1	It Takes a Village: Moving Towards Systems-Based Practice Andrew G. Lee, MD Associate Program Director, Ophthalmology Director, Educational Outcomes Initiative (GME) The University of Iowa Acknowledgments: Sarabdeep Singh & Mark C. Wilson, MD, MPH (UIHC)
2	I have no financial interest in the contents of this talk
3	Why am I talking to you at 7 AM today? What clerkship directors need to know about SBL! ACGME competencies (Outcome project) It makes no sense to integrate competencies into residencies if we don’t include medical students, fellows, & practicing physicians Medical schools will be asked to assume a lot of pre-requisites to competencies You (faculty) need to know it too! (Wait a minute, did he just say I need to know it too!!!!!..)
4	Have a piece of paper handy….
5	Pre-test: Objectives Define what you think is meant by “systems based competency” Describe your concept of your micro- and macro-systems of care List all the ways we are currently teaching systems based practice & learning List all the ways we are currently assessing systems based practice & learning
6	I am using this slide to force me to wait for you to formulate your answers Common complaint about Dr. Lee’s teaching style….. “Dr. Lee does not give me enough time to answer the question.” I am working on this for practice based improvement for myself
7	Defining Systems based competency ACGME speak: “Systems-Based Practice” Awareness of & responsiveness to larger context & system of health care Ability to effectively call on system resources to provide care that optimal In other words, work within health care system
8	Systems based care Micro-system of care (your clinic, your office, the O.R.) Small macro-system (your hospital, your state) Large macro-system (Medicare, US health care system, Pay for Performance)
9	Translating ACGME speak Systems based care Using the system to improve Patient centered care (performance) Patient safety (reduce medical errors) Patient satisfaction (wait time, quality) Microeconomics/Macroeconomics (stewards of care, conserve resources, billing & coding)
10	Institute of Medicine-speak Safe Effective Efficient Patient centered Timely Equitable
11	The system…. 42% of public survey reported experience with poorly coordinated, inefficient, or unsafe care 45% of recommended care is not delivered (RAND) 75% of US adults believe that US healthcare system needs fundamental change 50% of middle-lower income families report serious problems with health care coverage 47 million uninsured & 16 million underinsured patients (16% of US population!)
12	Part 1: systems based practice = patient safety Medical errors = bad systems NOT bad people or bad hospitals
13
14	Reason’s Swiss cheese model
15	Reason’s Swiss cheese
16	Active failures vs. latent conditions
17	Alignment of the holes leads to outcome of error
18	Jesica Santillan’s story Congenital restrictive cardiomyopathy Transplant was her only hope of survival Father was a truck driver near Guadalajara, Mexico (illegal immigrants to USA)
19	Feb 6, 2003 Carolina Donor Services offers heart to Duke (middle of night) First potential recipient not ready for transplant Duke asked if organs available for Jessica Organ procurement coordinator offers to check this & call back, & when they did…. Duke assumed that CDS wouldn't have called back & released the organs unless they were a match This was a wrong assumption
20	Part 2: Systems based practice = Communication lines
21	The rest of the story… Type A organs brought to Duke Following implantation of organs (10:00 p.m.) Surgeon received call from lab: Type A organs not compatible with Jesica’s Type O Despite aggressive treatment & second transplant, Jesica died
22	Multiple holes in the Swiss Cheese Organ Procurement didn’t ask if matched Harvesting surgeon knew Type A organs but assumed it was a match with Jesica Surgeon knew Jesica was Type O but assumed donor was a match 12 doctors came into contact with this chart but none noticed the mismatch
23	Wrong site surgery Scope of the problem Physician Insurers Assoc. America (1985-1986): 331 closed claims for wrong-site surgery Joint Commission Accreditation Healthcare Organizations (JCAHO): wrong-site surgery one of top ten most reported medical errors causing patient injury
24	Ophthalmology: Wrong site surgery Wrong patient or wrong medicine Wrong eye enucleated! (worse still because other eye has to come out) Wrong eye cataract surgery Wrong eye injected with medicine Wrong eye treated with laser
25	Old paradigm: M & M conference You operated on the wrong eye, you dunce! Same Name Shame Blame Game The last slice of cheese is NOT the problem No system repair!
26	New paradigm Near miss analysis Root cause analysis Find source of problem Deter active errors System defenses for latent errors Plug holes in Swiss cheese System repair
27	Systems latent errors Lack of formal procedure or protocol Lack of final check in operating room Lack of oral communication Lack of medical record information or imaging studies in operating room Lack of a checklist to assure that everything had been performed
28	Systems active errors Use of abbreviations (OD, OS) in chart Prepping the wrong side Dilating the wrong eye Patient gives wrong history at time of surgery Drawing eye on wrong side of page
29	An observational study of laterality errors El Ghrably & Fraser. Eye Sept 2006
30	An observational study of laterality errors El Ghrably & Fraser. Eye Sept 2006 100 charts analysed for left/right transpositions 44 transposition errors found in 32 charts Most common: Drawing eye on wrong side of page 19 errors had evidence of later correction 3 consent forms had incorrect eye denoted One patient listed for surgery on wrong side
31	Part 3: systems based practice = recognition that the elevator guys are part of the system of care too…. Duke University (surgical instruments washed in used elevator hydraulic fluid, n= 4000 surgeries) Automatic Elevator Company Emptied hydraulic fluid INTO old detergent barrels Barrels went to OR from loading dock Seals were broken, paperwork unconfirmed Duke surgeons & nurses noted instruments were “slick” & “oily”
32	The Duke hydraulic fluid mix up
33	Part 4: Systems based practice = It takes a village… Parking attendant Registration Emergency room Nurse Technician Resident or fellow Lab including blood bank Radiology Referring doctor Social worker PATIENT ….and yes the Elevator maintenance guy
34
35
36	Wrong medication given 28 y/o WF with optic neuritis Scheduled for IV methylprednisolone (ONTT) Nurse administers lidocaine during IV flush instead of saline
37	Old model Morbidity conference Blame the nurse “Nurse didn’t read the label” “Why?” “Because she was inattentive” (tautology) “OK, go yell at her”
38	Systems errors: root cause analysis Five (or however many) whys Why: The nurse didn’t look at the label Why: There was no label Why: The nurse thought it was right Why: She had done it hundreds of times before Why: She was the most experienced nurse we have, she doesn’t need the label
39	Thinking about error Accidents occur because of normal or routine behaviors not usually deliberate Name, blame, shame game does not address root cause (“nurse was incompetent”) & incentivizes culture of hiding error Root cause: Non-judgmental & not just most convenient (proximal) target Experience can harm you (think Titanic Captain Smith ---false sense of security)
40	Human error types Inattentional blindness (look but fail to see) Divided attention (multitasking) Distractions (think cell phone in car) Confirmation bias (assuming others have looked) Capture error (medications are in same drawer) Automatic behavior (overrides safety measures that novice would go through methodically) Inadequate warning mechanisms (similar looking bottles, labels too small, no labels)
41	Wrong drug given Five whys…. Nurse administered wrong drug No confirmation before administration Nurse had two vials on tray No confirmation before hand off All medicines in same drawer No label All syringes on same tray Nurse got paged (distraction) No way to distinguish the drugs
42	Medical student clerkships Only 16% of medical student clerkships ahd formal lectures about medication errors 65% said they would incorporate short educational modules about errors & adverse events if they were available Rosebraugh et al. Centers for education and research on therapeutics report: survey of medication errors education during undergraduate and graduate medical education in the United States. Clin Pharmacol Ther. 2002;71:4–10
43	Part 5: Systems-based practice = team work
44	So how do we teach and assess systems based competency? “Crouching Tiger, Hidden Dragon”: Managing the ACGME competency mandate
45	Inventory your educational resources You don’t know what you don’t know Time for self-reflection Do you want to see our hidden dragon? Describe our current teaching curriculum
46	Do you want to see our crouching tiger? Lectures SBL content Rotations Role modeling within system Journal club SBL journals Resident research SBL research project Grand rounds SBL rounds Morning report SBL issues for AM report Team rounds Systems based practice in action Morbidity conference Root cause analysis & system errors Talking about cases SBL improvement in real world
47	In other words…. We are teaching these competencies now! We know this implicitly We just don’t call it the same thing that ACGME speak calls it
48	Do you want to see our hidden dragon? Existing encounters Modification Lectures Pre-test & post-test Rotations 360 degree evaluation Journal club Structured checklist Resident research Portfolio Grand rounds Attendee evaluations Morning report Checklist-observation Team rounds Self-reflection project Morbidity conference Root cause analysis Chart rounds Chart stimulated recall
49	In other words… We are doing these things now We just aren’t collecting the data! We should “Teach & Assess” at the same time
50	Teaching systems based practice Integrating SBL into curriculum Patient safety issues Root cause & near miss analysis Inter- or multi-disciplinary rounds Patient safety project Systematic M & M conference
51	Part 6: Economics of your microsystem & macrosystem Dr. Lee to resident: “What level of service would you code this encounter?” Resident: “What’s a level of service?” Dr. Lee: “You know, what E & M code is this? Resident: “What’s an E & M code” Dr. Lee: “Systems based practice” Resident to himself: (Who cares!)
52	You don’t know what you don’t know Surveys of graduated residents in practice
53
54
55
56
57
58	The problem Residents don’t understand the need to know about billing & coding because they don’t need the information during residency They REGRET after they graduate Faculty teach “what they want to teach” (vs. what learners need to know)…eg. “my research” Faculty may not be best teachers or role models for billing & coding!
59	Another example My car wouldn’t start Mechanic You probably have a bad alternator You need to have these tests Me: How much do they cost? Mechanic: I don’t know but you need them
60	Another example My vision is bad Resident You probably have ischemic optic neuropathy You need to have these tests Patient: How much do they cost? Resident: I don’t know but you need them
61	I have no financial interest in the contents of this talk
62	Objectives Describe July 1, 2007 SBL resident portfolio project for systems based competency Discuss Lean and Six Sigma Show real world examples Engage you in process of self reflection on SBL
63	On the back of your piece of paper Write down systems aberrations that drive you crazy!!!!....Think about a system repair Some prompts: “We do this a goofy way….” “Whoever designed this was an idiot…” “I don’t know why we do it this way but we do”
64	VAMC Medical Error Project VA = largest health-care system in USA (> 3 million veterans a year, 172 hospitals) 3,000 medical errors--= 700 deaths (6/97-12/98) Bar-coding (patient, drug, nurse) & scanning Two VAMC (Kansas): medication error rate dropped 70% over a five-year period Storing concentrated potassium chloride away from patient care areas (nurse administered K instead of Lasix killing a patient)
65	Integration of SBL Clinical teaching (payer mix, billing, coding, resource utilization, cost) Mock financial reports Patient bill (cost) analysis Pharmacy print out (prescribing patterns, formulary choices, generics)
66	Other “good practice” examples Out-of-hospital care rotations Administrative rotation/responsibilities Conferences: interdisciplinary, case, follow-up, core curriculum, and grand rounds Committee participation: hospital-based, CQI, etc.
67	Portfolio SBL project Describe economic & treatment limitations imposed by systems Identify how payment methods may conflict with ethical standards Describe how different methods of cost control affect physicians' relationships with their colleagues, their patients, and society Describe strengths & shortcomings of U.S. system for financing and delivering medical care, particularly to those from underserved/minority groups.
68	A HEALTHCARE CRISIS IS LOOMING
69	PROVIDERS ARE FACING AN EXTREME PRICE/COST SQUEEZE
70	BREAK-EVEN VOLUMES HAVE INCREASED BY 25-35%
71	CONSUMERS ARE MORE DEMANDING, CREATING A STRATEGIC OPPORTUNITY
72	ACHIEVE SIMULTANEOUS IMPROVEMENTS IN COST, QUALITY, and SERVICE LEVELS
73	TRANSFORMATION IS A MULTIYEAR JOURNEY
74	What is “Lean?”
75	Four Rules Rule 1: All Activities of work are clearly specified by: Content Sequence Timing Outcome Rule 2: Connections Direct Yes/No Rule 3: Pathways Simple Each step is essential Rule 4: Improvement Direct response to problem As close to the problem as possible As an experiment By those doing the work Supported by a Coach
76	Think about your system?....are we following the rules….? Rule 1: Explicit written protocols Rule 2: Direct, clear, connections Rule 3: Simple pathways Rule 4: Improvement process
77
78
79
80	What is “Kaizen?”
81
82	LEAN TARGETS THE 8 TYPES OF WASTE
83	Reducing waste in the system of care
84	DMAIC (six sigma) Define process improvement goals Measure current process & collect relevant baseline data Analyze relationships & causality Improve process based on analysis Control variances before defects occur
85	Prove to me that it isnt just a “waste of time”?
86	The Continuous Improvement Process Understand the current process as it really is
87	Patient Endoscopy – Swimlane Diagram
88	The Continuous Improvement Process Identify best practices, waste, and opportunities for improvement
89	Results
90
91	You can observe a lot by just watching….Yogi Berra
92	Clinic Traffic Patterns HCCC
93	Part 5: SBL = improved patients satisfaction and system efficiency Bottom Line Staff Salary-Benefit Expenses per Patient Visit Before Kaizen Event $84.20 After Kaizen Event $51.04
94	Virginia Mason Med Ctr: Lean results (JAMA 2007;297:871-873) Breast CA dx to Rx time: 21 d to 11 d Infusion Tx: 240 minutes to 90 minutes Turnaround tests with EMR: 89% < 3 days
95	Systems based project Beginning July 1, 2007 All residents will be required to design and implement a systems based improvement project The SBL project can be patient safety or patient satisfaction based The projects will be presented at grand rounds The projects will be kept in the learner portfolio The audience will provide formative and summative feedback on projects to learner
96	Thank you for your time and attention