June 10, 2010

Meetings help transform patient safety one case study at a time

Meetings help transform patient safety one case study at a time

Each quarter, nearly 500 Vanderbilt surgical faculty and residents, operating room nursing staff, and faculty, residents and staff from Anesthesiology and Radiology and Radiological Sciences attend the quarterly Multi-Disciplinary Perioperative Morbidity & Mortality Improvement Conference to gain and share insights on improving surgical techniques as well as overall communications.

The group discusses how adverse events could have been avoided, how to prevent future occurrences, and how improvements can be applied across the entire hospital system.

Armed with conference findings and recommendations, the Perioperative Quality Improvement Committee (PQIC) then meets monthly to determine how to best implement solutions quickly and efficiently, while ensuring long-term sustainability. Solutions may be as simple as purchasing new equipment or as complex as adding entirely new surgical processes.

“These efforts have resulted in a continuous circuit whereby everyone involved in the perioperative process comes together in one arena to share findings, suggest improvements and implement change,” said Jeff Dattilo, M.D., assistant professor of Vascular Surgery and PQIC chair.

The M&M conference and corresponding committee are just one facet of an overarching commitment to improving surgical outcomes and, ultimately, patient care and safety. The Perioperative Services POD (Point of Delivery) structure is the next step in delivering continuous improvements. The system was developed to transfer ownership of the quality of surgical patient care to those who provide it.

Organized into a self-managing team model, POD leaders representing surgery, anesthesiology and nursing directly manage the day-to-day operation of their specific processes or departments. The leaders also meet each month to review issues identified by the morbidity and mortality improvement process, and task the corresponding POD members with implementing targeted solutions.

“The POD structure was chartered in late 2008 to empower our people to exercise their expertise and solve problems in a “bottom-up” fashion,” said William Furman, M.D., vice chair of Anesthesiology and executive medical director of Perioperative Services (ORs). “Our vision is that clinical process improvements and solutions should originate from the people who know best how perioperative services run: our staff.”

One notable improvement, led by Addison May, M.D., and the Surgical Site Infection Prevention Collaborative, resulted in the significant reduction of surgical site infections. By standardizing the administration of antibiotics based on Centers of Disease Control and Prevention (CDC) guidelines, surgical site infections among 10 commonly performed procedures dropped an average of 20 percent from 2006 through 2009.

While other practices were also standardized during this time and certainly play a contributing role, marked decreases were recorded for individual surgical procedures. Infection rates following chest-incision cardiac bypass surgery dropped 100 percent, and 90 percent following non-bypass cardiac surgery. Infection rates post-colon surgery dropped nearly 40 percent.

Another improvement first raised at the quarterly M&M conference signaled the need for improved placement of central venous catheters. A team of interventional radiologists developed training on the use of ultrasound to better guide placement of these catheters throughout the ICUs and ORs. All new residents now get hands-on training in the new procedure, which is used in all intensive care units and has resulted in an appreciable decrease in errors.

“We have created a quality improvement process and structure that is multidisciplinary and enables us to identify significant systems problems and then work collaboratively toward correcting those problems to improve quality and safety in the perioperative setting,” said Daniel Beauchamp, M.D., Foshee Distinguished Professor of Surgery and chair of the Section of Surgical Sciences.

“The collaborative engagement of nursing, Anesthesiology and the various surgical departments has been critical to the success of this effort. I am very proud of the surgeons who have helped to lead these improvements and I am grateful to those who have supported the efforts,” Beauchamp said.

Although implemented as a precursor to the M&M conference, the pre-surgery Time-Out program has been reinvigorated and continues to serve as an effective communications tool in reducing surgical errors.

Modeled after the aviation industry’s initiatives to improve safety in repetitive processes, Time-Out provides the entire surgical team an opportunity to review all procedures, equipment and patient needs prior to surgery.

“In years past, continuous improvement efforts focused too narrowly on individual areas, without recognizing the impact to the entire system,” said Nancye Feistritzer, M.S.N., R.N., associate hospital director of Vanderbilt University Hospital.

“With all disciplines enthusiastically working toward a common goal, we have made a significant difference in the level of patient safety provided. This is an extraordinarily powerful process, and I am continually struck by how committed everyone is to improving patient care,” she said.