that touches their experience along the way.

11/14/2013 14 Touchpoints

• Parking
• Family Lounge
• Pre-Op Room
• Operating Room
• PACU
• Floor

Example: The Day of Surgery Care Experience

Care Givers

• None
• DOS Nurse
• DOS Nurse, Anesthesiologist,

CRNA, Surgeon

• Surgeon, Sales Rep, CRNA, PA,

Surgical Tech, RN, Float RN, Anesthesiologist, Housekeeper

• Transporter, X-Ray Tech, RN,

Anesthesiologist

• PCT, Surgeon, Dietary Aide, Rehab

Aide, Internist, PT, Housekeeper, PA, Case Manager, Social Work, RN, Transporter

Silo’s, Teams and Bundling

Home Health Insurance Pharmacy Home Health Outpt Therapy Rehab or Skilled Nursing Facility Physician Office Acute Hospital

*Follow the Patient

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Volume with Value

“While we believe that the concept of

• perating-room efficiency is an

important one, and efficiency can be improved by making process changes, we also want to emphasize that no increase in efficiency can substitute for good, safe patient care.”

Saleh, Shaled J., MD, Wendy M. Novicoff, PhD, David Rion, MD, Linda H. MacCracken, MBA, and Richard Siegrist, MS, MBA. "Operating-Room Throughout: Strategies for Improvement.” JBJSC. The Orthopaedic Forum (2009). Pg 2028-2039.

Tools to Understand Your Current State, Efficiencies and Opportunities for Improvement

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• 1. Define Care Experience
• 2. Guiding Council
• 3. Shadow, Current State, Urgency
• 4. Working Group thru Touchpoints
• 5. Shared Vision of the Ideal
• 6. PFCC Project Teams

to Close the Gap

Shadowing

Ideal Experience Current State

The Catalyst for Improvement is Shadowing

Shadowing is repeated and independent

• bservation of patients and

families as they move through each step of their health care journey

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Shadowing

• Determines Your Current State

Accurately and Efficiently

• Current State of Care Pathways
• Continuously Engages

End Users in Real Time: Patients, Families and Care Givers (Co-Design)

Shadowing: Day of Surgery

Observations

• Main Entrance Locked

at 5am

• No Valet
• Expected Routine

Disrupted

• Difficult/Long Walk to

Surgical Services Resolution

• Directions to Enter ER
• Skeletal Parking

5am-9am until Valet

• Clear Wayfinding
• Wheelchairs and

Scooters Available at Garage

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OR Flow Data Sheet

OR Flow Study

• Patient in room
• Surgeon in room
• Anesthesiologist in room
• Start of spinal
• Anesthesia turnover to OR

staff

• Foley in
• Prep complete
• Tourniquet inflation

(for TKR’s)

• Incision
• Tourniquet deflation

(for TKR’s)

• Surgeon breaks scrub
• Incision closed
• Patient out of room/PSA

called

• PSA in room
• PSA out of room
• Case Cart in room
• Begin to open
• Next patient in room

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OR Observation Project

Information about the processes surrounding surgery were recorded and analyzed. Many improvements were made to enhance OR efficiency and process flow as well as patient safety.

OR Observation Project

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High Performance OR Teams and Efficiencies

18.2 24.25 30 33

10 20 30 40

Best Median

Time (min)

Patient Out to Patient In (Turnover) Comparison: Magee-Womens Ortho & Clinical Advisory Board (CAB)

Magee CAB 43.1 52.9 66 69

20 40 60 80 Best Median Time (min)

Close to Cut Comparison: Magee- Womens Ortho & Clinical Advisory Board (CAB)

Magee CAB

Drives Efficiencies and Safe Surgery

Patient In to Patient Out: Magee-Womens Ortho & Clinical Advisory Board (CAB)

75 72 138 152 50 100 150 200 Hip Knee Time (min) Magee CAB

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Dedicated Team Approach

• OR’s Assigned to BJC to Manage
• OR Specialty Team
• Subspecialty Anesthesia Team
• Central Processing Partnership
• Housekeeping Team
• Assigned Nurses to Pre-Op Room
• Committed PACU Slots

3rd Team: “Swing Team”

• Consists of RN and Surgical Tech
• Liaison for Central Processing,

Equipment, Patient Prep, etc.

• Relieve 1st and 2nd teams for breaks
• Double check all prep for next

patient

Create Efficiencies 3 Teams for 2 OR’s

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Strategy for Post-Op

• PACU gridlock affects OR

efficiencies

• Anesthesia recovery time
• Multidisciplinary approach

improves OR throughput

Saleh, Shaled J., MD, Wendy M. Novicoff, PhD, David Rion, MD, Linda H. MacCracken, MBA, and Richard Siegrist, MS, MBA. "Operating-Room Throughout: Strategies for Improvement.” JBJSC. The Orthopaedic Forum (2009). Pg 2028-2039.

UPMC… Who are we?

UPMC is a $10 billion integrated global health system Pittsburgh’s largest employer with 55,000 employees More than 20 academic, community, and specialty hospitals and 400 outpatient sites, employs more than 3,200 physicians, and an array of rehabilitation, retirement, and long-term care facilities

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Surgical Care Experience Working Groups

• Trauma
• Day of Surgery
• Breast

Reconstruction

• Geriatric Hip

Fracture

• CV/Heart Valve
• TJR
• Bariatric
• Transplant
• Hysterectomy
• Women’s Cancer
• Surgical Care

Experience

The Patient Focused Care Center Welcome to the Magee Bone and Joint Center

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The Office Sets the Stage

• Education materials
• Surgery preparation
• Follow-up

appointments

• Flow of accurate

information

• OR Reservations/Equipment

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• MD meets patient

and “coach” in holding area

• Shows up and

ready to go…..

• Staff cross training

Day of Surgery Experience

Reduce anxiety No delays or cancellations

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Improving Safety, Quality & Waste Reduction Total Joint Replacement Care Experience

Readmission Rate Within 30 days TKA = 2.5% THA = 4.2%

Value = Outcomes Value in Health Care Cost

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Identifies true cost to deliver care and for any care experience:

• Personnel
• Space
• Equipment
• Consumables

What is TDABC? Time Driven Activity Based Costing

Robert S. Kaplan and Michael E. Porter “How to Solve the Cost Crisis in Health Care,” HBR 2011

The Link Between Cost and Process Improvement

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TDABC Results for TJR 30 Days Prior to 90 Days Post-Op

THR TKR

Consumables

54% 45%

Personnel

43% 51%

Space/Equipm ent

3% 4%

Ma p #

Care Experience

THR Total TKR Total 1 New Patient Scheduling Visit 0.1% 0.2% 1a Pre-Surgical Office Visit (30 days pre surgery) 2% 3% 1b Renaissance Billing 0.3% 0.3% 1c Administration Support - Surgery 3% 4% 2 Pre-Op Testing 2% 2% 3 Day of Surgery 3% 3% 3a Operating Room 57% 48% 3b Central Sterile 0.6% 1% 4 PACU 2.6% 3% 5a Inpatient Post-Op Day Zero 4.5% 5% 5b Inpatient Post-Op Day 1 6.9% 8% 5c Inpatient Post-Op Day 2 5.9% 7% 5d Inpatient Post-Op Day 3 3.5% 5% 6 Home Therapy & 4 week Follow-Up 5.2% 6% 7 3 Month Follow-Up (90 days Post-Op) 2.6% 3%

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THR TKR % cost in OR % cost in OR

Personnel

22% 29%

Space & Equipment

1% 1%

Consumables

77% 70%

PFCC Shadowing TDABC Helps Providers

Process Improvement Personnel and Resource Utilization

• Redesign processes
• Eliminates steps
• Reduce waste
• Optimize Flow
• Who should be doing the

work? Where?

• Reduce unused staff time,

equipment, facilities

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PFCC Shadowing TDABC A Common Platform

• Generate conversations between clinical,

administrative and financial leadership

You can develop:

• Bundling
• Referenced Based Pricing
• “Surgical Care Experience”

Based Homes

Deliver Volume and Value

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Homework

• Shadow a Patient
• View the Care Experience through

the Patient’s Eyes

• Pick One Segment of Care

Homework

Go Shadow! Webinar Tuesday, November 19, 2013 1:00-2:00pm

Additional Resources

PFCC Go Guide 2.0: The Patient and Family Centered Care Methodology and Practice – The New Operating System for Health Care

If you would like to learn more information:

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Deliver Value by Design

Pittsburgh, PA May 9, 2014

PFCC VisionQuest

Pittsburgh, PA October 9-10, 2014

www.pfcc.org for more information

Upcoming PFCC Events

Questions?

Raise your hand Use the Chat

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What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

Model for Improvement

Act Plan Study Do

Aim of Improvement Measurement

• f

Improvement Developing a Change Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational

• Performance. San Francisco, CA: Jossey-Bass, 1996.

Plan

• Compose aim
• Pose questions/predictions
• Create action plan to carry
• ut cycle (who, what, when,

where)

• Plan for data collection

Do Study Act

• Carry out the test and

collect data

• Document what occurred
• Begin analysis of data
• Complete data analysis
• Compare to predictions
• Summarize learning
• Decide changes to make
• Arrange next cycle

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Principles & Guidelines for Testing

A test of change should answer a specific question A test of change requires a theory and prediction Test on a small scale Collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea Include a wide range of conditions in the sequence of tests

Repeated Use of the PDSA Cycle

Hunches Theories Ideas Changes That Result in Improvement

A P S D A P S D

Very Small Scale Test Follow-up Tests Wide-Scale Tests

• f Change

Implementation of Change

Sequential building of knowledge under a wide range of conditions

Spread

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Aim: Implement Rapid Response Team

• n non-ICU unit

Improved Communication

A P S D A P S D

Cycle 1: ICU nurse responds to rapid response team calls on one unit, one shift for one day Cycle 2: Repeat cycle 1 for three days Cycle 3: Have Respiratory Therapist attend rapid response calls with ICU Nurse Cycle 4: Expand coverage of RRT on unit to

• ne unit for one shift for five days

Cycle 5: Have Nurse Practitioner respond to calls in addition to RT and RN Cycle 6: Expand rounds to

• ne unit for one shift seven

days a week

Expedition Communications

Listserv for session communications: surgeryexpedition@ls.ihi.org To add colleagues, email us at info@ihi.org Pose questions, share resources, discuss barriers or successes

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Next Session

Thursday, December 5, 1:00 PM – 2:00 PM ET Session 2 – Optimizing Health Prior to Surgery Thomas Varghese, MD Strong for Surgery Program