Historically, morbidity and mortality conferences in surgical disciplines have been used for blaming, shaming, and explaining. Transparency was not a feature. The Department of Neurosurgery at Thomas Jefferson University Hospital decided to reconfigure their M&M conferences so that they could be used as an opportunity to focus on reporting and evidence-based medicine, and lead to quality improvement projects in the department and the neuroscience hospital. Join Dr. Ashwini Sharon to hear how that was accomplished

Cooper, MD, JD, Mary Reich

Sharan, MD, Ashwini D.

Jefferson Digital Commons

C O L L E G E  O F  P O P U L AT I O N  H E A LT HPopTalk Webinar SeriesOctober 14, 2020 | 12:00-1:00pm ETAshwini D. Sharan, MD, MSHQSVice Chair, Clinical Operation NeurosurgeryDivision Chief, Epilepsy and Neuromodulatory NeurosurgeryJefferson HealthDriving Quality Improvement through the Morbidity and Mortality Conference Portal| THOMAS JEFFERSON UNIVERSITY  | COLLEGE OF POPULATION HEALTHJefferson College of Population Health| THOMAS JEFFERSON UNIVERSITY  | COLLEGE OF POPULATION HEALTHToday’s PresentersMary Reich Cooper, MD, JDProgram Director, Healthcare QualityProgram Director, Operational ExcellenceJefferson College of Population HealthAshwini D. Sharan, MD, MSHQSVice Chair, Clinical Operation NeurosurgeryDivision Chief, Epilepsy and Neuromodulatory NeurosurgeryJefferson HealthDriving Quality Improvement through the Morbidity and Mortality Conference PortalM&Ms.  Our History. Image Retrieved from https://www.mms.com/historyDisclosures: these will not have any impact on my talk today• Entrepreneurism• Cerebral Therapeutics –Founder ~<5%%• Mudjala – Founder 5%• Tigerlabs – Shares <1%• Neuspera – Consultant• Neurotargetting – Shares 5%• Grants• NIH• Groff Foundation• Clinical Trials• SLATE(Mdt) for LITT• VNS for stroke• NEVRO NSRBOP for back pain• Fellowship Support - TJU• Medtronic• Abbot 2020• BSCI 2020• Private Foundation• DSMB (data safety monitor board)• Neuros• Mesoblast• HISTORY• COMPONENTS of M&M which must be addressed and taught• liability, transparency, reporting, authority gradient, culture • PROCESS • TRANSFORMATION (integrated QI)• RCA• Infection• CONCLUSIONS• Knowledge Sharing – (microlearning)Dagi, T. F., & Dagi, L. R. (2018). Commentary: Ernest Codman and the Impact of Quality Improvement in Neurosurgery: A Century Since the Idea of the “End Result.” Neurosurgery, 84(2). doi: 10.1093/neuros/nyy526• 100 errors that had occurred in 337 patients over a 5-yr period• Credited with starting the morbidity and mortality tracking process which involves tracking complications and outcomes • He was a close friend and collaborator with Harvey Cushing, whom he met while in medical school Ernest Codman published his classic text, A Study In Hospital Efficiency: As Demonstrated By the First Five Years of a Private Hospital National focus: leadership, research, tools and protocols to enhance the knowledge about safety Identifying and learning from errors through immediate and strong mandatory reporting Raising standards and expectations for improvements in safety through the actions of oversight organizations Creating safety systems inside health care organizations - CULTURE50% decrease in medical errors within 5 years.Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: building a safer health system. Washington: National Academy Press.IOM.  To Err is Human. Retrieved from https://www.sralab.org/lifecenter/resources/err-human-building-safer-health-systemJoint Commission (updated 2020). Sentinel Event Policy and Procedures. Retrieved from https://www.jointcommission.org/en/resources/patient-safety-topics/sentinel-event/sentinel-event-policy-and-procedures/ Established 1996 Reporting of sentinel events  Many barriers:  perceived liability, transparency, culture, power gradient, and even the lack of time and resource allocation Released in 1999 and published in 2000Morbidity & Mortality Reporting• Accreditation Council for Graduate Medical Education (ACGME) has instituted a required monthly conference be held as an educational tool for both training and educating resident physicians and practicing attending physicians.• Goal of creating a forum for open discussion, void of recourse, regarding AEs and complications that occurred and how to learnfrom them and minimize future occurrence.  • A missing component to the advent of the M&M conference was a standard definition of said events, which would allow to quantify the occurrence of a particular Adverse Events (AE) over time and its association with a procedure or how the process should occurACGME.  Image retrieved from https://www.acgme.org/Kravet, S. J., Howell, E., & Wright, S. M. (2006). Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. Journal of general internal medicine, 21(11), 1192–1194. https://doi.org/10.1111/j.1525-1497.2006.00523.x2006Liability• A recent PA Supreme Court decision held that a supervisor’s review of a physician’s case was discoverable. Physician case reviews were previously thought to be protected from discovery by the PA Peer Review Protection Act (PRPA).• The PA Supreme Court noted that the PRPA provides a narrow privilege to protect only the proceedings and documents of a review committee. Because the supervisor was not a review committee, the Court concluded that the documents were not protected from discovery by the PRPA.Reginelli v. Boggs: PA Supreme Court Case, 2018In 2005, the US Congress has protected the patient safety work product in an attempt to encourage reporting of adverse events.US Congress. Patient Safety and Quality Improvement Act of 2005, S. 544, enacted by the 109th Congress. Washington: US Government Printing Office, 2005 LIABILITY IS A REAL CONCERNTransparency has benefitsBrin, Dinah Wisenberg. (2018) The Best Response to Medical Errors? Transparency. Retrieved from https://www.aamc.org/news-insights/best-response-medical-errors-transparency• early reporting and analysis is better• full explanation for patients and families• emotional support for healthcare professionals• apologies and compensation to patientsWITHOUT TRANSPARENCY, WE CANNOT EXPECT FULL UNDERSTANDINGReporting• Most adverse events are not reported • Reporting - by provider volition and are labor intensive • Physicians may only report 2-4% of inpatient adverse events and nurses typically report more than physicians• Of 49,341 reported events in one study, 67% caused no harm• Centralized hospital systems such as a clinical performance improvement committee exist to remain in compliance with a variety of regulatory bodies but only 13% have broad staff involvementMilch, C. E., Salem, D. N., Pauker, S. G., Lundquist, T. G., Kumar, S., & Chen, J. (2006). Voluntary Electronic Reporting of Medical Errors and Adverse Events. An Analysis of 92,547 Reports from 26 Acute Care Hospitals. Journal of General Internal Medicine, 21(2), 165–170. doi: 10.1111/j.1525-1497.2006.00322.xFarley, D. O., Haviland, A., Champagne, S., Jain, A. K., Battles, J. B., Munier, W. B., & Loeb, J. M. (2008). Adverse-event-reporting practices by US hospitals: results of a national survey. Quality and Safety in Health Care, 17(6), 416–423. doi: 10.1136/qshc.2007.024638Authority Gradient• Rigid hierarchical structures from medical student, to intern, to post graduate year (PGY-N), to fellow and to attending physician• Crew resource management (CRM) programs (NOT EMBEDDED WITHIN OUR TRAINING)• Encourage cross talk and have team members speak up and voice their concerns• Most coworkers declare that they would not raise safety concerns during surgery as there is a culture of “speak at your own risk” • There needs to be clear protocols for reporting, teaching around the process, and a “no blame” approach Low on the Totem Pole (AHRQ): IHI - Institute for Healthcare Improvement. (2005) Low on the Totem Pole. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyLowontheTotemPole.aspxAuthority GradientCosby, K. S. (2004). Profiles in Patient Safety: Authority Gradients in Medical Error. Academic Emergency Medicine, 11(12), 1341–1345. doi: 10.1197/j.aem.2004.07.005Begin with an objective statementHow might I recognize this complication?Progressing to a more active statement of concernI’m worried.In extreme cases Something is wrong! You need to see this patient nowStarting rounds daily“Are there any patient safety events that occurred overnight?” CUS and Team STEPPSCultureHofstede, G. (n.d.) The 6-D model of national culture.  Retrieved from https://geerthofstede.com/culture-geert-hofstede-gert-jan-hofstede/6d-model-of-national-culture/AHRQ.  (2018) Hospital Survey on Patient Safety Culture: 2018 User Database Report.  Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf*Apuzzo, M. L. J. (1993). Brain surgery: complication avoidance and management. New York: Churchill Livingstone.Benzel, E. C. (1999). Spine surgery techniques, complication avoidance, and management. Philadelphia, PA: Elsevier.Donabedian, A. (1988). "The quality of care: How can it be assessed?". JAMA. 260 (12): 1743–8. DOI: 10.1001/jama.260.12.1743Millbank Memorial Fund. Celebrating Avedis Donabedian’s Seminal Article Published 50 Years Ago in The Milbank Quarterly.  Image Retrieved fromhttps://www.milbank.org/news/celebrating-avedis-donabedians-seminal-article-published-50-years-ago-milbank-quarterly/Structure, Process, and Outcome Neurosurgery approachGoal 1: Assess the current state• Peer review committee• Literature search• Data analysis• Focus groups• Comparisons with nationally reported data (PSI indicators)0246810121416Jun Jul Aug Sep Oct Nov DecMorbidity by Specialty and MeanSPINE TUMOR VASC MeanMorbidity & Mortality – Tracking (Future – Outcome)A comparison of death rate when comparing data reported into the Vizient data base when the Jefferson neurosurgery physician was included as the primary only on the admission.A comparison of death rate when comparing data reported into the Vizient data base when the Jefferson neurosurgery physician was included as the primary or secondary procedure MD on the admission.3 Month Comparison of NS-PRC to TJUH PI Mortality and PSI DataM&M Reporting – StandardizationGOAL # 2• The second goal is to develop standardized titles to classify the adverse events (GRANULARITY)• Nineteen categories were identified which were similar to the three neurosurgical divisions and 27,27, and 28 titles were identified for the three group0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0%CerebrovascularNeuro-oncologySpine/FunctionalTotalM&M Infection CSF Leak Hemorrhage• Total and divisional rates of morbidity and mortality, infection, CSF leak and hemorrhageMorbidity & Mortality - TrackingTRANSFORMATION• Standardization, Reporting, and Tracking System• Audit / Reconciliation Process with CPIC• How do we convert this to a Teaching Platform where actionable items are identifiedReadmission Rates• unruptured aneurysm clipping 6.3%• trans-sphenoidal surgery 8.5%• cranial tumor resection 10.7%• spinal neurosurgery 5.5%• epilepsy surgery 11%Ramos, C. L., Brandel, M. G., Rennert, R. C., Wali, A. R., Steinberg, J. A., Santiago-Dieppa, D. R., … Khalessi, A. A. (2018). Clinical Risk Factors and Postoperative Complications Associated with Unplanned Hospital Readmissions After Cranial Neurosurgery. World Neurosurgery, 119. doi: 10.1016/j.wneu.2018.07.136Kwon, C. S., Agarwal, P., Subramaniam, V., Dhamoon, M., Mazumdar, M., Yeshokumar, A., … Jetté, N. (2019). Readmission after neurosurgical intervention in epilepsy: A nationwide cohort analysis. Epilepsia, 61(1), 61–69. doi: 10.1111/epi.16401Bernatz, J. T., & Anderson, P. A. (2015). Thirty-day readmission rates in spine surgery: systematic review and meta-analysis. Neurosurgical Focus, 39(4). doi: 10.3171/2015.7.focus15342011-2016 from National Surgical Quality Improvement Plan on 40,802 cranial neurosurgical operation revealed a 10.2% (4147) rate of readmission within 30 days of the surgery Readmission Rates – Clinical Performance Improvement Committee (CPIC)Discharge Year CasesMean LOS (Obs)Mean LOS (Exp) LOS Index30 Day Readmit CasesPct 30 Day Readmit14 Day Readmit CasesPct 14 Day Readmit7 Day Readmit CasesPct 7 Day Readmit2016 3,522 5.86 6.30 0.93 340 10.04 212 6.26 134 3.962017 3,286 5.41 6.06 0.89 300 9.36 199 6.21 104 3.242018 2,899 6.30 6.67 0.94 271 9.58 176 6.22 105 3.712019 3,183 5.79 6.89 0.84 261 8.44 165 5.34 99 3.20Total 12,890 5.83 6.47 0.90 1,172 9.36 752 6.01 442 3.53• Summary: 71 year old female who was discharged home on 1/9/20 after a cervical operation. She was readmitted 1/11/20 (after 1 day of being at home) because she felt as if being at home was too overwhelming and she realized once she got home she did not have the adequate social support to be able to recover from surgery. She was re-evaluated by physical therapy and sent to subacute rehab.What HappenedCase Study Approach with RCAPCDF – Posterior Cervical Discectomy and Fusion• All neurosurgery residents and NPs will perform a discharge assessment and confirm patient is safe to go home or to rehab• Quality improvement and patient safety are higher priorities than efficient discharge and decreasing length of stayWhat Are Our Long-term Goals?Case Study Approach with RCACreating a discharge scorecard An assessment of the readmissions revealed the following:• Work with CPIC• Identify trends in surgical complications by Neurosurgery Service Lines• Added to the NS-PRC notology a category highlighting readmission• Perform 3-6 cases studies every academic year to create a plan on reducing a particular type of readmission• Work with Pre-admission testing and hospital IT to develop a neurosurgery specific pre-admission scorecardReadmission Rates•Start with a brief case scenario?•What happened – Sequence of events?•Why did it happen?•Graphically display the variables1.RCA2.PDSA3.People/Equipment/Place/Methods•Causes•Solutions1.Implementation strategies2.Who will monitor, what will be monitored3.How do you prevent this from happening again4.Costs of implementationFRAMEWORKFRAMEWORK1.Methods2.Patient issue3.Machines4.Measurements5.Environment6.Materials• Reduction of patient comorbidities when they can be managed, meticulous surgical techniques, preventing contamination, and pre-operative antibiotics have all been cited previously • AHRQ has also collated a set of resources on helping hospitals with a framework to reduce SSI• Others have used PDSA and RCA tools and there is a large body of experience, yet eliminating SSI is still a problem• Similarly, the CDC has also in 2017 reviewed guidelines based approaches to reducing SSISurgical Site Infections (SSI)Reichman, D. E., & Greenberg, J. A. (2009). Reducing surgical site infections: a review. Reviews in obstetrics & gynecology, 2(4), 212–221.AHRQ. (2009) Surgical Site Investigation Tool retrieved from https://www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/ssi-investigation.htmlNg, W. K., & Awad, N. (2015). Performance improvement initiative: prevention of surgical site infection (SSI). BMJ quality improvement reports, 4(1), u205401.w3279. https://doi.org/10.1136/bmjquality.u205401.w3279Shah, Mashood Ahmad. (2012). Root cause analysis in surgical site infections (SSIs). International Journal of Pharmaceutical Science Invention. 1. 11-15.Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. (2017) Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection. JAMA Surg. 2017;152(8):784–791. InfectionsFigure 1:  A report generated from the NS-PRC database of mortality, morbidity, and infection rate in grey bar for FY 2019 (2-4%)0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0%SPINETUMORVASCTOTALMortality, Morbidity and Infection Rates by SubspecialtyInfection Morbidity MortalityInfectionsSurgical site infection from 2016-2018 and 2018-2020 Q1 as tracked by hospital infection control.InfectionsFigure 4 The nurse practitioner for a single physician began taking pictures of the patients wounds in 2 week follow-up.  This was presented as a collage and shared with the resident (PGY4) on that service at that time.  The feedback has been enlightening as most residents never get to see how their own incisions that they closed actually heal.Infections – Education ProgramOnboarding for Junior Residents• Closure Teaching- Wound healing principle- Technique- Suture Principles• Feedback through EPIC – on-line follow-up pictures• Grading and evaluation• Dressing management• Wound management• Hand washing protocolsM&M Conference (NS-PRC)• The goal is to improve patient care• Mindset has to change, tracking is not enough• An education conference needs to transform into a platform where actionable items results• Re-admission RCA• Infection Reduction• Hospital Tracking• fulfilling regulatory requirements but tremendous opportunities are identified where there can be sustainable changesNEXT STEPSRisk Assessment ToolChallenges• Changing Culture• Leadership (we) must drive change and provide resources• Communication Plan will be essential• Tracking institutionally is different and should be reconciled• Integration with Epic will be challenging but again electronic reporting is desirable| THOMAS JEFFERSON UNIVERSITY  | COLLEGE OF POPULATION HEALTHQ & A| THOMAS JEFFERSON UNIVERSITY  | COLLEGE OF POPULATION HEALTHLearn more at: Jefferson.edu/HQSQuestions: JCPH.Admissions@jefferson.edu• 100% online• Accelerated 7-week courses• Expert practitioner facultyComplete a graduate certificate in 1 year or Master’s degree in 2 yearsInformation Session: October 20 from 12:00-1:00 pm ET| THOMAS JEFFERSON UNIVERSITY  | COLLEGE OF POPULATION HEALTHVisit our Website for more detailed information and upcoming PopTalksSave the DatesPublic Health Toolbox: Arts Informed ResearchOctober 21, 2020 | 1:00-2:00 pm ETRegister NowStrategies for a Healthier Employee Population: How Principles of Population Health ApplyOctober 26, 2020 | 12:00-1:00 pm ETRegister NowNavigating Through the COVID-19 Pandemic Utilizing Data & AnalyticsNovember 5, 2020 | 12:00-1:00 pm ETRegister Now| THOMAS JEFFERSON UNIVERSITY  | COLLEGE OF POPULATION HEALTHThank You!

Driving Quality Improvement through the Morbidity and Mortality Conference Portal

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Driving Quality Improvement through the Morbidity and Mortality Conference Portal

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