Surgical Patient Care: Improving Safety, Quality and Value

 

Description:

This book focuses exclusively on the surgical patient and on the perioperative environment with its unique socio-technical and cultural issues. It covers preoperative, intraoperative, and postoperative processes and decision making and explores both sharp-end and latent factors contributing to harm and poor quality outcomes. It is intended to be a resource for all healthcare practitioners that interact with the surgical patient. This book provides a framework for understanding and addressing many of the organizational, technical, and cultural aspects of care to one of the most vulnerable patients in the system, the surgical patient. The first section presents foundational principles of safety science and related social science. The second exposes barriers to achieving optimal surgical outcomes and details the various errors and events that occur in the perioperative environment. The third section contains prescriptive and proactive tools and ways to eliminate errors and harm. The final section focuses on developing continuous quality improvement programs with an emphasis on safety and reliability. Surgical Patient Care: Improving Safety, Quality and Value targets an international audience which includes all hospital, ambulatory and clinic-based operating room personnel as well as healthcare administrators and managers, directors of risk management and patient safety, health services researchers, and individuals in higher education in the health professions. It is intended to provide both fundamental knowledge and practical information for those at the front line of patient care. The increasing interest in patient safety worldwide makes this a timely global topic. As such, the content is written for an international audience and contains materials from leading international authors who have implemented many successful programs.

 

 

Table of Contents:

 

Part I: Fundamentals of Systems and Safety Science

1: The Burning Platform: Improving Surgical Quality and Keeping Patients Safe

Introduction

Threats to Patient Safety

Avoidable Errors

Variation

Overuse

Underuse

Disparities in Surgical Care

Measuring Surgical Quality

Conclusions

References

2: Risk Factors and Epidemiology of Surgical Safety

A Framework to Study Errors and Harm

The Scale of Harm in Surgery

Solutions to Prevent Errors and Harm in the Perioperative Arena

Surveillance and Monitoring of Surgical Safety

References

3: Concepts and Models of Safety, Resilience, and Reliability

Introduction

Normal Accident Theory

Complexity Science

Safety Drift and Procedural Violations

Safety Drift

Features of Drift

Possible Means to Reduce Potential for Drift

Procedural Violations

Stretching the Limits of Adaptive Capacity

Resilience

Four Pillars of Resilience

Limitations of Resilience

Principles of High Reliability

Concept and Characteristics of High Reliability

Common Characteristics of High Reliability

Different Characteristics

Limitations

Surgical Microsystems

Characteristics of Surgical Microsystems

Conclusions

References

4: Surgery Through a Human Factors and Ergonomics Lens

Introduction

Humans and Automation

Human Factors in Device Design

Cognition in Context

Performance-Shaping Factors

Summary

References

5: The Relationship Between Teamwork and Patient Safety

Introduction

Defining Teams, Teamwork, and Multi-Team Systems

Models of Teams and Teamwork

Healthcare Specific Models

Practical Principles for Effective Teaming in Surgery

Membership and Team Life Span Considerations

Interventions to Develop and Support Effective Teaming in Surgery

Conclusions

References

6: Enterprise Risk Management in Healthcare

Overview of Enterprise Risk Management

Principles of Risk Management

Risk Management in Healthcare Organizations

Identifying Risk

Measuring Risk

Culture

Avoiding a Culture of Fear

Defining a Culture of Prevention

Role of the Chief Risk Officer

Medicolegal Aspects of Patient Safety

Information Technology/Security/HIPAA

Understanding Health Information Privacy

Entities and Business Associates

Office for Civil Rights Pilot Privacy, Security, and Breach Notification Audit Program

Case 1: A Children’s Hospital Fined $40,000 for Data Breach

Case 2: Academic Medical Center Fined $1,500,000 for Deficiencies in HIPAA Compliance Program

How the OCR Enforces the HIPAA Privacy and Security Rules

Security Risk Assessment

Business Associates and Risk Assessments

Common CMS Audit Findings

Policies and Procedures: Problem Areas

The Evolving Role of the Risk Manager

Formal Risk Reporting and Risk Data Management

Patient Safety and Quality Improvement Act of 2005 Statute and Rule

Understanding Patient Safety Confidentiality

Common Formats

Report Types from the NPSD

Value to Providers

Patient Safety Evaluation System

Reporting Preventable Errors or Preventing Preventable Errors?

Event Underreporting

Federally Listed Patient Safety Organizations

Summary

References

7: The Patient Experience: An Essential Component of  High-­Value Care and Service

What Is High-Value Care?

What Is the Patient’s Role in High-­Value Care?

Shared Decision Making

Decision Aids

Barriers to Shared Decision Making and Value-Based Care

How Do We Measure Quality?

Patient-Reported Outcomes

Patient Experience of Care

Measuring Quality in Surgical Care

References

8: Patients and Families as Coproducers of Safe and Reliable Outcomes

Introduction

Co-commissioning

Codesigning

Co-delivery

Co-assessment

The Bigger Picture

References

9: Tools and Strategies for Continuous Quality Improvement and Patient Safety

A History of Quality Improvement

Approaches to Quality Improvement

Quality Improvement Tools

Checklists

Process Maps

Ishikawa Diagrams

Run Charts and Control Charts

Conclusions

References

10: The Future and Challenges of Surgical Technology Implementation and Patient Safety

The Current State of Robotic Surgery

Endoluminal Surgery and NOTES

Telesurgery and Telementoring

The Future of the Operating Room

Tissue Engineering

Immunotherapy in Surgery

References

Part II: Job and Organizational Design

11: Organizational and Cultural Determinants of Surgical Safety

Introduction

Open System Assumptions

Safety in Health Care: The Role of Organizing Processes

Two Approaches to Safety Management

Organizational Determinants and Safe Outcomes: Some Evidence

Safety in Health Care: The Role of Culture and Climate

How Does Culture Control and Develop?

Safety Culture and Outcomes: Some Evidence

Implications

Conclusion

References

12: The Role of Architecture and Physical Environment in Hospital Safety Design

Introduction

A Little History and Modern-Day Statistics (Figs. 12.1 and 12.2)

The Surgical Suite

Program Building Blocks

Surgical Suite Organization and Design

Suite Layouts

New Layouts and Flow

Suite Layout Characteristics

Public Areas

Preoperative Areas

Operating Rooms

Operating Room Size

Communications in the OR

Universal ORs

Planning for Change

Postanesthesia Care Unit

Phase 2 Recovery

Physician and Staff Support Areas

The Details: Design Thinking, Processes

Understanding the Needs of the Patient

Understanding the Needs of the Perioperative team

Lean Design

Working Definitions

Preoperative Phase: Opportunity for Enhanced Communication

Multiple Points of Entry: Designing for Safety, Efficiency, and Comfort

Interior Architecture and Design Considerations

Patient Safety

Patient Experience

Interior Specifications to Facilitate Optimal Human Performance

Opportunities for Efficiency, Patient Safety, and Patient Experience in Pre-op, Prep/Hold

Intraoperative Phase

The Details of Human Performance

The Complex Workspace of Surgical and Anesthesia Service

Observing for Errors and System Factors

Lighting and Performance

Human Needs

Interior Architecture and Design

Postoperative Phase

Patient Well-Being and Family Satisfaction

Form Follows Safe Surgical Function

Key Steps for Pre-design

References

13: Building Surgical Expertise Through the Science of Continuous Learning and Training

Learning and Expert Decision Making

Characteristics of Expertise and Expert Behavior

Learning Within the Surgical Microsystem

Learning at Various Stages of Training/Levels of Expertise

Recruiting and Training the Surgical Team

Training the Surgical Team

Assessing Expertise

Technical Skills

Nontechnical Skills

Entrustable Professional Activities

Future Directions

References

14: Promoting Occupational Wellness and Combating Professional Burnout in the Surgical Workforce

Burnout and Distress

Wellness

Research Behind Wellness

Integration and the Window of Tolerance

Mechanical vs. Complex Adaptive Systems

The Healthy Mind Platter

Sleep Time

Play Time

Downtime

Time-In (Reflection, Attunement, Mindfulness)

Connecting Time

Physical Time

Focus Time

Additional Wellness Tips

Release Yourself and Others from Unnecessary Judgements

Embrace Joy and Gratitude

Photographic Proof

References

15: Executive Leadership and Surgical Quality: A Guide for Senior Hospital Leaders

Introduction

Role and Responsibilities for Successful Oversight

Who is the Chief Surgical Quality and Patient Safety Officer?

Training and Resources Required for Success

Reporting Structure and Administrative Committee Support

Strategic Alignment and Leadership

Resources and Relationships Critical to Success

Developing a Culture of Safety and High Reliability at All Levels

Data Analytics and Validation

Metric Development and Goal Setting

Continuous Improvement Training and Support

Innovation in Process Improvement: Engaging the Team

Performance Management and Accountability

Managing the Tension Between Quality, Efficiency, and Patient Satisfaction

Dash Boarding and Bench Marking for Surgeons and Departments

Incentives and Compensation Aligned with Outcomes

Future Leadership in Value-Based Care

Academic Development of Administrative Roles and Outcome Researchers

Succession Planning for Quality Leaders

Key Points

References

16: Information Technology Infrastructure, Management, and Implementation: The Rise of the Emerg

Introduction

The Three Level Hierarchy Paradigm for Healthcare HIT

An Integrated Architecture for HIT Usability

System Adaptability

Immediate Adaptability (IA)

Objections to Immediate Adaptability (IA)

Functional Specifications of IA Clinical Information Systems

A Generic Architecture for IA-CIS: Repurposing the EMR Model

An Architecture That Supports the Levels of HIT Context

The Architecture in Practice: Clinical Care Information Systems (CCIS) and Clinical Services Infor

Case Study Results

Conclusions and Some Observations About the Future of HIT

References

17: Redesigning Hospital Alarms for Reliable and Safe Care

Introduction

The Detrimental Impact of Noise and Alarms on Patients and Providers

Characteristics of Systems and Risk Management Framework

Human Factors and Situation Awareness in Understanding Optimal Alarm Management

Medical Device Features

Source–Path–Receiver Model

The Role of Alarm Standards and Codes

The Role of Medical Device Designers and Manufacturers

Advocating for Change to Improve Alarm Management (Fig. 17.2)

Organizational Environment: The Role of Clinical Microsystems in Addressing Alarms

Guiding Principles in Alarm Management

Conclusions

References

18: Implementation Science: Translating Research into Practice for Sustained Impact

What is Implementation Science?

Implementation Frameworks

The Exploration, Preparation, Implementation Sustainment (EPIS)

Implementation Outcomes

Consideration of Organizational Context in Implementation

Implementation of Surgical Checklists

Early Support for Implementation of Surgical Checklists

Fading Evidence for Implementation of Surgical Checklists

Incomplete Plan for Implementation of Surgical Checklists

Summary and Challenges and Future Directions for Implementation Science Research

Future Directions and Global Initiatives for the Field of Implementation Science

Conclusion

References

Part III: Perioperative Quality and Patient Safety

19: The Leadership Role: Designing Perioperative Surgical Services for Safety and Efficiency

Introduction

Building a Safety Culture

Designing the Infrastructure for Safety

Hiring for Safety

Promoting Safety Norms

The Role of the Operating Room Management Committee

Collaborating for Safety

Executive Leadership

The Information Technology Department

Quality, Safety, and Risk Management Departments

Other Departments

External Partners

Staffing for Safety

Staffing Plan

Educating and Training in Patient Safety

Simulation

Spaced Education

Designing Processes for Safety

Presenting a Business Case for Safety

Sources of Data

Minimizing and Managing Resistance

Engage Emotionally

Maximize Efficiency

Leverage Peer Pressure and Support

Audit and Feedback

Dealing with Persistent Resistance

Summary

References

20: Operating Room Management, Measures of OR Efficiency, and Cost-Effectiveness

Introduction

Basic Definitions [1–4]

Case Duration Predictions

How to Make Duration Predictions

Improving Duration Predictions

OR Block Time and Utilization

Surgeon Block Time

Block Time Allocation

Block Time Utilization

Case Scheduling

Impact of High Utilization

OR Decision-Making

Utilization-Based Decisions

Decision-Making Priorities

Staffing

Managing Staff

OR Efficiency

Calculating Efficiency

Goals of Efficiency

Measures of OR Efficiency

Table 20.3 Discussion

Case Cancellations

PACU Delays

OR Summary Data

Conclusion

References

21: The Science of Delivering Safe and Reliable Anesthesia Care

Introduction

Designing and Enabling a Culture and Climate of Safety

Equipment and Monitoring Advances

Anesthesia Information Management Systems

Medication Safety

Preventing Medication Errors

Closed Claims Analysis and Associated Anesthesia Registries

Checklists and Cognitive Aids

Checklists

Cognitive Aids

Patient Transitions and Handoffs

Teams Training, Crisis Resource Management, and the Role of Simulation

Perioperative Safety Organizations

Caring for the Provider

Human Factors and Their Impact on Performance

The Second Victim

The Future: Coordination of Care and the Perioperative Surgical Home

Conclusions

References

22: Enhanced Recovery After Surgery: ERAS

Background

The ERAS Protocol: Individual Items

Preoperative Optimization

Prehabilitation and Exercise

Smoking and Alcohol Cessation

Preoperative Information, Education, and Counseling

Intraoperative Care

Preoperative Fasting and Preoperative Treatment with Carbohydrates

Antimicrobial Prophylaxis and Skin Preparation

Preanesthetic Medication and Anesthetic Management

Perioperative Fluid Balance

Avoiding Hypothermia

Access

Nasogastric Tube and Abdominal Drains

Urinary Catheter

Postoperative Care

Postoperative Analgesia

Postoperative Nausea and Vomiting (PONV)

Antithrombotic Prophylaxis

Early and Scheduled Mobilization

Early Oral Intake and Stimulation of Bowel Movement

Discharge

Audit

Implementation of an ERAS Program

Economics of ERAS

Research Outcomes and Quality of Life

References

23: The Next Frontier: Ambulatory and Outpatient Surgical Safety and Quality

Introduction and Overview

Factors That Drive a Culture of Safety in an ASC

Quality Assessment Performance Improvement

Risk Management

Environmental and Patient Safety

Infection Control and Prevention

Conclusion

References

24: Human Factors and Operating Room Design Challenges

Operating Rooms as Socio-technical Environments

Diffusion of Innovation

Risks in the Operating Room

Case Study I: Effects of Operating Floor Marking on the Position of Surgical Devices

Floor Marking Effects

Marking Floors as Improvement Design Intervention

Case Study II: Video Feedback to Improve Sensomotor and Non-­technical Skills

Sensomotor and Non-technical Factors in the Operating Room

Video Feedback as Means for Improvement

Awareness of Risks

Aversion to Error Reporting

Social Orientation

Automated Versus Handheld Video Feedback

Preliminary Results in Cataract Surgery

Computer-Assisted Surgical Systems

Recommendations�

Safety and Quality Improvement in the Operating Theatre Are Not Single Treatment Interventions B

Diffusion and Learning in Professional Organizations

Health Care Teamwork Is Work in Progress

Learning from Others

Conclusions

References

25: Diagnostic Error in Surgery and Surgical Services

Introduction

The Incidence of Diagnostic Error in Surgery

The Etiology of Diagnostic Error in Surgery

Addressing Diagnostic Error in Surgery

Addressing Interpretive Diagnostic Error in Surgical Pathology and Cytology

Addressing Cognitive Errors

Addressing System-Related Errors

The Future Reliability and Assurance of Surgical Diagnosis

References

26: Preventing Perioperative ‘Never Events’

Introduction

Misidentification (Wrong Patient/Procedure/Site)

Medication Errors

Pressure Ulcers and Related Positioning Never Events

Surgical Site Infections

Electrical and Other Energy-Related Never Events

Retained Surgical Items

Device Failures and Misuse

Difficult Airway, Failed Airway, Air Embolus

Difficult Airway

Failed Airway

Air Embolus

Venous Air Embolus

Arterial Air Embolus

Surgical Specimen Never Events

Hypothermia

Instrument Care and Reprocessing Never Events

Conclusions

References

27: Healthcare-Associated Infections in Surgical Practice

Introduction

Catheter-Associated Urinary Tract Infection (CAUTI)

Prevention

Catheter-Related Bloodstream Infection

Prevention

Surgical Site Infections (SSI)

Prevention

Pneumonia

Prevention

Clostridium difficile Infection

Prevention

Conclusions

References

28: Safer Medication Administration Through Design and Ergonomics

Part I: Introduction

Patient Story

Case Commentary

When to Suspect Wrong Drug Administration in the Operating Room

Clinical Management of Apnea

Medication Errors in Operating Room

System Theory and System Checks to Prevent Wrong Drug Administration

Part II: Organizational Medication Safety Management and Procurement

Formulary Management

Controlled Drug Management

Safe Medication Management Education

Drug Procurement

Injection Practices

Compounding Pharmacy Selection�

Drug Recalls

Drug Defect Reporting

Clarity of the Medical Record

Role of the Pharmacy Consultant

Pharmacy and Medication Safety Committees

Emergency Preparedness

Additional Resources

Conclusions

Appendix 1: Contract Pharmacy and Medication Management Consultation Services

References

29: Preventing Venous Thromboembolism Across the Surgical Care Continuum

Background

Definitions

Incidence and Cost

Harm to Patients

Risk Factors

Prevention

Pharmacologic Prophylaxis

Mechanical Prophylaxis

Prophylactic Inferior Vena Cava Filters

Systems of Care to Improve Prevention

VTE Risk Assessment and Prescription of Prophylaxis

Administration of VTE Prophylaxis

Patient Engagement and Education

Overcoming Hospital Culture Obstacles

Public Reporting of VTE Outcomes

Screening of Asymptomatic Patients and Surveillance Bias

Linking Process Measures and Outcome Measures

Quality and Safety Aspects of Diagnosis and Treatment

Conclusions

Key Points

References

30: Preventing Perioperative Positioning and Equipment Injuries

Introduction

Anatomy and Physiology

Risk Factors

Positioning Equipment

Equipment and Positioning Injuries

Preoperative Assessment

Skin Assessment

Surgical Positions: Safety Considerations

Supine Position

Trendelenburg Position

Modifiable Risk Factors and Prevention

Patient Factors

Padding

Positioning Devices

Team Communication

Prone Position

Lithotomy Position

Lateral Position

Positioning the Obese Patient

Safety Considerations

Conclusion

References

31: Challenges in Preventing Electrical, Thermal, and Radiation Injuries

Introduction

Background

Etiologies of Intraoperative Tissue Injury

Histology and Etiology

Investigation Guidelines for Perioperative Skin and Tissue Injuries

Injury Prevention and Management: Pre- and Post-Operative Considerations

Finding an Injury

Incident Report Documentation

Patient and Family Discussion

Components of a Thorough ­Investigation

The Investigation Process

The Investigation Team

Identifying the Cause

The Investigation Format

Lesion Assessment

Baseline Information

Lesion Assessment

Equipment Inspection

Using the Investigation Questionnaire

Instructions

Electrosurgical and Electrocautery Technology

Electrosurgery vs. Electrocautery: Untangling the Terminology

Electrosurgical Units (ESUs) and Accessories: Overview

The Clinical Knowledge Base About Electrosurgery

Nerve Monitoring Units and Electrosurgery

Direct Current Injury

Handling Electrodes During Investigations

Endoscopes and Laparoscopes

Thermal Injuries

Hypo/Hyperthermia Units

Hyperthermia Pads

Hypothermia Pads

Forced Air Hyperthermia Blankets

Phacoemulsifiers

Pulse Oximeters

Irradiant and Other Heat Sources

Radiant Warmers

Blanket and Solution Warming Cabinets

Fluoroscopy

MR Imaging

Thermal Injury from Surgical Fires

Summary

Appendix 1: Questionnaire for Investigating Accidental Perioperative Skin or Tissue Injury [51]

Appendix 2: Posters—Preventing Surgical Fires and Extinguishing Fires Burning On or In a Pati

References

32: Improving Clinical Performance by Analyzing Surgical Skills and Operative Errors

Introduction

Surgical Assessment

Observation-Based Methods

Objective Structured Assessment of Technical Skills

Checklists

Global Rating Scales

Technology-Based Performance Measures

Motion Analysis

Attention Monitoring Technology

Physiologic Stress Monitoring

Error Analysis in Other Fields

Aviation

Mining

Anesthesia

Errors in Surgery

Malpractice Claims Studies

Observational Studies

Future Directions

Defining “Error” and Understanding Error Management

Integrating Technology and Observation-Based Methods

References

Part IV: Approaches to Managing Risks

33: Perioperative Risk and Management of Surgical Patients

Overview of Risk Management

Clinical Case

Individual Risk

Process Risk

Risk Engineering in the Perioperative Environment

Phases of Care

Quantifying Risk in the Care Setting

Practical Applications of the FMEA Methodology

Other Factors in Managing Patient Safety Risk

Process

Dangers of Technology

Supply Issues

Governance

Scope of Practice Issues

Credentialing and Privileging

Staff Competency

Association of periOperative Registered Nurses

Nontechnical Skills

Surgical Setting

Equipment

The Second Victim

Case #1: The Almost Event

Case #2: The Angry Physician

Case # 3: A Different Type of Impairment

Summary

References

34: Managing the Complex High-Risk Surgical Patient

Risk and Risk Registries

High-Risk Surgery

Economics of High-Risk Surgery

Host Risk Factors

Thermoregulation

Age

Mass and BMI

Neurologic System

Pulmonary System

Cardiovascular System

Splanchnic System

Renal System

Endocrine System

Skin and Wounds

Metabolism and Nutrition

Hematologic and Immune System

Non-host Factors

Surgeon Factors

Team Factors

Collaboratives and Quality Improvement Programs

Failure to Rescue

Readmission Risk Factors

Pharmacology

Blood Management

Systems of Care

Peri-Surgical Home

Organizational Structure

Process

Conclusions

References

35: Geriatric Surgical Quality and Wellness

Introduction

Frailty

Problems with Cognition

Polypharmacy

Decreased Mobility/Falls

Nutrition

Function (Activities of Daily Living)

Goals of Life/Care

Depression/Seclusion

Comorbid Conditions

Caregiver Burden

Conclusion

References

36: Patient Transitions and Handovers Across the Continuum of Surgical Care

Introduction

Transitions Overall and Their Risks

The Transition into the Operating Room

The Surgery Is Scheduled

Sign In/Time-Out/Sign Out

The WHO Surgical Safety Checklist

Postoperative Transitions

Postanesthesia Care Unit (PACU)

The Transition of the Postoperative Patient from the ICU or PACU to the General Floor

Shift and Service Handoff Transitions

The Discharge Transition

The Discharge Transition Process: What Is Involved?

Risks Associated with the Postoperative Discharge Transition

Strategies to Improve the Postoperative Discharge Transition

Enhanced Recovery After Surgery (ERAS)

Perioperative Surgical Medical Home

Conclusions and Implications

References

37: Failure to Rescue and Failure to Perceive Patients in Crisis

Failure to Rescue and the Context of Surgical Patient Management

Definition

Epidemiology

Impact of Culture and Climate of Care

Surgical Clinical Microsystem and Implications for Rapid Response Success and Impact

Rapid Response Systems

Box 37.1: Clinical Microsystems: Five Stages of Growth

Box 37.2: Questions to Ask When Assessing an RRT Team’s Performance [39]

Chain of Survival

Principles of Reliable and Safe Care

Failure to Record

Failure to Recognize Pathophysiological Changes

Failure to Report

Failure to Treat

Evidence for Impact of Rapid Response Teams in Surgical Patients

Failure to Repeat

Failure to System Design

Failure to Measure

Conclusions

References

38: A Quiet Revolution: Communicating and Resolving Patient Harm

Public Policy Underpinnings of CRPs

Communication-and-Resolution Essentials

Involving Patients and Families in Safety Improvement

The Long Shadow of Medical Malpractice Liability

From Error Disclosure to CRPs

Pioneers and Early Adopters

Disclosure and Apology: Veterans Health System

Early Resolution: University of Michigan and University of Illinois – Chicago

Limited Compensation: COPIC

Broadening Consensus

Self-Regulatory and Professional Bodies

State Laws

Recent Developments

AHRQ Demonstration Projects

CandOR Toolkit and Collaborative for Accountability and Improvement

Individual, Institutional, and Environmental Optimization

Institutions

Individual Professionals

Legal and Regulatory Environment

Conclusion

References

39: It’s My Fault: Understanding the Role of Personal Accountability, Mental Models and Systems in

Introduction

The First Story: What Happened

The Second Story: Why It Happened

The Role of Mental Models

Discovering Flawed Systems

The Story Continues

Accountability

Root Cause Analysis

Writing a New Story

Closing Thoughts After 20 Years

References

40: Capturing, Reporting, and Learning from Adverse Events

Introduction

Types and Definitions of Incident Reporting Systems

Ideal Characteristics of Hospital-­Based Reporting Systems

Fostering a Reporting Culture

Integrating Reporting Systems with Other Patient Safety Surveillance

Barriers to Reporting

Participation Bias

Anonymity Versus Confidentiality

The Importance of Near Misses for Learning and Recovery

Aviation Near-Miss Reporting Systems

Nuclear Power Safety Systems

Costs Versus Benefits of IRS

Conclusions

References

41: How Not to Run an Incident Investigation

Don’t Let the Investigation Get in the Way of Learning from People

A Surgical Trauma Case

Define Your Purpose

A Cautionary Word About Methods of Inquiry

Building a Body of Knowledge About Adverse Events

An Overreliance on Rational Analysis Paralyzes Local Knowledge

How to Run a Local Investigation

Risk Assessment and Triage

Framing the Investigation Process

Asking Questions and Gathering Information

Facilitating Team Meetings

Identifying Contributing Factors

The Investigation Report

Staff Debriefings

How to Interpret an Investigation Report

What Is in a Name?

Engaging Staff in Learning Through Feedback and Debriefing

Building an Adaptive Workplace Culture

Applying Probabilistic Risk Assessment (PRA)

Applying Failure Modes and Effects Analysis (FMEA)

Looking Beyond the Investigation Phase

Translate Insights into Everyday Operations

Actively Explore the Problematic Situation with the People Involved

Test Alternative Actions and Hypotheses in the Perioperative Setting

Develop Effective Strategies for Insight into Local Systems

References

42: Multi-institutional Learning and Collaboration to Improve Quality and Safety

Introduction

History of the Quality Improvement Collaborative

Improving Surgical Quality via the Collaborative Model

The Nuts and Bolts of a Quality Improvement Collaborative

Evaluation

Conclusion

References

43: Lessons Learned from Anesthesia Registries About Surgical Safety and Reliability

Introduction

The Regulatory Environment

The History of Anesthesia Registries

Wake Up Safe

Pediatric Regional Anesthesia Network (PRAN)

The MPOG Registry

The National Anesthesia Clinical Outcomes Registry (NACOR)

NACOR vs. Surgical Registries

The Digital Future

Clinical Data Warehouses and Large Group Practices

Other National Anesthesia Registry Projects

Summary

References

44: Use of Data from Surgical Registries to Improve Outcomes

Introduction

Examples of Surgical Databases

The American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®)

The Society of Thoracic Surgeons National Database

Key Components of Surgical Databases

Use of a Common Language and Nomenclature

An Established Uniform Core Dataset for Collection of Information

Incorporation of a Mechanism to Evaluate and Account for Case Complexity

Availability of a Mechanism to Assure and Verify the Completeness and Accuracy of the Data

Collaboration Between Medical and Surgical Subspecialties

Standardization of Protocols for Lifelong Follow-up

Incorporation of Strategies for Quality Assessment and Quality Improvement

Graphical Depiction of Outcomes Data

Conclusion

References

Part V: Regulation, Policy, and the Future of Surgical Care

45: How Regulators Assess and Accredit Safety and Quality in Surgical Services

Background

Systems Thinking and Surgical Safety

Quality of Care in Surgery Settings

Comparison of Current Assurance Schemes in Surgical Safety: National and International

Outpatient/Ambulatory Surgery

Future Challenges in the Assessment and Regulation of Surgical Safety and Quality

Developing and Applying Surgical Standards

Building Safety Through Accreditation and Risk-­Thinking: Responsibility and Accountability

Optimizing and Standardizing Clinical and Organizational Processes

A Culture Devoted to Quality and Reliability

Wrong-Site Surgery: A Dynamic Risk Management Model

Learning from Experience: The Accreditation Process and How to Ensure Effective Implementation

Does Accreditation and Certification Make a Difference?

How Best to Prepare for Accreditation Visit?

Conclusions

References

46: The Perioperative Surgical Home: The New Frontier

Introduction

The Perioperative Surgical Home as a Value-Based Proposition

Quality

Patient Safety

Patient Satisfaction

Cost

Evidence to Support the Perioperative Surgical Home

Identifying and Overcoming Barriers to Implementation

Conclusions

References

47: Surgical Graduate Medical Education Program Accreditation and the Clinical Learning Environmen

Introduction

Patient Safety, Health Care Quality, and Accreditation of Surgical Training

Specialty, Subspecialty, and Common Program Requirements

Patient Safety and Quality for Institutions Seeking to Sponsor ACGME-Accredited GME (Institution

The Clinical Learning Environment (CLE)

Why Is the CLE Important in the Training of Residents and Fellows?

Why the Current Need for Attention to the Clinical Learning Environment for Surgeons in Train

The Surgical Health Care Environment

Surgical Faculty: Teaching Clinicians, Clinical Educators

Surgical Learners

Challenges and Barriers for Surgeons

Focus Areas and Key Questions

Early CLER Findings

Practical Approach to the Surgical CLE Focus Areas

Patient Safety

Health Care Quality and Quality Improvement

Transitions of Care

Supervision

Fatigue Management and Mitigation, and Fitness for Duty

Professionalism

Summary and Future Considerations

References

48: Affordable Care Act, Public Legislation, and Professional Self-­Regulation: Implications for 

Introduction

Evidence-Based Decision Making

Improved Patient Safety and Quality Outcomes

Congressional Legislation

Sustainable Growth Rate

Medicare Access and CHIP Reauthorization Act (MACRA)

Merit-Based Incentive Payment System (MIPS)

Alternative Payment Models (APM)

Hospital Value-Based Purchasing

Conclusion

References

49: Surgical Quality and Patient Safety in Rural Settings

Definition of a Rural Hospital

The Rural Surgeon: Challenges and Solutions to Practicing in a Rural Setting

The Rural Hospital in the Context of a Care System

Measuring Quality in Rural Hospitals

Regionalization of Care

Patient Preferences and Resources

Conclusion

References

50: Global Surgery: Progress and Challenges in Surgical Quality and Patient Safety

Introduction

The Donabedian Model

Structure

HIC Surgeons Practicing in LMICs

Enhanced Training for LMIC Surgeons

Frugal Innovation

Process

Surgical Quality Improvement in LMICs

Implementing Surgical Safety Processes in LMICs

Outcomes

Conclusions

References

51: International Perspectives on Safety, Quality, and Reliability of Surgical Care

Background

How Safe Is Surgical Care?

Challenges in International Practice

Lack of Education

Cultural Barriers

Language/Communication Barriers

Patient and Family Involvement

Health Tourism and Travelling

Problems with Benchmarking and Data Reliability

Status Hierarchy Barriers

Culture of Safety

Conclusions

References

52: Surgical Safety in Developing Countries: Middle East, North Africa, and Gulf Countries

Health-Care Systems in MENA Region

Epidemiology of Harm in Saudi Arabia

Quality Standards

Saudi Arabia Major Health Reform

Health Services During the Pilgrimage (Hajj) Season

Conclusions

References

53: Future Directions of Surgical Safety

Introduction

Measuring Health Care Quality

Health Care Systems Engineering

Culture of Safety

Team Training

Checklists and Team Briefings

High Reliability Organizations

Resilience Engineering

Improvement Science

Conclusions

References

Epilogue

Index

 

An aparitie	8 Jun. 2017
Autor	Juan A. Sanchez
Dimensiuni	17.15 x 5.72 x 26.04 cm
Editura	Springer
Format	Hardcover
ISBN	9783319440088
Limba	Engleza
Nr pag	909