Quality Safety Complications/Pulmonary Board Review

Quality, Safety, and Complications
Michael H. Baumann, MD, MS

Professor of Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine
University of Mississippi Medical Center
Jackson, MS Email: mbaumann@umc.edu
1
NONE
Conflict of Interest
Related to this Talk
2
Thank you:
Amber Arnold, RN, DNP, UMMC Patient Safety
Officer
Elham Ghonim, PhD, Director, Infection
Prevention
3
4
Gone To The Dark
Side?

NO!
The Message The Messenger
Quality, Safety and Complications
5
Quality, Safety, and
Complications
ABIM outline:
6
ABIM Site Accessed July 7, 3013
Complications
ABIM outline:
7
ABIM Site Accessed December 30, 2012
ACGME Core Competencies
6 core competencies
Patient care and procedural skills
Medical knowledge
Interpersonal and communication skills
Practice based learning and improvement
Systems based practice
8
ACGME web site, March 27, 2013
Complications
Bottom Line Objectives:
Core quality/safety and complications knowledge
What you need to know to survive the real world
HOPEFULLY: picked likely testable issues too!
AND: understand basics of systems, quality
improvement and patient safety jargon

9
In the United States health system, which entity is currently
the largest driver / enforcer of pay for performance (value
based purchasing)?
A. The Blue Cross/ Blue Shield third party payer groups
B. National Quality Forum
C. American Medical Association Physician Consortium for
Performance Improvement
D. Centers for Medicare and Medicaid Services (CMS)
10
Medicare Costs
12

Medicare Trends: FFY 2007 FFY 2009

Costs increasing!

Losses increasing!

Courtesy of Dr. David Potash, Press Ganey Evaluation
Complications
Introduction
Basic definitions and theory: quality and safety
Errors and error theory
Complications of care
Hospital acquired conditions (HACs)
Hospital acquired infections (HAIs)
Infection Control (infection prevention)
Systems-based practice
Practice-based learning/improvement

13
Complications
Introduction

14
Quality Definition
Quality: the measure of who well a product
or service matches a need.

15
The Improvement Guide, 2009 (2
nd
edition)
Quality Theory
Quality: Definition?:
peculiar or essential character
inherent feature: property
degree of excellence: grade
social status: rank
a distinguishing attribute: characteristic

Merriam-Websters Collegiate Dictionary, 10
th
ed, 2000
16
Quality Theory
Quality: Related terms?:
Quality Improvement
Quality Improvement Tools
Briefly!!

17
Quality Theory
Quality Improvement (vis a vie, health care)
Combined and unceasing efforts of everyone
health care professionals, patients, and their
families, researchers, payers, planners and
educators to make the changes that will lead to
better patient outcomes (health), better system
performance (care) and better professional
development (learning).

18
Batalden PB. What is quality improvement and how can it transform healthcare?
Qual Safe Health Care 2007; 16: 2-3.
Linked Aims of Quality Improvement

19
Better patient (and
population) outcomes
Better professional
development
Better system
performance
EVERYONE
Batalden
Quality Theory
Quality Improvement
Reward and accountability
Everyone has TWO jobs when they come to
work:
1. Do their work
2. Improve their work

20
Which of the following correctly defines value for
a patient?
A. Dollar cost / Patient preference
B. Quality / Price
C. Patient preference / Time cost
D. Price / Time cost
21

C
o
p
y
r
i
g
h
t
,

T
h
e

J
o
i
n
t

C
o
m
m
i
s
s
i
o
n

FORMULA FOR EFFECTIVE
RESULTS
[CHANGE EFFECTIVENESS EQUATION]

E = Q X A X A

Effective results (E) are equal to the Quality (Q) of the
solution times the Acceptance (A) of the idea times the
Accountability (A) for the implementation

62% of quality efforts fail from lack of attention to
the cultural or people side of change - the "As"
Quality Theory

Value = Quality / Price

The Improvement Guide, 1996
24
Quality Theory
Value = Quality / Price
Value: Relative worth, utility, or importance of something
Higher Quality " Higher Value ???
Price plays a role
Price: what consumer has to pay for product or service; not
just price tag; also cost to use

25
A Story of Value, Quality and Price

26
3X (Porsche) X (Honda)
Value = Quality / 3X Value = Quality / X
Quality Theory
Value!.lets focus here!
High Value: high quality at a relatively low price
Who determines value?
The customer?
Expand customer expectations to increase
demand
Value / quality determined by the customer

27
Patient Safety?
28
The Scope of Medical Errors
According to the Institute of Medicine (IOM) report in
1999, as many as 44,000 to 98,000 people die in
hospitals each year as the result of medical errors.
The IOM reports that medical errors cost the nation
approximately $37.6 billion each year; about $17 billion
of those costs are associated with preventable errors.
An estimated 15,000 Medicare patients die each
month in part because of care they receive in the
hospital. USA Today, November 16, 2010

Every system is
perfectly designed
to achieve the
results that it gets.
--Don Berwick
(really Paul
Batalden)
How do we define patient safety?
pa!tient [pey-shuhnt] safe!ty [seyf-tee]
(n) freedom from unintended injury associated with the provision
of healthcare services
Ensuring patient safety involves the establishment of operation
systems and processes that minimize the likelihood of errors
and maximize the likelihood of intercepting them, so patient
harm will not occur.

Which of the following terms is associated with
James Reasons model for error events?
A. Gorganzola cheese model
B. Camembert cheese model
C. Swiss cheese model
D. Blue cheese model
32
Swiss Cheese Model
(Error Theory)
Proposed by British psychologist James Reason
Learning from our Errors
Reporting
Sentinel events
Unsafe acts
Near misses

Which of the following terms most correctly describes a
sentinel event involving patient care?
A. An expected occurrence involving limited injury to a patient
B. An unexpected occurrence involving no injury to a patient
C. An unexpected occurrence involving serious injury to a patient
D. An expected occurrence without harm to the patient, but, the
patient is filing a complaint
36
Sentinel Event
An unexpected occurrence involving death or
serious injury (such as the loss of limb or
function). Such events are deemed sentinel
because they signal the need for immediate
investigation and response.

Example: Operating on the right leg instead of the
left leg.
38
Complications
Introduction

40
Hospital Acquired Conditions (HACs)
Deficit Reduction Act of 2005 required the Secretary to identify
conditions that are:
High cost or high volume (or both)
Result in assignment of a case to a DRG that has a higher
payment when present as a secondary diagnosis, and,
Could be reasonably have been prevented through application
of evidence-base guidelines
July 2008, Inpatient Prospective Payment System (IPPS) for fiscal
year 2009 included 10 categories of conditions selected for HAC
payment provision.
Payment implications began October 2008
NOW 11 categories for 2013 with two new HACs

CMS web site: June 2013
Hospital Acquired Conditions (HACs)
Hospital Acquired Condition: We Done It!!
The system, the health care providers, other factors
allow an unwanted condition / event to occur to a
patient while in hospital.
NOT just CMS!!
Mississippi Blue Cross / Blue Shield: open ended option to
define anything as a quality or HAC issue and impact
payment
HAC 2013 LIST
43
HAC List 2013
Foreign object retained after
surgery
Air embolism
Blood incompatibility
Falls and trauma
Manifestations of poor
glycemic control
Iatrogenic pneumothorax with
venous catheterization*
Catheter-associated urinary
tract infection (CAUTI)
Vascular catheter-associated
infection (central line
associated blood stream
infections-CLABSI)
Surgical site infection (SSI),
mediastinitis, post CABG
SSI following bariatric
surgery for obesity
SSI post ortho for spine,
neck, shoulder, elbow
SSI post cardiac implantable
electronic device*
44 * New 2013
HAC List 2013 Infection Prevention
Foreign object retained after
surgery
Air embolism
Blood incompatibility
Falls and trauma
Manifestations of poor glycemic
control
Iatrogenic pneumothorax with
venous catheterization
Catheter-associated urinary
tract infection (CAUTI)
Vascular catheter-associated
infection (central line associated
blood stream infections-
CLABSI)
Surgical site infection (SSI),
mediastinitis, post CABG
SSI following bariatric surgery
for obesity
SSI post ortho for spine, neck,
shoulder, elbow
SSI post cardiac implantable
electronic device 45
Hospital Acquired Infections (HAIs)
Catheter-associated urinary tract infection
Vascular catheter-associated infection
Surgical site infection (SSI), mediastinitis, post
CABG
SSI following bariatric surgery for obesity
SSI post ortho for spine, neck, shoulder, elbow
SSI post cardiac implantable electronic device
46
Healthcare-Associated Infections
(HAIs)
A localized or systemic condition resulting from an
adverse reaction to the presence of an infectious
agent(s) or its toxin(s). There must be no evidence that
the infection was present or incubating at the time of
admission to the care setting.

Healthcare-associated infections are one of the top ten
leading causes of death in the United States.
47
Infection Prevention TEAM
48
Infection Prevention: Terminology
Infection prevention and control program refers to a
program (including surveillance, investigation, prevention,
control, and reporting) that provides a safe, sanitary and
comfortable environment to help prevent the development and
transmission of infection.
Infection preventionist (IP) (a.k.a. infection control
professional) refers to a person whose primary training is in
either nursing, medical technology, microbiology, or
epidemiology and who has acquired additional training in
infection control.
49
CMS Manual System. Pub. 100-07 State Operations Provider Certification, 2009
(Accessed June 2013)
50
Catheter Insertion Bundle for Blood Stream Infection Control

TYPE OF CATHETER (CHECK ONE)
! Central Line
! PICC Line
! Dialysis
! Other: Please specify______________

SITE (CHECK ONE)
! Subclavian
! IJ
! Femoral*
! Umbilical
CHECK ONE
! New line
! Re-wire
! Catheter changed
over a wire
CHECK ONE
! Elective
! Emergent

*If a FEMORAL site is accessed, justification MUST be documented in the Progress Notes

PRE-PROCEDURE YES NO
Consent Obtained ! !
Timeout Sticker Done &Documented in EPIC ! !
Cleansed Hands (practitioner & assistant) ! !
Prepped Procedure Site with Chlorhexidine and allowed to dry
(cleansing agent for specific patient population)
! !
Draped Patient in Sterile Fashion using large drape (full body) ! !
PROCEDURE YES NO
Sterile Gown (practitioner & assistant) ! !
Mask and Hat (practitioner & assistant) ! !
Sterile Gloves (practitioner & assistant) ! !
Sterile Field Maintained ! !
All Persons in Room Wore Mask ! !
POST-PROCEDURE YES NO
Sterile Field Maintained while applying sterile dressing
Biopatch applied

!
!

!
!

Dressing Dated ! !
Type of dressing ! Semipermeable ! Gauze ! Other ! NA

SURGICAL SITE INFECTIONS
51
Selected Procedures
*Coronary Bypass with Chest & Donor Incision
*Coronary Bypass Graft with Chest Incision
Heart Transplant
Peripheral Vascular Bypass
*Cardiac Procedures (procedures on the heart; includes valves or
septum)
*Abdominal Hysterectomy
Vaginal Hysterectomy
*Hip Prosthesis
*Knee Prosthesis
Herniorrhaphy
*Colon Procedures
Small Bowel
*Regulatory Required

MULTI-DRUG RESISTANT
ORGANISMS
(MDRO)
53
Multi-Drug Resistant Organisms
(MDROs)
Defined as organisms, mainly bacteria, that are
resistant to one or more classes of antimicrobial
agents
54
Clinical importance of MDROs
Infection with MDROs have been associated
with:
Increased length of stay
Increased cost of care
High mortality rate
Few therapeutic choices-makes treatment very
difficult

55
MDROs
Methicillin-resistant Staphylococcus Aureus
(MRSA)
Vancomycin-resistant Enterococcus spp.
C. difficile
Multi-drug resistant gram negative bacteria
(MDRO) include ; Acinetobacter spp. Klebsiella
spp., CRE-E.coli, and Pseudomonas spp.
56
Target: Principal Modes of
Transmission
MODE
Person-person via
hands of health care
providers
Patient and personal
equipment and clothing
Environmental
contamination
STRATEGY
! Hand hygiene
! Dedicated equipment
and disinfection

! Cleaning and disinfection
57
Control Methods for MDROs
Transmission
Strict adherence to hand hygiene and isolation
precautions practices
MDRO education; facilitywide that includes patients
and families
Activating computer alerts to identify previously
infected or colonized patients
Maintaining a clean environment

58
Contact Precautions
Used for diseases transmitted by direct contact with the patient
or the patients environment
Patient placement; A single room is preferred
Personal Protective Equipment(PPE):
Wear gown and gloves upon room entry
Change the gown and gloves between patients
Remove gown and gloves before exiting the room and wash
hands
59
Hand Hygiene

(Wax On, Wax Off)
(Wash In, Wash Out)
60
Center Wide Hand Hygiene Compliance April
2013

Total # of
Observations
Total % Compliance % MD Compliance % RN Compliance
!"#$%& ()*) *+, *-, **,
Hand Hygiene
April 2013

# HH Observations
# of RN
Observations
# of MD Observations RN compliance MD Compliance
Adult Tower 698 444 56 100% 100%
Children's Hospital 746 575 40 100% 100%
Wiser 731 539 96 100% 96%
Critical Care Tower 443 355 58 98% 94%
ISOLATION ISSUES / CATEGORIES
63
64
1ransmlsslon 8ased recauLlons Culck 8eference Culde*
!"#$% '()*+),)-) ./01#203#45 6778
Pand Pyglene 8efore and AfLer aLlenL ConLacL

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+'),-.#
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)4 *)5621%6 ,#7

81'9)'%. :%4.*#1)%
:/)-$#1)% ;8::<

Cllnlcal SlLuaLlon

All aLlenLs

MuLl-drug reslsLanL
organlsms (Mu8C),
dlarrhea, dralnlng wounds
and exudaLlve leslons

upper 8esplraLory
lnfecLlons, lncludlng
known or suspecLed
lnfecLlons l.e., lnfluenza,
menlngococcal menlnglLls

1uberculosls-pulmonary or
laryngeal dlsease
conflrmed or suspecLed,
chlckenpox, measles,
smallpox

8oom reference

rlvaLe or Seml-rlvaLe

rlvaLe
ConsulL lnfecLlon ConLrol
for cohorLlng

rlvaLe
ConsulL lnfecLlon ConLrol
for cohorLlng
SeparaLe paLlenLs by 3fL
(novel flu by 6 fL*)

rlvaLe
All negaLlve alrflow, door
closed

Wear Cloves

lf conLacL w/blood, body
flulds, or poLenLlally
conLamlnaLed maLerlal or
surfaces ls anLlclpaLed

Wear gloves upon enLerlng
room

Same as SLandard

Same as SLandard

Wear Mask/Lye roLecLlon

flulds, or poLenLlal sprays
of resplraLory secreLlons
Lo eyes, nose and mouLh ls
anLlclpaLed

Same as SLandard

Wear mask/eye proLecLlon
when wlLhln 3 fL of
paLlenL*
Wear an n-93 mask or
hlgher level resplraLor
Wear Cown
flulds, or poLenLlally
conLamlnaLed maLerlal ls
anLlclpaLed

Wear gown upon enLerlng
room

Same as SLandard

Same as SLandard
Transmission Based Precautions (Quick Reference Guide), HICPAC/CDC Guidelines, 2007
Remember:

Hand Hygiene Before and After
Patient Contact
65
ISOLATION COMPLIANCE
66
What Are We Trying to Implement
In Daily Practice of Medicine?
Recommendations from evidence based
guidelines
These are often turned into performance
measures
Sackett DL, et al. Evidence-based medicine. How to practice and teach EBM.
2
nd
edition. Philiadelphia, PA; Churchill Livingston. 2000
Straus S, et al. Evidence-based medicine. How to practice and teach EBM.
3
rd
edition. Philiadelphia, PA; Churchill Livingston. 2005

Evidence Based Medicine
EBM is the integration of best research
evidence with clinical expertise and patient
values.
What is a performance measure?
Methods or instruments to estimate or monitor
the extent to which the actions of a health care provider
conform to practice guidelines or standards of quality.
(IOM)
A value against which an individuals (group, hospital,
etc) performance can be compared (bench marked).
(Baumann)
Can be a process measure (tobacco cessation) or an
outcome measure (death).

Jargon to Contend With Today!.
Outcome measure
Performance measure
Process measure

Outcome Measure = Performance Measure
Performance Measure = Process Measure
Process Measure " Outcome Measure (generally)
Jargon to Contend With Today!.
Outcome Measure
Performance Measure
Process Measure
Hierarchy
30,000 feet
Front lines, 0-5 feet
(Trenches)
Why Be Concerned About Performance
Measures?
73
Evidence Based Medicine
Evidence Based Guidelines
Performance Measures
Public Reporting
(Hospital Compare-CMS,
Health Grades, UHC)
Pay for Performance
(Value Based Purchasing)
ANATOMY OF A PERFORMANCE
MEASURE
74
NQF COPD PM 3: Bronchodilator Use
Numerator:
Symptomatic patients who are prescribed an inhaled
bronchodilator (#2 agonist and/or anticholinergic)
Denominator:
$ 18 yo, COPD, FEV
1
/FVC < 70% and have symptoms
Exclusions:
Document medical reason not prescribe inhaled BD (allergy,
drug interaction, contraindication, other)
Document patient reason not doing spirometry (economic,
social, religious, other)
Data Source
Paper medical record, paper flow sheet, EMR
75
What is pay for performance
(P4P)?
Also known as: Value-Based Performance
(Purchasing)
Based upon critical measures by which a
physicians performance is compared to
benchmarks (performance measures)!
Individuals performance level determines his/her
financial reimbursement
$$$$$$$$$$$$

76
Why should you care?
To improve the care of your patient and the
system where you work!

Why should you care?
What is Hospital Value Based
Purchasing (VBP)?
A rule under the Affordable Care Act of 2010
creating a hospital value based purchasing
program for acute care hospitals paid under the
Inpatient Prospective Payment System (IPPS)
for inpatient services to Medicare beneficiaries
Creates incentive payments to hospitals based on
the quality of care provided as shown in their
attainment or improvement of quality measures in
specific domains
79
Value Domains
80
Clinical Process
of Care
12 measures
(13 in FY 2014)
70% of score
weight
FY 2013
Experience of
Care
8 measures
30% of score
weight
FY 2013
Outcomes
7 measures
Score weight to
be determined
FY 2014
Outcome Measures to be Added FY 2014
Acute myocardial infarction 30 day mortality rate
Heart failure 30 day mortality rate
Pneumonia 30 day mortality rate
Mortality measures
Foreign object retained after surgery Falls and trauma
Blood incompatibility Air embolism
Vascular catheter associated infections Pressure ulcers, stages III & IV
Catheter associated urinary tract infections Poor glycemic control
Hospital acquired conditions (HAC)
Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)
Agency for Healthcare Quality and Research (AHRQ) Patient Safety
Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite
measures
81
Proposed Efficiency Measure
Inpatient Stay
Pre-op
lab work
Dr.
Visit
Three Days Prior:
Dr.
Visit
ED
Visit
Rehab
Ninety Days Post:
Dr.
Visit
Dr.
Visit
One Episode
Reference: Mississippi Hospital Association
PUBLIC REPORTING
83
Creating Quality Health Care
How YOUR Hospital Looks Externally
84
CMS web site!
http://www.hospitalcompare.hhs.gov/hospital-search.aspx
85
Physician Compare: Official Site Launched 3/17/11
http://www.medicare.gov/find-a-doctor/provider-search.aspx
August 5, 2011

McComb Hospital
on front page
88
Clarion Ledger, Jackson, MS: October 23, 2010
LOCAL PUBLIC REPORTING
89
Complications
Introduction

90
SYSTEMS BASED PRACTICE
91
92
ACGME, March 27, 2013; from 5/20/2008 document
Systems Based Practice
Key words
Systems
System errors
Interprofessional teams
93
Key words
Systems
System errors....already did this one!
94
Every system is
perfectly designed
to achieve the
--Don Berwick
(really Paul
Batalden)
Systems?
Every system is perfectly designed to get the
Paul Batalden
Your practice is a small system
A complex adaptive system
Biologic with adaptive capabilities
A clinical microsystem
The Microsystems Approach to
Quality Improvement
Acknowledgement for ideas, materials, and a great deal of
teaching!.
Paul Batalden, MD
Gene Nelson DSc, MPH
Margie Godfrey, MS, RN
CESC:
Now: The Dartmouth Institute

http://www.dartmouth.edu/~cecs/about.html
http://tdi.dartmouth.edu/
99
100
Microsystem - Definition
A health care clinical microsystem can be defined as the
combination of a small team of people who work together on a
regular basis or as needed to provide care and the
individuals who receive that care (who can also be recognized
as members of a discrete subpopulation of patients.)
It has clinical and business aims, linked processes, a shared
information environment and produces services and care which
can be measured as performance outcomes. These systems
evolve over time and are (often) embedded in larger systems /
organizations.
As any living adaptive system, the microsystem must: (1) do the
work, (2) meet staff needs, (3) maintain themselves as a clinical
unit
102
The Chain of Effect for Quality
Top Down Level Bottom Up

Environmental Context

Organizational Context

Microsystems

Patient and Community
103
104
Change Idea/Concepts
PDSA SDSA
105
The PDSA Cycle
Plan
Do Study
Act

% Objective
% Questions and
predictions (why)
% Plan to carry out the
cycle (who, what,
where, when)
% Plan to measure

% Carry out the plan
% Document
problems and
unexpected
observation
% Begin analysis
of the data

% Complete the
analysis of the data
% Compare the data
to predictions
% Summarize what
was learned

% What changes are
to be made?
% Next cycle?
% Action based on
data

If you are not keeping score,
you are just practicing.
Vince Lombardi
"#$%&'()#* #+ ,-&* &*. /(0 /(1$&
S|x S|gma was deve|oped by Motoro|a |n the 1980s to systemat|ca||y
|mprove qua||ty by e||m|nat|on of defects.
S|x S|gma Lean
Cb[ect|ve De||ver va|ue to the customer De||ver va|ue to the customer
1heory keduce Var|at|on kemove Waste
Iocus rob|em Iocused I|ow Iocused
-A prob|em ex|sts
-I|gures and numbers are
va|ued
-System output |mproves |f
var|at|on |n a|| processes |nputs
|s reduced
-Many sma|| |mprovements are
better than system ana|ys|s
Assumpt|ons
-Waste remova| w||| |mprove
bus|ness performance
Key words
Systems
System errors
108
What is TeamSTEPPS
TM
?
An evidence-based teamwork system
Designed to improve:
Quality
Safety
Efficiency of health care
Practical and adaptable
Provides ready-to-use materials for training and
ongoing teamwork
Why Use TeamSTEPPS?
Goal: Produce highly effective medical teams
that optimize the use of information, people and
resources to achieve the best clinical outcomes
Teams of individuals who communicate
effectively and back each other up dramatically
reduce the consequences of human error
Team skills are not innate; they must be trained
WHAT WILL TEAMS LEARN?
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7&&4KMM&$(/,&$44,E(7#NE-*0M&$(/,&$44,3*-*E7&/
How Does TeamSTEPPS Work?
I. Assessment
! Clearly define the need
II. Planning, Training, and Implementation
! Plan to sustain the effort
! Train individuals
! Implement and test the strategies
III. Sustainment
! Integrate into daily practice
! Monitor and measure programs

PRACTICE-BASED LEARNING AND
IMPROVEMENT
114
115
ACGME, March 27, 2013; from 1/15/2009 document
Practice-Based Learning and
Improvement
Key words
Life long learning and quality improvement
Self assessment and reflection skills
Evidence-based medicine related skills
Quality improvement skills
Teaching skills
116
Quality, Safety, and Complications
Summary
Quality is defined by the customer
The system is (a/the) significant determinant of outcomes
Sentinel events tracking is important to improve systems
Hospital acquired conditions including infections are
avoidable
Isolation types: memorize.
VBP and performance measures: learn yours!
Improvement tools: PDSA, lean, six sigma
Team based care: not a solo sport anymore!

117
EXTRA TOPICAL SLIDES TO
STUDY
118
SENTINEL EVENT
120
121
122
123
Multi-Drug Resistant Organisms
(MDRO)

(More Information)
124
More Detail: MDROs (1)
Methicillin-resistant Staphylococcus aureus (MRSA), defined as;
Staph aureus cultured from any specimen that is oxacillin-resistant,
cefoxitin-resistant, or methicillin-resistant by standard susceptibility
testing methods
OR
MRSA positive result from molecular testing; these methods may
also include positive results of specimens tested by any other FDA
approved PCR test for MRSA
125
Vancomycin resistant Enterococci (VRE): Any Enterococcus
spp. (regardless of whether identified to the species level), that
is resistant to vancomycin

CephR- Klebsiella: Any Klebsiella spp. testing non-susceptible
(i.e., resistant or intermediate) to ceftazidime, cefotaxime,
ceftriaxone, or cefepime

CRE-Klebsiella: Any Klebsiella spp. testing non-susceptible
(i.e., resistant or intermediate) to imipenem, meropenem, or
doripenem.

126
CRE-E.coli: Any E. coli testing non-susceptible
(i.e., resistant or intermediate) to imipenem,
meropenem, or doripenem.
MDR- Gram negative organisms; i.e.,
Pseudomonas spp., definitions are not
standardized. We define as a gram negative
bacteria resistant to all but one class of
antibiotics (excluding colistin)

127
MDR-Acinetobacter: Any Acinetobacter spp. testing
non-susceptible (i.e., resistant or intermediate) to at
least one agent in at least 3 antimicrobial classes of the
following 6 antimicrobial classes:
#-lactam/#-lactam #-lactamase inhibitor combination
Aminoglycosides
Carbapenems
Fluoroquinolones
Cephalosporins
Sulbactam
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Methicillin Resistant Staph. aureus
(MRSA)
Isolation from any site implies wide- spread skin
carriage and requires Contact Precautions
1/3 of individuals colonized with MRSA develop
serious new infections in 18 months follow-up
Infections due to MRSA associated with higher
risk of morbidity/mortality.
129
Vancomycin Resistant Enterococcus
(VRE)
Contact Precautions for those infected or
colonized

Wear gloves and gowns for any entry into room
since VRE widely contaminates the environment

Remove gown and gloves before exiting the
room and wash hands

130
Vancomycin Resistant Enterococcus
(VRE)
Discontinuation of isolation;
Eight weeks after a patients last positive culture, a follow up
surveillance stool or rectal culture may be obtained to screen
for clearance
The patient does not need to be off antibiotics prior to being
cultured
If the initial culture is negative for VRE , two additional
cultures should be obtained at least one week apart(three
negative cultures over 3 weeks)
131
Clostridium difficile
Patient should be on isolation for the duration of illness (as long
as the patient has Clostridium difficle associated diarrhea)
Soap and water should be used for hand hygiene; spores are
not killed by alcohol- based hand products
Meticulous environmental cleaning using an Environmental
Protection Agency (EPA)-registered disinfectant with a sporicidal
claim, generic sources of hypochlorite (e.g., household chlorine
bleach) also may be appropriately diluted and used
132

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3
The Ongoing Quality Improvement
Journey: Next Stop, High
Reliability

By Mark R. Chassin and Jerod M. Loeb
Health Affairs, April 2011

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" What is a High Reliability
Organization?

# a complex organization with
# consistent performance
# at high levels of safety
# over long periods of time
# across all services and settings

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The Three Requirements For
Achieving High Reliability
" Leadership (1)
$ The commitment must be shared by all levels of
leadership.
$ Requires embedding the aim of High Reliability into
the mission and vision statement of the organization,
setting measurable goals and monitoring their
achievement.

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Just Culture
Managing Behavioral Choices
Reckless
Behavior

Intentional Risk-taking
Manage through:

Remedial action
Disciplinary action

At-Risk
Behavior
Unintentional Risk-Taking
Human
Error

Product of our current
system design

Manage through changes in:

Processes
Procedures
Training
Design
Environment
Console Coach Punish
Manage through:

Removing incentives for at-
risk behaviors
Creating incentives for
healthy behaviors
Increasing situational
awareness

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" Culture of Safety (2)
$ Just Culture
$ Trust in fellow workers; trust in leadership
$ Empowerment stop the line
$ Near-misses regarded by all as opportunities for
improvement.
$ Recognition

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Robust Process Improvement (3)
$ Lean
$ Six Sigma
$ Change Acceleration Process
$ Baumann adds: MICROSYSTEMS Knowledge

Quality Safety Complications/Pulmonary Board Review

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Quality Safety Complications/Pulmonary Board Review

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Quality, Safety, and Complications

Michael H. Baumann, MD, MS

Now: The Dartmouth Institute

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