Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.
Generally speaking, if somebody slices into you with a knife, burns holes in your body, or sticks something into you with the aim of tearing parts of you out, there would be a just cause to call the police, pick up a weapon, or run like heck. Yet every day, thousands of people are very happy that a surgeon is going to wield a scalpel, laser, or endoscope because there is goodwill and good odds that one will be better off as a result.
However, surgery is still a kind of violent assault on the body, and there is always a risk, a price to pay, and an off-chance of things going very wrong. There are many ways in which adverse surgical events can occur, many ways in which they manifest, and the effects can range from negligible to death.
We can usefully talk of an adverse event in which there was a risk or near miss, but in which the patient wasn’t reached. If the patient was reached, we can talk of an adverse incident, which may or may not result in harm. However, not everyone uses these terms in the same way, and the AHRQ talks of “Never Events“ as those errors that pose serious and unnecessary risk of great harm.
The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 7 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.
The general idea then, is to stop risks from becoming events, keep events from ever reaching a person, and keeping those that do from resulting in harm to the person.
The following pertinent articles have been provided by Physician’s Weekly:
- Is Your Operating Room Fit for Successful Outcomes?
- The influence of gender on early adverse events, hospital charges and length of stay after shoulder arthroplasty
- Acute Kidney Injuries & CABG
- Prospective Analysis of Minor Adverse Events After Colon Polypectomy
- Low Incidence of Adverse Events for A-Fib Catheter Ablation
We will take a QI approach, and discuss the topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.
Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:
- Policies: office, organization, or national policies, including MU, HIPAA, etc
- Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
- Workload: demands of the job, and whether they exceed the resources and ability to meet the demand.
- Insurance Models, payer systems
- Vendor policies and processes
- Machines (incl equipment, EHR)
- Medical or office equipment
- Home equipment specific to the patient condition
- Integration/interoperation with other office or medical systems, or user personal health records
- Medication dispensing systems
- Personal Health Record and encounter planning systems
- Transportation systems, incl. wheelchairs, lifts, ambulances, etc.
- Access control
- Ergonomics (right size, shape, location, etc)
- Analytical software
- Patient identification
- HCP Identification
- Staffing: sufficient and qualified staff
- Training: base training, ongoing training, CME, and patient or carer training
- Attitudes: staff attitudes to technology, adoption vs resistance, bullying
- Fatigue (especially alert fatigue)
- Peer support
- Friends and family
- Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
- Supplies: medical or office, inferior fax paper,
- Data: ability to securely share with correct patient, specialist, lab, etc
- Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
- Internet sources
- Checklists, SoPs
- Uniforms, footwear, personal protective equipment
- Health outcomes
- KPIs: operational metrics required by practice, local government, state, federal
- Quality and safety metrics
- Targets: set by practice, insurer, etc. as well as patient goals
- Incentives and rewards
- Adverse Eventss reporting
- Effectiveness of measurement
- Noise: distracting noises, sound levels too high, etc. due to computer systems
- Space: Cramped, uncomfortable work space etc.
- Time: Too little time per patient or order, too little time in a day, too many demands
- Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
- Control: the degree to which the individual can control their workload and how to accomplish it
- Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
- Temperature: too cold, too hot, too variable
Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.
- What METHODS increase or reduce risks of Adverse Surgical Events
- What MACHINE factors increase or reduce risks of Adverse Surgical Events
- What PEOPLE issues increase or reduce risks of Adverse Surgical Events
- What MATERIALS increase or reduce risks of Adverse Surgical Events
- What MEASUREMENT factors increase or reduce risks of Adverse Surgical Events
- What ENVIRONMENTAL factors increase or reduce risks of Adverse Surgical Events
MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.
To quote the IHI on what the Triple Aim encompasses:
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.
The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.