close

Вход

Забыли?

вход по аккаунту

код для вставкиСкачать
Texas Center for Quality & Patient Safety-Strategies
for Prevention of Surgical Site Infections: Putting
Them into Context
April 10th, 2013 | 11:00 AM - 12:00 PM EST
..
>> WELCOME TO YOUR STRATEGY IS PREVENTION OF SURGICAL SITE INFECTIONS.
ALL LINES HAVE BEEN PLACED ON A LISTEN-ONLY MODE. IF YOU WOULD LIKE TO
SUBMIT A QUESTION AT ANY TIME, YOU MAY USE THE CHAT BOX LOCATED ON THE
LOWER RIGHT HAND SIDE OF YOUR SCREEN. TECH OUR MESSAGE IN THE BOX AND
CLICK SEND. IF YOU SHOULD REQUIRE ASSISTANT TO REPRESENTATIVE THE
CONFERENCE, PLEASE PRESS 0.
>> GOOD MORNING, EVERYONE. THANK YOU FOR TAKING TIME TO PARTICIPATE IN A
SPECIAL WEBINAR PRESENTATION. I WANT TO INTRODUCE OUR GUEST SPEAKER,
ASSISTANT PROFESSOR OF SURGERY OF CRITICAL CARE AT THE UNIVERSITY OF
TEXAS MEDICAL SCHOOL IN HOUSTON. HER RESEARCH FOCUSES ON IMPROVING
COMPLIANCE WITH INFECTION PREVENTION GUIDELINES IN THE PERRY OPERATIVE
PERIOD INCLUDING SURGICAL RESEARCH AND ADVANCING THE RESEARCH OF
QUALITY ASSESSMENTS. THANK YOU FOR YOUR TIME THIS MORNING. I WILL TURN
THE FLOOR OVER TO YOU.
>> THANK YOU FOR HAVING ME. AS EVERYONE KNOWS SURGICAL SITE INFECTIONS
ARE A SIGNIFICANT PROBLEM. THE RESULT IN INCREASED LENGTH OF STAY,
READMISSIONS, MORTALITY, AND COST. 40% TO 60% OF INFECTIONS ARE DEEMED
PREVENTABLE. THERE HAVE BEEN MULTIPLE STUDIES TO PREVENT SSI'S.
CLINICIANS WILL EMPLOY MULTIPLE INTERVENTION SIMULTANEOUSLY WHICH MAY
OR MAY NOT BE EFFECTIVE. ULTIMATELY, TODAY'S TALK WILL FOCUS ON STRATEGY
FOR IMPLEMENTING THESE EVIDENCE- BASED INTERVENTIONS. IN AN IDEAL SETTING
, SUCCESSFULLY IMPLEMENTATION OF AN EVIDENCE-BASED INTERVENTION SHOULD
RESULT IN A CHANGE IN OUTCOME, PREFERABLY AN IMPROVEMENT. HOWEVER,
THERE ARE MULTIPLE FACTORS THAT MAY AFFECT THE EFFECTIVENESS OF AN
INTERVENTION IN PRODUCING OUTCOMES. THE INFLUENCE OF THESE FACTORS ARE
OFTEN UNDERESTIMATED. INTERVENTION COMPLEXITY, PARTICULARLY WHEN YOU
ARE IMPLEMENTING A MULTIFACETED INTERVENTION CAN INFLUENCE UPTAKE.
FURTHERMORE, THE STRATEGY THAT YOU USED IN ORDER TO IMPLEMENT THE
INTERVENTION OR THE PACKAGE OF INTERVENTIONS CAN ALSO AFFECT OUTCOMES.
THERE ARE A FEW STRATEGIES THAT HAVE BEEN WIDELY USED TO IMPLEMENT
EVIDENCE-BASED MEASURES FOR SSI PREVENTION. THIS INCLUDES
IMPLEMENTATION OR USE OF GUIDELINES AND PROTOCOLS, PARTICIPATION IN A
QUALITY IMPROVEMENT COLLABORATIVE, OR USE OF A CHECKLIST THAT
INCORPORATES ANTIBIOTIC PROPHYLACTICS AND ADDITIONAL BASED MEASURES.
HOWEVER, WHAT IS THE DATA THAT THESE STRATEGIES ARE EFFECTIVE? THE DATA
IS NOT AS STRAIGHTFORWARD AS IT MAY SEEM. THERE ARE MANY PROTOCOLS AND
GUIDELINES BASED ON ANTIBIOTIC PROPHYLACTIC. IN FACT, ONE OF THE MORE
WELL- KNOWN PROJECTS IS THE SURGICAL CARE IMPROVEMENT PROJECT. IN 2003,
A SURGICAL INTERVENTION AND PREVENTION MEASURES BECAME CORE
MEASURES. IN 2004 -- SOMEHOW MY ANIMATION DID NOT SHOW UP -- HOSPITALS
BEGAN COLLECTING CORE MEASURED DATA FOR PATIENT DISCHARGES. IN 2006,
THE SURGICAL CARE IMPROVEMENT PROJECT REPLACED THIS ALTOGETHER. THE
EVIDENCE FOR SCIP IS BASED ON RANDOMIZED TRIALS, EXPERT OPINION
PROPHYLACTIC ANTIBIOTICS ELECTION, HAIR REMOVAL TECHNIQUES, THE
AVOIDANCE OF HYPERGLYCEMIA AND OTHERS ARE SUPPORTED BY RANDOM TRIAL.
THERE HAVE BEEN MULTIPLE SINGLE CENTER STUDIES THAT HAVE DEMONSTRATED
A REDUCTION IN SURGICAL SITE INFECTION WITH INSTITUTION OF SCIP MEASURES.
THIS IS AN EXAMPLE OF A SINGLE STUDY. CHANGES TO IMPROVE COMPLIANCE WITH
GUIDANCE WITH ANTIBIOTICS, NORMAL TERM YEAH, GLYCINE YET RESULTED IN A
REDUCTION OF SURGICAL SITE INFECTIONS. THIS REDUCTION WAS ACCOMPANIED
BY AN INCREASE IN COMPLIANCE WITH THE PROCESS MEASURES FOR ANTIBIOTIC
PROPHYLACTICS FOR NORMAL FIRM YET. IN ADDITION, A STUDY OF 44 HOSPITALS
PARTICIPATING IN A COLLABORATIVE TO REDUCE SSI BY IMPROVING COMPLIANCE
WITH MEASURES RELATE TO ANTIBIOTIC PROPHYLACTIC. OVERALL, THE BASELINE
RATE OF SSI WAS FAIRLY LOW, 2.3%, SO THE PRODUCTION WAS DOWN TO 1.7%.
HOWEVER, DESPITE THESE SUCCESSES, OVER TIME, PUBLICATION BEGAN
APPEARING QUESTIONING THE BENEFIT OF SCIP. THIS IS A 2010 ANALYSIS OF A
LARGE ADMINISTRATIVE DATABASE FROM CALIFORNIA OF OVER 400,000 PATIENTS.
THE SHOW'S OVER TIME CLIENTS WITH INFECTION PREVENTION MEASURES
INCREASED. THE MISSING GROUT WAS SUPPOSED TO BE OF SSI'S, WHICH ALSO
INCREASED IN THE SAME TIME PERIOD. IN A CROSS-SECTION OF STUDY OF IN
NATIONAL SURGICAL QUALITY DATA, HOSPITAL THAT PARTICIPATED -- THE STUDY
LOOKED AT THE ASSOCIATION BETWEEN SCIP INFECTIONS, OUTCOME MEASURES,
AND OVER ALL, THIS COLUMN HERE REPRESENTS THE COALITION FOR THE
REGRESSION MODEL, LOOKING AT THE RELATIONSHIP BETWEEN SCIP MEASURES
AND SSI. AS YOU CAN SEE, ONLY SCIP 2 CORRELATED TO SSI RATES. THE STUDIES,
ALONG WITH MULTIPLE OTHER PUBLICATIONS, MIGHT SUGGEST SCIP IS A FAILURE.
YOU CAN SEE THESE PUBLICATIONS ARE ASKING IF IT IS TIME TO MOVE BEYOND
SCIP. WE WILL COME BACK TO THE TOPIC OF WHY THIS MAY NOT HAVE RESULTED IN
THE IMPROVEMENT WE WERE EXPECTING. I HAD MENTIONED ANOTHER STRATEGY
FOR IMPLEMENTING EVIDENCE-BASED MEASURES IT TO PRESS TO PAY -PARTICIPATE IN A COLLABORATIVE. EVEN BEFORE THIS, THE STUDY I PREVIOUSLY
MENTIONED, A CMMS DEMONSTRATION PROJECT WHEREBY MULTIPLE HOSPITAL
PARTICIPATED IN A COLLABORATIVE. EACH HOSPITAL WAS ALLOWED TO MODIFY THE
EVIDENCE-BASED MEASURES OR TARGETS BASED ON THE LOCAL CIRCUMSTANCES,
BUT THEY COULD NOT DO IT SO AS TO RESOLVE A SPURS IMPROVEMENT. THEY
COULD NOT ALTER THE GLUCOSE TARGETS, FOR EXAMPLE, IN THE MIDDLE OF THE
FOUR QUARTERS, BUT THEY COULD ALTER THE TYPE OF FORMING THEY USED. THE
COLLABORATIVE INCLUDED TWO DAY FACE-TO-FACE MEETINGS AND THE
INTERACTION BETWEEN THAT INCLUDED E-MAILS AND CALLS. AS YOU CAN SEE,
THERE WAS IMPROVEMENT IN ALL OF THE COMPLIANCE MEASURES. THESE ALL
STATISTICALLY SIGNIFICANT, ALTHOUGH YOU WILL SEE AT THE END OF THE DAY,
NOT ALL OF THE PROCESS MEASURES REACHED 100% COMPLIANCE. THIS IS
ANOTHER EXAMPLE OF A STUDY EVALUATING PARTICIPATION IN A COLLABORATIVE.
THIS IS A CLUSTER -- TROUT TO REDUCE ANTI MICROBREW PROPHYLACTIC ERRORS.
THE UNIT OF A RENOVATION WAS THE HOSPITAL AND NOT THE INDIVIDUAL. IN THE
TRIAL, THE OFFICE COMPARED PARTICIPATION IN A QI COLLABORATIVE INCLUDING
TWO IN- PERSON MEETINGS, INCLUDING MONTHLY TELECONFERENCES AND
SUPPLEMENTAL MATERIALS FOR NINE MONTHS ALONG WITH FEEDBACK, AND
COMPARE THIS TO FEEDBACK ALONE. INTERESTINGLY, THEY NOTED NO
DIFFERENCE IN THE RATES OF COMPLIANCE. THESE NON-STRIP OF BARS ARE THE
BASE LINE RATES OF COMPLIANCE. THE BLACK BAR REPRESENTS THE FEEDBACK
ONLY GROUP. THE GRAY IS THE BACK -- THE BLACK AND WHITE BARS ARE THE
BEFORE. AFTER IS THE GRAY AND STRICT. THESE HAVE TO DO WITH PARTICIPATION
IN THE COLLABORATIVE. THESE HAVE TO DO WITH THE BACK ALONE. THERE WAS NO
CHANGE IN THE LEVEL OF IMPROVEMENT AND ANTIBIOTIC PROPHYLACTICS
WHETHER HOSPITALS PARTICIPATED IN THE COLLABORATIVE OR NOT. SO WHAT
ABOUT NSCLIP? AS EARLY AS 1994, THE NATIONAL SURGICAL QUALITY
IMPROVEMENT PROJECT WAS BORN. THERE WAS A PILOT STUDY IN NON- V.A.
HOSPITALS. IN 2001 THE AMERICAN COLLEGE OF SURGEONS ADOPTED THIS. BY 2004,
THIS BECAME AVAILABLE TO ALL PRIVATE HOSPITALS. TODAY, 5 AND HOSPITALS
PARTICIPATING IN NSQIP. THIS IS BASED ON A PRODUCTION MODEL. THEY
CALCULATE AN EXPECTED RATE OF SSI BASED ON PATIENT RISK FACTORS. AND
THEY LOOK AT THE OBSERVED TO EXPECTED RATIO AS A BENCHMARK. IF THE
OBSERVER TO EXPECTED RATIO IS LESS THAN ONE, THAT MEANS THE HOSPITAL
PERFORMS BETTER THAN EXPECTED. IF THE 95% CONFIDENCE INTERVAL,
REPRESENTED BY THE VERTICAL BARS, IS ENTIRELY LESS THAN ONE OR EXCLUDES
ONE, THAT IS CONSIDERED AN ALL OUT LIAR OR HIGH PERFORMERS. SIMILARLY, IF
THE TESTAMENT OF THE OBSERVED EXPECTED RATE RATIO IS GREATER THAN ONE,
AND A 95% CONFIDENCE INTERVAL EXCLUDES ONE, THOSE ARE THE HIRE OUT
LIARS, POOR PERFORMERS. THERE IS A SPECTRUM OF HOSPITALS PROVIDING DATA
AS TO WHICH, HOW THEY COMPARE WITH OTHER HOSPITALS. IN A STUDY LOOKING
AT ABOUT NSQIP 200 NSQIP HOSPITALS, THEY EXPECTED A CHANGE IN RATIOS. A
NEGATIVE CHANGE REPRESENTS AN IMPROVEMENT, WHERE AS A POSITIVE CHANGE
REPRESENTS WORSENING OUTCOMES. IN FACT, THIS GRAPH IS SKEWED, MEANING
MOST HOSPITALS DEMONSTRATED AN IMPROVEMENT. HOWEVER, ONE COULD ASK
WHAT CAUSED THESE HOSPITALS NOT TO IMPROVE OR TO WORSEN OVER TIME. WE
WILL GET BACK TO THAT LATER IN THE TALK. THE THIRD STRATEGY THAT I
MENTIONED FOR IMPLEMENTING EVIDENCE-BASED MEASURES IS TO USE A
CHECKLIST. PERHAPS THE MOST WELL KNOWN IS THE WHO CHECKLIST. IN 2009, THIS
IS A LANDMARK STUDY, LOOKING AT A BEFORE AND AFTER STUDY OF EIGHT
HOSPITALS IN EIGHT COUNTRIES WORLDWIDE WHERE A CHECKLIST WAS
IMPLEMENTED. MORBIDITY WAS REDUCED ALL THE HOSPITALS AND MORTALITY WAS
REDUCED AT ALL EXCEPT ONE HOSPITAL. BASED ON THE STUDY, THE WHO FOR
QUEST -- CHECKLIST WAS WIDELY ENDORSED AN ADOPTED. IF YOU LOOK CLOSELY
AT THE STUDY RESULTS THERE WERE SOME QUESTIONS ABOUT WHY THE
CHECKLIST WAS EFFECTIVE. HERE, AS YOU CAN SEE, IN SEVERAL INSTANCES,
THERE WAS NO IMPROVEMENT IN PROCESS MEASURES. NONETHELESS, MORTALITY
WAS REDUCED. IN FACT, IN ONE HOSPITAL, THE PROCESS MEASURE COMPLIANCE
IMPROVED BUT MORTALITY INCREASED UNEXPECTEDLY. THE SAME CAN BE SAID
ABOUT THE MORBIDITY DATA WHICH IS FOUND IN SOME HOSPITALS. THERE WAS NO
CHANGE IN PROCESS MEASURE COMPLIANCE BUT MORBIDITY WAS REDUCED
NONETHELESS. ONE COULD ASK, WHY WOULD THIS BE? I HAVE SHOWED YOU THREE
DIFFERENT STRATEGIES FOR IMPLEMENTING EVIDENCE-BASED MEASURES. THESE
WERE THE SCIP, GUIDELINES AND PROTOCOLS, PARTICIPATION IN A QI
COLLABORATIVE, AND USE OF THE CHECKLIST. SO WHY WOULD IT BE THAT THESE
STUDIES ARE VARIABLE IN TERMS OF THE EFFECTIVENESS OF THE STRATEGIES?
ONE REASON MIGHT BE THE QUALITY OF THE EVIDENCE. IT MAY BE ONE OR MORE
OF THE INTERVENTIONS THEMSELVES, THE EVIDENCE-BASED MEASURES, ARE
ACTUALLY NOT EFFECTIVE, OR ABOUT THE QUALITY OF THE EVIDENCE FOR THEIR
EFFECTIVENESS IS POOR. IN ADDITION, MAYBE IT IS THE STUDIES THEMSELVES
ABOUT THE IMPLEMENTATION STRATEGIES. AFTER ALL, FOR PARTICIPATION IN THE
COLLABORATIVE, WHEN TESTED, THERE WAS NO IMPACT OF PARTICIPATION,
WHEREAS LOOKING AT AN UNCONTROLLED BEFORE AND AFTER STUDY, IT SEEMED
TO BE EFFECTIVE. MAYBE IT HAS TO DO WITH THE QUALITY OF THE EVIDENCE.
PERHAPS IT HAS TO DO WITH THE QUALITY OF THE IMPLEMENTATION. MAYBE THE
STRATEGIES ARE EFFECTIVE, BUT DEPENDING ON HOW WELL YOU IMPLEMENT IT AT
THE LOCAL LEVEL, RESULTS IN DIFFERENT LEVELS OF EFFECTIVENESS. LASTLY, WE
WILL TALK ABOUT CONTEXT, WHICH INCLUDES THINGS LIKE INFRASTRUCTURE FOR
QUALITY IMPROVEMENT, AND SAFETY CULTURE. MAYBE IT HAS TO DO WITH A LOCAL
SETTING. STARTING WITH QUALITY OF THE EVIDENCE, LET'S TAKE, FOR EXAMPLE,
SCIP 1, WHICH RECOMMENDS AND BY THE PROPHYLACTICS ARE PROVIDED WITHIN
AN HOUR ON AS YOU ARE USING VANCOMYCIN WITHIN AN HOUR OF THE INCISION.
THIS IS A RETROSPECTIVE REVIEW PUBLISHED IN 1992. IN THE STUDY THEY'D
DETERMINE THE RATE OF SURGICAL SITE INSPECTION WAS LOWEST IF YOU GAVE
THE AND ABIDED WITHIN AN HOUR PRIOR TO THE SESSION. BASED ON THE STUDY,
SCIP 1 WAS REVIVED AND ADOPTED. THIS YEAR IN 2013, MARY PUBLISHED AN
ANALYSIS OF NSQIP DATA ON OVER 30,000 PROCEDURES LOOKING AT TIMING OF
ANTIBIOTIC PROPHYLACTICS. THE BOTTOM LINE IS THE TIMING DID NOT CORRELATE
WITH SSI. IN FACT, YOU CAN SEE THAT IT IS KIND OF A PARABOLIC CURVE HERE. IF
YOU STRIP OUT, IF YOU LOOK AT A TIME BEFORE THE INCISION, ONE HOUR, EVEN UP
TO THREE HOURS POST- INCISION, THERE IS NO DIFFERENCE IN THE SSI. SO THE
AUTHORS INCLUDED -- CONCLUDED PROVIDING ANTIBIOTICS WITHIN 60 MINUTES IS
NOT BAD CARE, BUT DID NOT IMPROVE QUALITY OF CARE. IN FACT, IF YOU GIVE THE
ANTIBIOTIC AFTER THE DECISION WITHIN A REASONABLE TIMEFRAME, THEY HAVE
THE SAME OUTCOMES. THIS FINDING CORRELATES WITH THE OTHER NSQIP THAT
SHOWED SCIP DID NOT FOLLOW. ONE OF MY TRAINEE'S RECENTLY DID A REVIEW OF
ALL STUDIES THAT THE VALLEY WITH THE EFFECTIVENESS OF ONE OR MORE
STRATEGIES OR INTERVENTIONS TO IMPROVE COMPLIANCE WITH ANTIBIOTIC
PROPHYLACTIC GUIDELINES. AS YOU CAN SEE, THE QUALITY OF THESE TILES WAS
NOT VERY HIGH. THERE IS ONLY ONE CLUSTER RANDOMIZED TRIAL, THE ONE THAT
WE DISCUSSED. THERE IS ONE DESIGNED WHERE THE INTERVENTION WAS
IMPLEMENTED AT MORE THAN ONE HOSPITAL IN A STAGGERED FASHION. DESIGNS
WERE UNCONTROLLED, MEANING ALTHOUGH THE AUTHORS LOOK AT MULTIPLE TIME
FRAMES AND IMPROVEMENT OVER MULTIPLE PERIODS, THEY DID NOT HAVE A
CONTROL HOSPITAL. THE MAJORITY WERE UNCONTROLLED BEFORE AND AFTER
STUDIES. THE QUALITY OF THE STUDY DESIGN WAS NOT VERY HIGH. THIS SLIDE
LOOKS AT, AMONGST THE STUDIES THAT DID BOOK INTERVENTIONS TO IMPROVE
SCIP COMPLIANCE ARE ANTIBIOTIC PROPHYLACTIC COMPLIANCE, WHAT DID THEY
FIND? THERE WERE THE FEW STUDIES WHERE THERE WERE NO IMPROVEMENTS IN
COMPLIANCE OR A SLIGHT WORSENING. IN FACT, WITHIN THE STUDIES, THE
BASELINE COMPLIANCE WITH SCIP 1 WAS MORE THAN 90%. ONLY IF THEY WERE
HARDER FOR ME TO START WITHIN THE HAVE NO IMPROVEMENTS. THERE WERE
OTHER STUDIES THAT SHOWED LARGE EFFECT SIZES WITH SIGNIFICANT RATES OF
COMPLIANCE. IN THESE STUDIES, THE BASE NONCOMPLIANCE WAS LESS THAN 10%
WITH SCIP 1. ULTIMATELY, THIS MAY BE A PHENOMENON REFERRED TO AS
REGRESSION OF THE MEAN. OFTENTIMES YOU START MEASURING A PHENOMENON
WHEN IT IS OUT OF CONTROL. WHEN THERE IS SOME IMPETUS TO MAKE SOME SORT
OF EFFORT OF QUALITY IMPROVEMENT. IF YOU MEASURE THAT OVER TIME,
REGARDLESS OF WHETHER YOU DO AN INTERVENTION, YOU MAY SEE THAT THE
OUTCOME REGRESSES TOWARDS THE MEAN, OR GROWS CLOSER TO THE AVERAGE.
IN FACT, WHEN YOU LOOK AT THE STUDY LOOKING AND INTERVENTIONS TO
IMPROVE AND TO BUY THE COMPLIANCE, WE SAW THAT MOST STUDIES SHOWED
THERE WAS SOME IMPROVEMENT IN COMPLIANCE. THOSE STUDIES THAT HAVE THE
GREATEST IMPROVEMENT HAD THE POOREST COMPLIANCE TO START. AT THE END
OF THE DAY, NONE OF THESE -- FEW OF THESE STUDIES ACTUALLY MEASURED SSI,
SO WHAT WAS THE EFFECT OF IMPROVING AND TO BUY THE COMPLIANCE ON THE
SSI RATES? IN SOME STUDIES, THE RATE WENT UP, AND OTHERS, IT IMPROVED.
AGAIN, THE QUALITY OF THE STUDIES WAS NOT VERY GOOD. SO ARE THEIR
EFFECTIVE STRATEGIES FOR CHANGE IN PRACTICE? THIS WAS ACTUALLY A
SYSTEMATIC REVIEW LOOKING AT MULTIPLE STRATEGIES FOR IMPLEMENTING IT
EVIDENCE-BASED PRACTICE AND FOR CHANGING PHYSICIAN BEHAVIOR. THE TRUTH
IS, ALL OF THE STRATEGIES HAD AT LEAST A MODERATE A FACT. BUT NOT ALL
STRATEGIES WORKED IN ALL CONTEXTS. FURTHERMORE, IT WAS NOT ALWAYS TRUE
THAT WHEN MULTIPLE STRATEGIES WERE USED TOGETHER THEY WERE MORE
EFFECTIVE THAN A SINGLE STRATEGY. HERE IS IT DOES SAY MORE EFFECTIVE THAN
SINGLE, BUT THAT HAS NOT BEEN CONFIRMED IN RECENT REVIEWS. WE HAVE
ALREADY SEEN THAT THE QUALITY OF THE EVIDENCE IS NOT AS GOOD AS WE
WOULD LIKE IT TO BE. WHAT ABOUT THE QUALITY OF IMPLEMENTATION, DOES THAT
MATTER? I SHOWED YOU PART OF THIS SLIDE EARLIER SHOWING YOU FACTOR THAT
MODERATED THE AFFECT OF THE INTERVENTION ON OUTCOME. ONE FACTOR THAT I
HAD NOT PUT IN THE PREVIOUS SLIDE WAS FIDELITY. FIDELITY OF IMPLEMENTATION
MEANS THE INTERVENTION IS BEING CARRIED OUT IN A MANNER IN WHICH IT WAS
INTENDED. FOR EXAMPLE, A COLLEAGUE OF MINE TOLD ME, AT HER INSTITUTION, IN
ORDER TO MEET GUIDELINES WITH NORMAL TERM VILLA, MEETING THE FIRST
TEMPERATURE IN THE POST OPERATIVE RECOVERY ROOM HAD TO BE ABOVE A
CERTAIN NUMBER, THAT THEY WOULD KEEP THE PATIENTS IN THE OPERATING
ROOM AFTER THE CASE UNTIL THEY REACH THE TEMPERATURE THAT WAS DESIRED.
IN FACT, THE METRIC WAS REALLY INTENDED TO MEASURE NORMAL THIRD VIA THE
ROUTE THE OPERATIVE CASE BECAUSE OF THE ADVERSE CONSEQUENCES OF
HYPERTHERMIA. IN REALITY, THE WAY THEY IMPLEMENTED THAT MEASURE REALLY
SHOULD NOT HAVE EFFECTIVE OUTCOMES. MORNING EDITION OF AT THE END OF
THE CASE IS NOT THE SAME AS KEEPING A PATIENT WAR BROUGHT THE CASE. THAT
IS AN EXAMPLE WHERE FIDELITY WAS NOT MAINTAINED. HERE IS ANOTHER STUDY
FROM ONE OF MY RESEARCH RESIDENTS WHO LOOKED AT COMPLIANCE WITH
ANTIBIOTIC PROPHYLACTIC GUIDELINES AT OUR LOCAL CHILDREN'S HOSPITAL. EVEN
THOUGH OVER ALL DOCUMENTATION WAS GIVEN IN ANY CASE, IF YOU LOOKED AT
THE SPECIFICS RELATED TO ANTIBIOTIC TYPE, INTERVAL, REDUCING, COMPLIANCE
WAS SIGNIFICANTLY LESS THAN OPTIMAL. IF YOU LOOK AT ALL PATIENTS IN WHOM
ALL GUIDELINES WERE FOLLOWED, IT WAS LESS THAN 50%. EVEN THOSE THAT
CHARGE DOCUMENTED AS 100% RECEIVING AN EDGEWATER PROPHYLACTICS,
WHEN YOU LOOK AT THE DETAILS, MOST OF THEM DID NOT RECEIVE ADEQUATE AND
TO BLACK PROPHYLACTICS. SO WHY IS THIS IMPORTANT? THE STUDY THAT I HAD
SHOWN BEFORE, LOOKING ADMINISTRATIVE DATA FROM CALIFORNIA, SHOWED
DESPITE IMPROVEMENTS IN COMPLIANCE WITH ANTIBIOTIC PROPHYLACTICS,
INFECTION RATES WENT UP, ACTUALLY DID SHOW THERE WAS AN ALL OR NONE
PHENOMENON. SO INDIVIDUAL ANTIBODY PROPHYLACTIC MEASURES DID NOT
CORRELATE WITH SSI'S OR OUTCOMES, BUT WHEN DONE ALTOGETHER, THERE WAS
A CORRELATION IN THE REDUCTION OF SSI. SO IT DOESN'T MATTER IF YOU DO ALL
OF INTERVENTION OR NOTHING. AS ANOTHER EXAMPLE OF FIDELITY, WHY
CHECKLISTS MAY WORK IN SOME PLACES AND NOT IN OTHERS. AGAIN, THIS IS FROM
OUR CHILDREN MEMORIAL HOSPITAL WHERE THERE WAS AN ADOPTED CHECKLIST
FROM THE WHO CHECKLIST. ALTHOUGH THE TERM DOCUMENTED 100% OF CASES
USE THE CHECKLIST, IF YOU LOOK AT INDIVIDUAL COMPONENTS, THE USE WAS
HIGHLY VARIABLE. IN SOME CASES, LESS THAN 5% OF CASES LOOKED AT THAT
CHECKLIST COMPONENT. FIDELITY AGAIN WAS POOR. SO HOW CAN WE BETTER
MEASURE IMPLEMENTATION OR ENSURE THAT WE ARE IMPLEMENTING MEASURES IN
THE WAY THAT THEY ARE INTENDED? THIS IS ONE FRAMEWORK THAT IS CALLED
REAIM. THE STAND FOR THE PROPORTION AND REPRESENTED THIS OF INDIVIDUALS
WHO PARTICIPATE IN THE INTERVENTION. EFFICACY IS TO WHAT DEGREE THE
INTERVENTION WORKS. ADOPTION LOOKS AT THE PROPORTION AND
REPRESENTATIVE THIS OF SETTINGS BUT IN ORGANIZATIONS AND SETTINGS THAT
USE THE INTERVENTION. IMPLEMENTATION OF THAT FIDELITY, WHICH WE JUST
TALKED ABOUT. MAINTENANCE LOOKS AT CANNES THAT IMPROVEMENT BE
SUSTAINED OVER TIME? THIS REMARK IS NOT USED AS OFTEN AS IT SHOULD BE. IN
THE STUDY WHERE WE LOOKED AT ALL THE PUBLISHED MATERIAL ON
INTERVENTIONS TO IMPROVE AND TO BUY THE PROPHYLACTICS, WE LOOKED AT
HOW OFTEN METRICS RELATED TO REAIM WERE RECORDED. IN FACT, IN VERY LOW
PERCENTAGES THE STUDY, WHICH PARTICIPANTS WERE INCLUDED IN THE
INTERVENTION GROUP, WHAT WAS THE SETTING IN WHICH THE INTERVENTION WAS
ADOPTED, WHAT KIND OF IMPLEMENTATION BARRIERS EXISTED, AND VERY FEW
LOOK AT WHAT IS THE STRATEGY FOR SUSTAINABILITY. WE CAN IMPROVE
SIGNIFICANTLY BY USING METRICS SUCH AS REAIM. LASTLY, I MENTIONED CONTEXT
MIGHT AFFECT HOW WELL AN INTERVENTION WORKS LOCALLY. IN A RECENT REVIEW
BY ONE OF MICHAEL INVESTIGATORS, CONTEXT WAS DEFINED AS ANYTHING NOT
DIRECTLY PART OF THE TECHNICAL QUALITY IMPROVEMENT PROCESS, THAT
INCLUDES THE QI METHODS THEMSELVES. CONTEXT COULD MEAN
INFRASTRUCTURE, IT COULD MEAN LEADERSHIP, IT COULD MEAN AVAILABILITY OF
QUALITY IMPROVEMENT TOOLS. IT COULD MEAN SAFETY CULTURE. THIS IS THE
PARIS FROM MARCH. THERE ARE MULTIPLE REMARKS, BUT I PARTICULARLY LIKE
THIS ONE. PROMOTING ACTION AND RESEARCH IMPLEMENTATION IN HEALTH
SERVICES. THIS SAYS THE EFFECTIVENESS OF A STRATEGY TO IMPLEMENT
EVIDENCE- BASED INTERVENTIONS DEPENDS ON THE EVIDENCE, SO THE EVIDENCE
COULD RANGE FROM WEEK TO STRONG AND WE SAW THERE WAS A WIDE RANGE IN
A VARIETY OF DATA. THE CONTEXT COULD BE WEAK TO STRONG. ALTERNATELY IN
AN IDEAL SITUATION, YOU WOULD HAVE A PRACTICE FOR WHICH THERE WAS
STRONG EVIDENCE AND A STRONG CONTEXT IN WHICH TO IMPLEMENT. PERHAPS
THE MORE IMPORTANT QUESTION IT IS WHAT DO YOU DO IT IF THE EVIDENCE OR
CONTEXT ARE WEAK? WHAT IS THE BEST STRATEGY TO FACILITATE
IMPLEMENTATION INTO PRACTICE? MY COMPUTER APPEARS TO BE FROZEN.
>> THE YOU NEED TO TAKE CONTROL AND GO TO THE NEXT SLIDE?
>> YES, THANK YOU. WHEN WE GET TO THE NEXT SLIDE , THE AGENCY FOR
HEALTHCARE RESEARCH AND QUALITY AHRQ, HAS PUT OUT AND NEVER OF -NUMBER OF THINGS FOR CONTEXT.
>> DO YOU KNOW WHAT NUMBER WE WERE ON?
>> 41. AS I WAS SAYING, HRQ HAS PUT OUT A NUMBER OF STUDIES LOOKING AT THE
IMPLEMENTATION OF SAFETY SAVE -- PATIENTS IF THE PRACTICE. THIS IS DEFINED
AS INTERVENTION STRATEGIES OR APPROACHES INTENDED TO PREVENT OR
MITIGATE UNINTENDED CONSEQUENCES OF THE DELIVERY OF HEALTH CARE AND TO
IMPROVE THE SAFETY OF HEALTH CARE FOR PATIENTS. IN THIS PICTURE, PATIENT
SAFETY PRACTICE HAS MULTIPLE BOXES WHICH REPRESENT ITS DIFFERENT
COMPONENTS. THE OVAL REPRESENTS THE CONTEXT IN WHICH THE PRACTICE IS
EMBEDDED. DEPENDING ON THE PRACTICE AND CONTEXT YOU MAY RESULT IN
EFFECTIVE CHANGE IN OUTCOME, OR YOU MAY HAVE UNINTENDED HARM AND
CONSEQUENCES. FURTHERMORE, THE PRACTICE LOCALLY MAY LEAD TO
INCREASED ADOPTION AND SPREAD. NEXT SLIDE. HRQ HAS CALLED FOR THE
CONTEXT SENSITIVE EVALUATION OF THESE EVALUATION PATIENTS A PRACTICES.
THEY ARE ASKING THE QUESTION, WHAT WORKS AND IN WHAT CONTEXT? THEY
STATE IN ORDER TO BE ABLE TO ANSWER THE QUESTION, YOU NEED TO BE ABLE TO
LOOK AT NOT ONLY THE PRACTICE COMPONENTS BUT ALSO AT A LOGIC MODEL,
WHICH IS A CONCEPTUAL FRAMEWORK OF HOW EVERYTHING IS INTERRELATED.
YOU WANT TO LOOK AT EXTERNAL ABILITIES, WHICH IS HOW GENERALIZEABLE ARE
YOUR RESULTS, HOW APPLICABLE TO ANOTHER SETTING, WHAT IS THE INTERNAL
THE ABILITY, WHICH HAS TO DO WITH HOW CLOSE TO THE TRUTH OR YOU? THAT
GOES BACK TO HOW WELL YOUR STUDY OF HOW EFFECTIVE INTERVENTION WAS. AT
THE END OF THE DAY, YOU WANT TO SYNTHESIZE ALL OF THESE PUZZLE PIECES IN
ORDER TO ANSWER THE QUESTION. BONN HOW THEN DO YOU MEASURE CONTEXT? I
DO NOT THINK WE HAVE A GOOD ANSWER TO THIS QUESTION. THIS IS JUST ONE
MODEL. HEATHER IS FROM CINCINNATI. SHE PERFORMED A COMPREHENSIVE
LITERATURE REVIEW AND CONVENED AN EXPERT PANEL USING A PROCESS COMING
UP WITH 25 DIFFERENT CONTEXTUAL FACTORS THAT INFLUENCE QUALITY. AS YOU
CAN SEE FROM THE BOLD LABELS ON TOP, THERE ARE DIFFERENT LEVELS AT WHICH
THESE FACTORS WERE. ORGANIZATION, Q.I. TEAM, AND OTHERS. THIS CAN OFTEN
BE TRIGGERED BY AN EVENT. NOT ONLY DOES THIS MODEL IDENTIFIED 25
DIFFERENT FACTORS, SHE DEVELOPED A QUESTIONNAIRE THAT CAN HELP
MEASURE THESE CONTEXTUAL FACTORS, AND THE MODEL ALSO LOOKS AT HOW
THE FACTORS ARE INTERRELATED TO EACH OTHER. SHE HAS DONE SOME
PRELIMINARY WORK THAT SUGGESTED THESE CONTEXTUAL FACTORS DO, INDEED,
CORRELATE WITH SUCCESS IN QUALITY. OF COURSE, FURTHER STUDY IS REQUIRED.
BACK TO THE AHRQ. A PANEL OF INTERNATIONAL PATIENT SAFETY EXPERTS
RECOMMENDED THERE SHOULD BE FOUR HIGH PRIORITY CONTEXTS INCLUDED IN
ALL REPORTS ON PATIENT SAFETY RESEARCH. ONE LOOKS AT THE EXTERNAL
FACTORS. THESE WOULD BE REGULATORY REQUIREMENTS, PUBLIC REPORTING,
PAY FOR APARTMENTS, AND LOCAL SOME OF THE EVENTS. ORGANIZATIONAL
JURISDICTIONS INCLUDE HOW BIG IS A HOSPITAL? COMPLEXITY AND FINANCIAL
STATUS OR STRENGTH OF THE ORGANIZATION. TEAM WORK FOR PATIENT SAFETY
CULTURE, SOMEONE IS SELF- EXPLANATORY. MANAGEMENT TOOLS, LIKE TRAINING
RESOURCES, WHAT ARE THE INTERNAL ORGANIZATION AND INCENTIVES FOR
QUALITY IMPROVEMENT, AUDIT AND FEEDBACK, QUALITY IMPROVEMENT
CONSULTANT AVAILABILITY. LOOKING BACK AT THE SAME SLIDES THAT WE SAW
PREVIOUSLY, LOOKING AT HOSPITALS PARTICIPATING IN NSQIP, I ASK THE QUESTION
WHY DID SOME HOSPITALS STAY THE SAME OR WORSE IN OVERTIME? WE
DISCUSSED THAT THERE MIGHT HAVE BEEN A PROGRESSION IN THE MEAN, WHICH
MEANS THE POOREST PERFORMING HOSPITALS WERE THE ONES THAT SHOW THE
GREATEST IMPROVEMENT. HOSPITALS THAT WERE HIGH PERFORMING,
FUNCTIONING AT A VERY HIGH LEVEL OF PERFORMANCE, MAY SUFFER NO CHANGE
OVER TIME WITH THE NECESSARILY MEAN THEY ARE GIVING POOR QUALITY CARE.
HOWEVER, THERE IS STILL SOMETHING DIFFERENT AMOUNTS THOSE THAT DID NOT
IMPROVE. WAS THERE A DIFFERENCE IN CONTEXT TO EXPLAIN WHY THESE
HOSPITALS WERE SEND OVER TIME? IN AN EDITORIAL, A SURGEON FROM MICHIGAN
STATED THAT Q.I. IS LOCAL. HE ASKED A QUESTION, WHAT WAS IT ABOUT THE BEST
PERFORMER HERE THAT ACCOUNTED FOR THEIR SUCCESS, OR CONVERSELY, WHY
WERE SOME HOSPITALS STRUGGLING? KIMBLE AND HIS COLLEAGUES CONDUCTED
SITE VISITS OF HIGH AND LOW LYING HOSPITALS BASED ON THEIR RATIOS TO TRY
TO UNDERSTAND THIS QUESTION OF WHY DID SOME HOSPITALS IMPROVE AND WHY
DID SOME WERE SENT? INTERESTINGLY, THEY DID NOT IDENTIFY ANY BEST
PRACTICES THAT ARE LIVING WITH PERFORMANCE. INSTEAD, THEY IDENTIFY
VARIOUS STRUCTURAL AND PROCESSES OF CARE VARIABLES ASSOCIATED WITH
THIS REDUCTION IN MORBIDITY, AND SPECIFICALLY, IN SSI. MORE IMPORTANTLY, ALL
OF THE CYBER VIEWERS WERE ABLE TO CORRECTLY IDENTIFY 100% OF THE TIME
WHICH HOSPITAL WERE HIGH, WHICH WERE LOW PERFORMING. THIS SUGGESTS
THERE IS SOME CONTEXTUAL FACTORS THAT MAY OR MAY NOT HAVE BEEN
MEASURABLE THAT CLUE THEM IN TO WHAT WAS HIGH AND WHAT WAS A LOW
PERFORMED HOSPITAL. SIMILARLY, WHEN LOOK BACK AT THE STUDY I SHOWED YOU
BEFORE LOOKING AT HOSPITAL PERFORMANCE WITH SCIP 1 AND 2, WHEN I SAID
ONLY 2 WAS CORRELATED WITH HOSPITAL MORBIDITY. THE SAME PAPER SHOWED
THAT HOSPITALS THAT ADHERE TO PROCESSES OF CARE HAD BETTER OUTCOMES.
ONE OF THE HIGH PRIORITY CONTEXTS THAT THE AHRQ PAPER I MENTIONED
PREVIOUSLY DISCUSSED WAS A CULTURE. ONE WAY THAT SAFETY CULTURE MIGHT
BE MEASURED IS THE SAFETY ATTITUDE QUESTIONNAIRE, OR THE SQ. A LOT OF OUR
CONCEPTS ABOUT PATIENT SAFETY ARE DERIVED FROM AVIATION. THIS IS ICICLE
MAGICALLY VALIDATED TOOL FOR MEASURING SAFETY CULTURE AND INCLUDE SIX
DIFFERENT SCALES, INCLUDING TEAM WORK CLIMATE, JOB SATISFACTION,
PERCEPTIONS OF MANAGEMENT, SAFETY CLIMATE, WORKING CONDITIONS, AND
STRESS RECOGNITION. THERE HAVE BEEN MULTIPLE STUDIES THAT HAVE
CORRELATED VARIOUS SAQ MEASURES WITH RISK ADJUSTED MORBIDITY. IF YOU GO
BACK TO THE STUDY LOOKING AT CHECKLISTS, WHERE I ASK THE QUESTION, WHY
WOULD IT BE IF YOU HAVE NO IMPROVEMENT IN PROCESS MEASURES THAT YOU
WOULD SEE ANY IMPROVEMENT IN SURGICAL MORBIDITY OR MORTALITY? THE
AUTHORS THEMSELVES ASK THE SAME QUESTION AND WENT BACK AND LOOKED AT
CHANGES IN THE SAFETY ATTITUDE QUESTIONNAIRE AFTER CHECKLIST
IMPLEMENTATION. YOU CAN SEE THE GREATER THE CHANGE IN SAQ SCORED THE
GREATER THE REDUCTION IN COMPETITION. IN FACT, MAYBE THE EFFECTIVENESS
OF CHECKLISTS IS NOT DEPENDENT ON CHANGING PROCESS MEASURE
COMPLIANCE, BUT IN FACT, CHANGING SAFETY CULTURE. ONE MIGHT ASK, HOW DO
WE CHANGE CONTEXTS THEN, IN ORDER TO IMPROVE EFFECTIVENESS OF OUR Q.I.
EFFORT? ONE SLIDE IS THE COMPREHENSIVE UNIT BASED MEASURE PROGRAM. THIS
IS FROM THE AHRQ WEBSITE. THERE ARE MULTIPLE STEPS INVOLVED. THERE WAS A
RECENT STUDY IN 2012 WHERE THEY APPLIED THIS TO SSI PREVENTION'S. THIS
FOCUSED ON EDUCATING TEAM MEMBERS ABOUT HOW TO ASSESS THE SAFETY, IN
GAUGING SENIOR LEADERSHIP TO OVERCOME SYSTEM BARRIERS, LEARNING FROM
DEFECTS, AND IMPROVING TEAM WORK AND COMMUNICATION. YOU CAN SEE THE
SPECIFIC WAYS IN WHICH THEY USED CUTS AND APPLIED THEM TO SSI PREVENTION.
THEN THEY DEVELOPED AND IMPLEMENTED MODIFICATIONS TO THEIR SSI
PROTOCOL FOR COLORECTAL SURGERY. AS YOU CAN SEE, THEY DEMONSTRATED A
SIGNIFICANT REDUCTION IN SSI RATES FOR ALL TYPES OF SSI. THEY ALSO LOOKED
AT COMPLIANCE WITH ANTIBIOTIC PROPHYLACTICS. THERE WERE ONE OF THE
STUDY THAT SHOWED NO IMPROVEMENT IN COMPLIANCE OR AN ACTUAL
WORSENING PROPHYLACTICS. IN FACT, THERE WERE HIGH PERFORMER TO START.
THE INTERVENTION THEY IMPLEMENTED HAD TO DO WITH OTHER MEASURES THAT
COULD HELP TO REDUCE SSI. SIMILARLY, BASED ON PREVIOUS POUR CHECKLIST
COMPLIANCE AT CHILDREN'S MEMORIAL, WE HAVE DEVELOPED A MULTIFACETED
INTERVENTION WHICH CONSISTED OF WORKSHOPS TO IMPROVE O.R. SAFETY
CULTURE, A SIMON A CHECKLIST RESPONSIBILITY, AND ALL THIS WAS PERFORMED
IN A SETTING OF REORGANIZATION OF THE HIERARCHY IN THE O.R. TO MAKE A
SURGEON A QUALITY IMPROVEMENT CHAMPION, AND THE CHIEF OF SURGERY. NEXT
SLIDE, LOOKING AS IF THE CULTURE, SOME SAFETY IMPROVEMENTS. SOME
DEMANDS IMPROVED MORE THAN OTHERS. ALTON IT MAY, AFTER IMPLEMENTATION
OF THIS MULTIFACETED INTERVENTION, COMPLIANCE WITH THE CHECKLIST
IMPROVED SIGNIFICANTLY. IN SUMMARY, NO ONE INTERVENTION OR
IMPLEMENTATION STRATEGY IS NECESSARILY UNIVERSALLY EFFECTIVE. THE
EFFECTIVENESS OF " PROVEN INTERVENTIONS" TO REDUCE SSI DEPENDS ON HOW
YOU IMPLEMENT THAT INTERVENTION AND THE LOCAL CONTEXT YOU TRY TO
INTRODUCE IT. AND MULTIFACETED SAFETY CENTERED APPROACH TO CHANGE
CONTEXT CAN IMPROVE YOUR LIKELIHOOD OF SUCCESS. BETTER METHODS ARE
NOT DEAD -- NECESSARY FOR IDENTIFYING WHICH COMPONENTS IN A BUNGLED
PROTOCOL ARE MOST EFFECTIVE, AND WHICH ARE MINIMALLY EFFECTIVE. THERE IS
AN IDEA AND IMPLEMENTATION SCIENCE CALLED EQUIFINALITY WHICH MEANS
THERE ARE MULTIPLE WAYS TO ACHIEVE THE SAME OUTCOME. THERE'S ALSO
SOMETHING AS THE MINIMAL INTERVENTION NECESSARY FOR CHANGE. NOT ALL
COMPONENTS ARE NECESSARY BUT THE KEY IS TO FIGURE OUT HOW TO IDENTIFY
WHAT IS THE KEY COMPONENT TO IMPROVE THE OUTCOME. ULTIMATELY, STUDIES
ON IMPROVING ITS TO MEASURE AND REPORT ON THE QUALITY OF
IMPLEMENTATION. ALL OF THESE STUDIES NEED TO HAVE BETTER DESIGNED THAN
THEY NEED TO PROVIDE INFORMATION THAT WILL HELP WITH THE GENERALIZED
ABILITY OF THE OUTCOME. IT IS HARD TO EXTRACT IMPROVEMENTS FROM
PUBLICATION THAT YOU CAN USE AT YOUR OWN HOSPITAL. FURTHER STUDY IS
NECESSARY TO BE ABLE TO MEASURE CONTEXT AND TO DETERMINE WHAT
CONTEXTUAL FACTORS ARE ASSOCIATED WITH THE COLLECTIVE IMPLEMENTATION
OF EVIDENCE-BASED PRACTICES. ONCE YOU CAN MEASURE THE CONTEXT FOR
EFFICIENTLY AND CHANGING FOR IMPLEMENTATION, SUCH AS THE COMPREHENSIVE
HUMAN-BASED SAFETY PROGRAM, ARE NEEDED. I WOULD LIKE TO ACKNOWLEDGE
MY COLLEAGUES IN PATIENT SAFETY, RESEARCH, QUALITY IMPROVEMENT EFFORTS,
SOME OF THE PEOPLE THAT I HAVE QUOTED IN THE PRESENTATION TODAY. I AM
HAPPY TO TAKE ANY QUESTIONS. I THINK THERE IS SOME POLLING BEFORE THE
QUESTIONS.
>> BEFORE WE OPEN UP THE FLOOR TO QUESTIONS THERE ARE A COUPLE OF
POLLING QUESTION THAT EVERYONE NEEDS TO ANSWER. THE FIRST ONE IS HOW
MANY TEAM MEMBERS ARE PARTICIPATING IN THIS EVENT, INCLUDING YOURSELF?
TAKE A MINUTE TO VOTE. WE ARE GOING TO GO ON TO THE NEXT ONE. HERE IS THE
NEXT QUESTION. THINKING ABOUT THE RECENT TRADING ACTIVITY, PLEASE RATE
THE FOLLOWING AS EXCELLENT, GOOD, FAIR, OR PORT. -- POOR. WE ARE GOING ON
TO THE NEXT QUESTION. RATE THE SAME WAY, USEFULNESS OF MY HOSPITAL TO
THE INFORMATION AND IDEAS PROVIDED. THE LAST QUESTION IS A CHANCE THAT
INFORMATION AND IDEAS PROVIDED WILL IMPROVE MY EFFECTIVENESS AND
RESULTS? PLEASE RATE IN THE SAME WAY. NOW WE ARE GOING TO OPEN UP THE
FLOOR FOR QUESTIONS. YOU CAN SUBMIT YOUR QUESTIONS ANY TIME THROUGH
THE CHAT. IF YOU WANT TO ASK A QUESTION, PRESS THE NO. 7 ON YOUR
TELEPHONE KEYPAD AT THIS TIME. QUESTION WILL BE TAKEN IN THE ORDER THEY
ARE RECEIVED. IF YOUR QUESTION HAS BEEN ANSWERED, YOU MAY REMOVE
YOURSELF FROM THE QUEUE BY PRESSING 7. IF YOU HAVE A QUESTION, PLEASE
ENTER IT INTO THE CHAT BOX OR PRESS AND NO. 7 ON YOUR TELEPHONE KEYPAD. I
DO HAVE A CHAT QUESTION FOR YOU. CAN YOU FORESEE THE EVALUATION OF
FIDELITY RELATED TO SCIP WOULD OCCUR? FALSELY RELATED DID IT IS
DESTROYING ITS VALUE NATIONALLY.
>> I THINK, ULTIMATELY, IT WOULD BE NICE IF FIDELITY WAS MEASURED ON A
NATIONAL LEVEL. IT IS UP TO THE LOCAL SETTING TO MAKE SURE THERE IS FIDELITY.
OTHERWISE, YOU ARE ACTING ON INCORRECT DATA. MOST OF THE TIME IS YOUR
THINKING IS REALLY WELL, BUT WHEN YOU ARE NOW.
>> IF YOU HAVE A QUESTION, PLEASE ENTER IT IN THE CHAT BOX OR PRESS THE NO.
7 ON YOUR KEYPAD AT THIS TIME. THERE APPEAR TO BE NO MORE FURTHER
QUESTIONS. DO YOU HAVE ANY CLOSING REMARKS?
>> NO, I JUST THINK THAT WE TEND TO FOCUS A LOT ON THE SPECIFIC PRACTICES
TO REDUCE SURGICAL SITE INFECTIONS. I THINK, WHILE IT IS IMPORTANT TO LOOK
FOR OTHER WAYS TO REDUCE SSI, WHEN WE DO NOT EVEN DO WHAT WE KNOW
WELL, MORE EFFORT NEEDS TO BE FOCUSED ON THAT EFFORT. THAT IS IT. FEEL
FREE TO E-MAIL ME WITH ANY OTHER QUESTIONS OR COMMENTS.
>> I DO HAVE A QUESTION, ACTUALLY. LINDA FROM SETON HOSPITAL. PLEASE TO
YOUR QUESTION.
>> I JUST WANT TO THANK YOU VERY MUCH FOR GIVING ME TWO WORDS FOR MY
VOCABULARY THAT I HAD NOT HAD BEFORE. THAT IS FIDELITY AND CONTEXT. I WAS
THE ONE THAT COMMENTED ABOUT THE EVALUATION OF FIDELITY. WHEN SCIP
MEASURES BECAME RELATED TO PAY, SOME OF US THOUGHT IT WOULD BE COOL,
BUT IN ORDER TO MAKE SURE WE LOOK GOOD, THE CONTEXT OF MANY HOSPITALS
IS THAT WE NEED TO LOOK GOOD. FIDELITY IS PROBABLY AN ISSUE. YOU HAD THE
SUGGESTION ABOUT ONE THING. I HAVE THE SAME ISSUES GLUCOSE CONTROL IN
CABBAGES AND OTHER MEASURE THAT ARE NOT MEASURED. IF CUZCO'S -- IT IS
GLUCOSE CONTROL FOR 24 HOURS OR AT 6:00 A.M.? I AM EXCITED TO READ THAT
ARTICLE WHEN IT COMES OUT. ANYTHING ELSE YOU HAVE TO SUGGEST HOW WE
CAN MAKE THAT TURN -- I HAVE OFTEN SAID EXACTLY WHAT YOU SAID, WHY WERE
WE NOT LOOKING FOR OTHER THINGS WHEN WE ARE NOT SURE ABOUT THE
QUALITY WE ARE DOING NOW?
>> I THINK IF WE ALL LOOKED, WE WOULD FIND THE SAME PROBLEM. SOMETIMES IT
IS MORE COMFORTING NOT TO LOOK AND THINK YOU ARE DOING WELL.
>> IT DEFINITELY PAYS BETTER.
>> OKAY GREAT. THERE APPEARED TO BE NO MORE FURTHER QUESTIONS. THIS
CONCLUDES TODAY'S WEBINAR. THANK YOU FOR YOUR PARTICIPATION. YOU MAY
DISCONNECT YOUR LINE AT THIS TIME. HAVE A GREAT DAY.
1/--страниц
Пожаловаться на содержимое документа