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10 years after “To Err is Human”
An RCA of Patient Safety Research?
Peter Pronovost, MD, PhD
Objectives
• To reflect on some of the barriers to patient safety research
• To consider an overview for training in patient research
Bilateral cued finger movements
System Failures Slowing Progress in Patient Safety
Failure to viewthe delivery of care
as a science
Insufficiently robust research
Insufficient partnershipsBetween academic and
quality communities
Insufficient capacity totrain researchers
Reason model
Patients continue to suffer preventable harm
Reason
Translational Research Model
UnderstandingDisease Biology
T1Translating to Humans
ImprovedHealth
Outcomes
Identifying andComparing Effective
Therapies
T2Translating to Practice
Implementing,Disseminating and
Sustaining Research,Monitoring Outcomes
Summarizingevidence andunderstanding
if and howthese therapieswork in practice
Formulating,Analyzing, and
TestingPre-Clinical
Models
Figure 1
Translation Superhighway
System Failures Slowing Progress in Patient Safety
Failure to viewthe delivery of care
as a science
Insufficiently robust research
Focus on differences rather than similarities
with other types of research
Insufficient capacity totrain researchers
Reason model
Patients continue to suffer preventable harm
Reason
Central Mandate
Local Wisdom
Scientifically Sound Feasible
xx
ExercisePlease answer each question with a score of 1 to 5.
1 is below average, 3 is average and 5 is above average
• How smart am I
• How hard do I work
• How kind am I
• How tall am I
• How good is the quality of care we provide
Improving Sepsis Care(n= 19 ICUs)
Mortality
13.1
21.9
41.8
0.0
10.0
20.0
30.0
40.0
50.0
Oct - Dec2003
Mar - May2004
July - Sept2004
%
69% Reduction (p < 0.001)
ICU LOS
6.2
7.6
10.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Oct - Dec2003
Mar - May2004
July - Sept2004
Day
s
36% Reduction (NS)
Improving Sepsis Care(n= 19 ICUs)
Mortality
13.1
21.9
41.8
0.0
10.0
20.0
30.0
40.0
50.0
Oct - Dec2003
Mar - May2004
July - Sept2004
%
69% Reduction (p < 0.001)
ICU LOS
6.2
7.6
10.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Oct - Dec2003
Mar - May2004
July - Sept2004
Day
s
36% Reduction (NS)
Framework for Patient Safety Research and Practice
• Measuring Patient Safety
• Translating Evidence Intro Practice (TRIP)
• Identifying and Mitigating hazards
• Improving Culture and Communication
• Building Capacity and Organizing for Safety
• Reducing Diagnostic Errors
Pronovost Circulation in press
Translating EvidenceInto Practice
* Envision the problemwithin the larger health
care system
* Engage collaborativemulti-disciplinaryteams centrally(stages 1,2,&3)
and locally(stage 4)
1. Summarize the Evidence
Convert interventions to behaviors
2. Identify local barriers toimplementation: understandthe process and context of
work
3. Measure Performance
4. Ensure all patientsreceive the interventions
Identify Interventions associatedwith improved outcomes
Select interventions with the largestbenefit and lowest barriers to use
Enlist all stakeholders to shareconcerns and identify potentialgains/losses associated withintervention implementation
Observe staff performing theinterventions
"Walk the process" to identifydefects in each step of intervention
implementation
Measure Baseline Performance
Develop and pilot test measures
Select Measures(process and/or outcome)
Engage
Explain why the interventions are
important
Execute
Design an intervention “toolkit” targeted to barriers employing standardization,
independent checks and reminders, and learning from mistakes
Educate
Share the evidence supporting the interventions
Evaluate
Regularly assess performance
measures
Pronovost BMJ in press
•Identify Hazards•(
3. Mitigate Risks
2. Analyze & Prioritize Hazards
4. Evaluate Effectiveness of Risk Reduction
Patient Safety Learning Communities
Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control.
System Failures Slowing Progress
Failure to viewthe delivery of care
as a science
Insufficiently robust research
Focus on differences rather than similarities
with other types of research
Insufficient capacity totrain researchers
Reason model
Patients continue to suffer preventable harm
Reason
Context become Mechanism
ContextMechanism Outcome
Pawson Tilley
System Failures Slowing Progress in Patient Safety
Failure to viewthe delivery of care
as a science
Insufficiently robust research
Focus on differences rather than similarities
with other types of research
Insufficient capacity totrain researchers
Reason model
Patients continue to suffer preventable harm
Reason
Simple Rules for Producing Researchers
• Obtain formal degree
• Identify willing and capable mentor
• Obtain protected time to participate in research project
Core Skills for Patient Safety Researchers
• Epidemiology• Biostatistics• Health services • Economics• Sociology• Psychology• Informatics• Systems analysis
• Qualitative• Leadership• Change management• Project management
EPI
/Stats
Psych
/Soc
HSR Econ
Critical care
Surgery
Pediatrics
Medicine
Quality and Safety Research Group Mixing Bowl
Improving Patient Safety in Michigan ICUs
Funded by AHRQ
24
Time period Median CRBSI rate Incidence rate ratio
Baseline 2.7 1
Peri intervention 1.6 076
0-3 months 0 0.62
4-6 months 0 0.56
7-9 months 0 0.47
10-12 months 0 0.42
13-15 months 0 0.37
16-18 months 0 0.34
2 year results from 103 ICUs
Pronovost NEJM 2006
84% 82%
23% 22%
0
10
20
30
40
50
60
70
80
90
100
Safety Climate TeamworkClimate
2004 2007
"Needs Improvement“ Statewide Michigan CUSP ICU Results
•Less than 60% of respondents reporting good safety climate =“needs improvement”
•Statewide in 2004 84% needed improvement, in 2006 41%•Non-teaching and Faith-based ICUs improved the most•Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”
Keystone ICU Safety Dashboard
2004 2006
How often did we harm (BSI)
2.8/1000 0
How often do we do what we should
66% 95%
How often did we learn from mistakes
30% 100%
% Needs improvement in Safety climate
Teamwork climate
84%
82%
43%
42%
Focus and Execute