Wednesday, October 15, 2008

Hey, we're a case study!

I received a lovely note recently from Paul Batalden, one of the true gurus of patient safety and quality, who teaches at Dartmouth:

Dear Paul,
I write to tell you of one application of your transparency about the wrong site surgery event this past summer.

In starting my class this fall on the intellectual underpinnings of the improvement of health care, I decided to take your blog and its responses, the Globe blog and responses and the WSJ blog and responses and give them to my Master's class ahead of our first session. I assigned a "role" of patient, family member, surgeon, anesthesiologist, nurse, payer, CEO, board member to each student and asked them to prepare a two page description of the actions they would recommend and the worries that they might have about what they were recommending.

At the start of class, I divided them into tables of mixed roles and asked them to come up with a plan, why they thought it might work and how they might know it was.

We had a very good conversation and I'm including some of the outputs of the discussions for your interest.

Here are the reports from two of the groups. Good work, I say. Whatever you think of their conclusions, it is terrific that these students have real-life examples to work from, to hone their analytic skills and think through the types of problems they will certainly face in their careers. And they are really lucky to have Paul as an instructor to help them think through these matters.

Group 1

1. What concrete actions are needed? Why?
a. Overall, our group felt that there were safety mechanisms in place to prevent such incidents from occurring (i.e the time out) but for some reason they did not work in this case. The focus of our groups actions were understand why the safety mechanisms did not work and “fix the process” as needed.
b. A quick thorough investigation of the actual event, report this to Chair of Surgery, CEO, Governing Board.
c. Direct observation of the process of patients coming in and out of surgery. There will be multiple processes going on, so it will be important to observe how these different processes work with and against each other.
d. The Chair of Surgery would review and be responsible for approving the overall workflow and process of how patients are brought in and out of the surgical suites.

2. What monitoring process should be used to know that you have effectively prevented the recurrences of the problem?
a. It is often the case that adverse events such as performing surgery on the wrong site are due to multiple small errors occurring and building on each other. They may also occur at transition points. While serious events are rare, there are probably many near misses that need to be defined and measured.
b. Need to measure severe adverse events as well.
c. Simulation of the process, to have the different surgical teams practice during high patient volume scenarios. Tapes of these simulations need to be reviewed to understand team functioning and strengthen teamwork/communication.

3. How will you monitor the costs of what you have put in place?
a. There will need to be someone who observes the process and maps the process out-this is a cost incurred.
b. There may need to be fewer procedures per day-this is a cost incurred.
c. The cost of one adverse event will need to be balanced with the cost of monitoring the process.

4. When might you review the actions taken.
a. The Governing Board and CEO would get monthly reports of near misses as well as the change in the process that occur because of observations.
b. The Chair of Surgery will get weekly reports of near misses and the change process that occur because of the observation.
c. The surgical teams will have real time feedback of near misses and will be expected to implement change processes immediately and measure the effect of a change.
d. Graphical displays (dashboards) will be available throughout the hospital and will show the real time performance of the surgical teams in terms of successes and near misses.

5. How might you help others learn from the actions you’ve taken?
a. Team performance can be improved and the lessons learned about how to improve the functioning of teams can give insight to other teams within the hospital.
b. Adapted M&M conferences for all staff.
c. Implement simulations for all teams.

6. Why haven’t these actions already been taken?
a. Competing demands
b. Busy surgical schedule
c. There may be a culture of just checking the box that a safety check has been done, without reflection on what it means.
d. Observation and process improvement require additional training and money (at least initially).

Group 2

Below is a summary of our group presentation regarding the "wrong side surgery" case. In order to prevent future wrong side surgeries (and other medical errors), we have devised a 3-part approach involving:
-Pay for performance
-Better pre-op procedures
-Better time-out procedures

Pay for Performance
From a financial perspective, nobody wants to pay for the cost of a medical error. Our position is that payers should reimburse based on performance. In order to measure this performance, it is beneficial to assign a quality score to each organization. This way, insurance companies and payers can choose to only contract with high quality providers.

Better Pre-Op Procedures
We recognize that miscommunications and errors happen, and so it is important to devise a standard protocol for making those errors less likely. Before surgery, the surgical site is usually marked. However, those markings can be ambiguous. By color coding a "yes" on the correct side and a "no" on the wrong side, there is less likelihood of error due to misinterpretation. We also suggest allowing the patient to be involved in the marking. The patient (if able), pre-op nurse, and the surgeon should all sign the surgical site in an effort to further reduce error.

Better Time-Out Procedure
Time-outs are already "implemented," but the key is making sure that they are actually being carried out. In an operating room, there is often a superiority issue that may cause a nurse or assistant not to speak up if the surgeon goes through the time-out incorrectly or skips it altogether. To remedy this, we suggest assigning a "time out captain" who will always initiate the time out. This may be the surgical nurse, or a tech in the OR who is prepping the tools. By assigning a role, it is more likely to be done. We also recommend having some sort of written time-out. By forcing the people in the OR to write out the right person, right place, and correct site rather than just quickly checking it off, it ensures that this step will not get skipped. Finally, a visual projection on the wall of the operating room may be a good tool to reinforce the time out. By projecting a picture of the patient (or outline of a patient) and highlighting the correct area to be operated on, surgeons will have a visual check before they begin.

In order to track the efficacy of our approach, we recommend tracking the time-outs missed and also tracking quality scores of the hospital itself. It is also important to conduct random safety checks in order to confirm the quality scores.
Wrong-side surgeries are not regular occurrences, but other medical errors happen more frequently. We believe that our three steps will help to correct the underlying issues, leading to less overall medical errors.


Anonymous said...

This is fascinating and it's how it should be - learning from errors. There's nothing like a real-life case study. I am curious what course Professor Batalden is teaching and to what type of student - masters in health administration, perhaps?


Anonymous said...

What a wonderful idea of having masters level students, of any discipline, examine and critique this case.

The involved patient surely will obtain satisfaction and healing knowing that their experience was being used to educate students on improvement strategies.

Incorporating real life stories (and real life patients and caregivers) into your curriculum by sharing never events will prove to be a forever event that will continue to give.