1. Quality & Safety at Hadassah: A Progress Report September 8, 2009 Mayer Brezis, MD MPH Professor of Medicine Center for Clinical Quality & Safety

2.  Family’s Involvement during Physician’s Rounds Oded Lagstein, Liran Levy, Matan Cohen, Lois Gordon & Mayer Brezis  Ventilator-Associated Pneumonia Ina Apelbaum, Nurit Katz, Philip Levine, Shmulick Benenson, Carmela Shwartz, Colin Block, Lois Gordon & Mayer Brezis  Disruptive Behavior Orit Samuel Ben-Dov, Robert Cohen & Mayer Brezis Perspective on recent years of activity by the Center of Clinical Quality & Safety Several Projects of Clinical Quality

3. National Priorities Partnership © Setting a National Agenda for Healthcare Quality and Safety Patient and family engagement Population health Safety Care coordination Palliative care Overuse

4. Involvement of family during physician’s rounds in the departments of Medicine Oded Lagstein, BA, Liran Levy, MD, Matan Cohen, MD MPH, Lois Gordon, MPH & Mayer Brezis, MD MPH Center for Clinical Quality & Safety

5. To what extent would you like a family member next to you during doctors' visit? Very much 78% Does presence of family member help getting information on your condition? 92% on your treatment 95% making treatment decisions 84% Patients (n=93) Does presence of a family member help reducing your family's anxiety 85%

6. To what extent would you like to be present during doctors' visit? Very much 70% Does presence of a family member help getting information on pt’s condition? 96% on the treatment 92% making treatment decisions 82% Family (n=105) Does the presence of a family member help reducing family's anxiety 88%

7. To what extent do you support presence of family during doctors' visit? Very much 56% To what extent family involvement is important for patient’s treatment? Very much 71% Nurses (n=55) How does family presence affect communication with the patient? “Improves communication” 63%

8. To what extent do you support presence of family during doctors' visit? Very much 55% To what extent family involvement is important for patient’s treatment? Very much 85% Physicians (n=31) How does family presence affect communication with the patient? “Improves communication” 55%

9. Duration of rounds was not affected by presence of relatives Observations on 129 rounds in 3 depts of Medicine

10. Involvement of family during physician’s rounds: conclusion A majority of patients, relatives, nurses and physicians: support the idea support the idea think it improves communication think it improves communication and relieves family’s anxiety and relieves family’s anxiety Observations show presence of relatives during round does not affect its duration Findings are consistent with literature and suggest need for change in policy

11. Ventilator-Associated Pneumonia Project aim: reduce VAP incidence at Hadassah Ina Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson, Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis General Intensive Care, Unit for Infection Control and the Center for Clinical Quality and Safety

13. VAP Prevention: Recommendations Rated With High Level of Evidence ICHE 2008

14. Survey results Period of observation: February – March 2009

15. Department Mean ventilation days/pt. Ventilation days during observation period Total ventilated patients during observation period ICU A1244932 ICU B1117519 Neurosurgical ICU1619511 Medical ICU1022017 Total12103979 Intern. Medicine A1121217 Intern. Medicine B1013913 Intern. Medicine C923825 Total1058955

16. Diagnostic criteria for VAP

17. Total Internal MedicineICUs Department 672443 Patients observed 1123296827 Ventilation days 20515 Cases of VAP 30%21%35% Percent developing VAP 18‰17‰18‰ VAP cases/1000 ventilation days Mean cases/1000 ventilation days in literature* 11‰ (95%CI, 10-13) Rates of Ventilator-Associated Pneumonia: Hadassah vs literature * Chest 2008 (before interventions, down by 50% after interventions)

18. Process of Care Measures All variables are dichotomous (yes/no) VariableDefinitionData Source Elevation of head of bed Head of the bed elevated at 30 o - 45 o ; measured daily with a protractor but not during treatment of patient Daily observation Hand hygieneWashing hands with soap and water or an alcohol-based solution before and after contact with ventilator, patient or patient’s belongings Patient record Oral careDocumentation in patient record regarding oral treatment with chlorhexidine solution, once every shift Patient record Cleaning of ventilator tubing No visible discharge or dirt in ventilator tubing Daily observation

19. Adherence to VAP Guidelines Department Total days observed Head of bed up to 30 o - 45 o Oral care documented Ventilator tubing clean %% ICU A 187596874 ICU B 78586975 Neurosurgical ICU 86324668 Medical ICU 81546872 Total432%4861%72% Intern. Medicine A 79363471 Intern. Medicine B 55373568 Intern. Medicine C 10637 69 Total24037%35%68%

20. Adherence to Hand Hygiene (nurses) Department Hands washed before contact Hands washed after contact Gloves put on before contact %% ICU A 355565 ICU B 335262 Neurosurgical ICU 304023 Medical ICU 354855 Total33%47%46% Intern. Medicine A 294022 Intern. Medicine B 273725 Intern. Medicine C 273824 Total27%38%23%

21. Department Hands washed before contact Hands washed after contact Gloves put on before contact %% ICU A 125958 ICU B 136061 Neurosurgical ICU 84540 Medical ICU 115658 Total11%54%53% Intern. Medicine A 114944 Intern. Medicine B 104742 Intern. Medicine C 94845 Total10%47%43% Adherence to Hand Hygiene (Respiratory Technicians)

22. Summary for the VAP project Summary for the VAP project 1.The incidence of VAP in the ICUs of Hadassah is higher than those reported in the literature. 2.The percent of adherence to guidelines recommended for VAP prevention is lower than desirable. 3.How can adherence to these guidelines be improved? E.g.:  Elevating the head of the bed between 30 o - 45 o  Hand washing by staff before and after contact with ventilator, patient and patient’s belongings  Oral hygiene (including brushing and documentation)  Discontinuation of sedation once a day

23. Intervention Findings discussed with senior staff of surgical ICU’s Review of guidelines at staff meetingsReview of guidelines at staff meetings Email or newsletterEmail or newsletter Sign at room entranceSign at room entrance PostersPosters Buttons or tagsButtons or tags ScreensaversScreensavers

24. before and after contact with ventilator, patient or patient’s belongings No visible discharge or dirt in breathing tube Head of the bed elevated at 30 o - 45 o Oral hygiene (chlorhexidine solution), once per shift Hand washing: soap & water or alcohol-based solution

25. Button on physician’s or nurse’s uniform Don’t touch me until you’ve washed your hands! “Ask Me if I’ve Washed My Hands” Poster on door or bed

27. Intervention Findings discussed with senior staff of surgical ICU’s Review of guidelines at staff meetingsReview of guidelines at staff meetings Email or newsletterEmail or newsletter Sign at room entranceSign at room entrance PostersPosters Buttons or tagsButtons or tags ScreensaversScreensavers Re-evaluation scheduled for early 2010

28. Joint Commission now requires hospitals to have a written code of conduct and a process for enforcing it Disruptive Behavior Mark Chassin, MD, MPP, MPH Professor of Medicine & VP for Excellence Mount Sinai School of Medicine President of the Joint Commission “Do you have disruptive behavior at Hadassah?”

29. Disruptive behavior is a form of physician impairment and has become a focus of public health attention due to its destructive impact on hospital staff, institutions, and patient care (The Physician Executive 2008). Disruptive Behavior “Conduct by individual working in the organization that intimidates others to the extent that quality and safety are compromised” Joint Commission Definition

33. Disruptive Behavior at Hadassah: Survey of communication measures critical to quality & safety Orit Samuel Ben-Dov, MD, Robert Cohen PhD, Mayer Brezis, MD MPH Center for Clinical Quality & Safety, Hadassah & Hebrew University “Don’t be shamed of learning truth from any source, even from a lower person” Rabbi Solomon Ibn Gabirol (ca. year 1030)

34. Methods  Surveys tools validated in the literature (AHRQ)  Departments of Medicine & Surgery, EK & MS  Convenient sample during morning workdays  Compliance: 96/108 (86%)  37 physicians (29 residents, 8 seniors)  59 nurses  Average length of service 5 years (1 month – 39 years)  Standard statistics

35. Didn’t answer Rarely or Never Sometimes Frequently or Very frequently 160309 Refuses to answer questions/calls 1324818 Arrogant tone 1364122 Impatience to answer questions 273169 Strong verbal insult 176159 Threatening body language 175168 “Just do it” 09730 Physical violence Last year exposure to intimidating behavior (%)

36. Results (cont’d)  29% report most of the time they don’t speak freely when they perceive a risk to a patient  23% report they pretended an order was correct, in spite of their doubts, to avoid conflicts  20% feel pressured to fulfill orders despite their reservations about safety (3x during last year)  5% report their were involved in an error during last year, related to threatening behavior  Perceived threat higher in surgery than medicine; similar among nurses and physicians  38% feel poor handover between shifts affects quality

39. Perspective on recent years of activity by the Center of Clinical Quality & Safety Achievements Dozens of projects in important fields, e.g.: Prevention of thrombo-embolism Training patients for warfarin use Safety in drug administration Coronary care measures Palliative care ER (waiting, pain R x, ankle D x, UTI R x ) Reliability of imaging readings Specific surgeries (Hernias, Eye, ENT) Hand hygiene Impact of translators Infections in central lines hadassah.org.il/departments/quality Challenges No translation of project into routine work No continous measure of quality indices No increase in error reporting by physicians No cultural change Correct identification of improvement opportunities Failure in a shift to systematic improvement