1. Quality & Safety at Hadassah A Progress Report Mayer Brezis, MD MPH Professor of Medicine, Center of Quality & Safety Chairman, Quality & Safety Committee Yoel Donchin, MD, Nurit Porat, RN

2. Students Projects Students Projects Institution-wide Projects Institution-wide Projects Educational Activities Educational Activities National Impact National Impact Quality & Safety at Hadassah

3. Making Health Care Safer: A Critical Analysis of Patient Safety Practices Evidence Report Agency for Healthcare Research & Quality www.ahrq.gov/ clinic/ptsafety

4. Venous Thromboembolism in Neurosurgery Dr. G. Rosenthal, S. Goldman RN, Prof. F. Umanski, Prof. D. Varone, Dr. Y Weiss Departments of Neurosurgery, Hematology, Central Management, Center for Quality & Safety Hadassah University Hospital Jerusalem, Israel

5. 58 year-old woman underwent resection of meningioma58 year-old woman underwent resection of meningioma On post-op day 2, sudden onset of respiratory distressOn post-op day 2, sudden onset of respiratory distress Chest CT demonstrates massive pulmonary embolismChest CT demonstrates massive pulmonary embolism Vena cava filter inserted & anticoagulation initiatedVena cava filter inserted & anticoagulation initiated On post-op day 6 sudden onset of severe headache and vomitingOn post-op day 6 sudden onset of severe headache and vomiting

6. Post-op CT Follow-up CT

7. 10/239 4% 0/94 0% 5/75 7% Control Cases of thrombo-embolism 5 months (2003) 10 cases of thromboembolism 7 vena cava filters inserted Extended ICU & hospital stays

8. 10/239 4% 0/94 0% 5/75 7% July 2003: Introduction of intermittent pneumatic compression devices Cases of thrombo-embolism ControlIntervention

9. 10/239 4% 0/94 0% 5/75 7% Cases of thrombo-embolism ControlIntervention

10. 10/239 4% 0/94 0% 5/75 7 % ControlIntervention ControlIntervention Cases of thrombo-embolism Control

11. Quality can reduce morbidity & save costs Conclusion:

12. Quality indicators for the management of myocardial infarction M. Cohen, Dr. A. Pollack, Prof. A. Weiss, Prof. C. Lotan Intensive Cardiac Units, Division of Cardiology & Department of Medicine, Mt. Scopus & Ein Kerem Hadassah University Hospital Jerusalem, Israel

13. Quality indicators for myocardial infarction, Hadassah vs. US data Hadassah ( % Hadassah ( %) 89 90 50 83 69 44’ 102’

14. Peterson R, JAMA 2004;291:195 Hadassah

15. Evidence-based Evidence-based System-minded System-minded Quality in Health Care

16. Will the pathology result get lost? Percent of patients having received the result of their skin biopsy p<0.05 A clinic-based intervention (led by the head nurse, involving both physicians & patients) An institution-wide intervention: electronic alerts sent to physician’s computer whenever a pathology report is ready 4% failed malignancy reports 0% 1% Will the pathology result get lost? P. Topol, RN, Dr. A. Zlotogorski, Prof. A. Ingbar, Dr. A. Mali, T. Friedman, RN, M. Benhur, N. Porat, RN Departments of Dermatology, Pathology, Information Systems, Nursing and Quality & Safety Committee How can we make sure the patient gets the result?

17. This quality improvement project, awarded prize of best poster at the meeting of the Israeli Society for Quality in Medicine, is posted at the dermatology clinic as a reminder for both patients, nurses and physicians

18. Quality & Safety Committee Subcommittee for Medication Errors

20. Specific labels for lines to patients - to avoid mix up

21. Screen from software asking: “Would you approve this prescription?” Interactive software to learn prescribing for new physicians

22. Evidence-based Evidence-based System-minded System-minded Quality in Health Care Patient-centered Patient-centered

25. Palliative Care in General Internal Medicine: A successful pilot intervention among elderly patients with life threatening illness and impaired cognition S. Gottsman, RN, MA et al. Head Nurse, Medicine B, Mt Scopus

26. Staff-initiated meetings with relatives, to communicate information on patient’s condition; to listen to their questions and to their preferences based on patient’s prior wishes – if any had been expressed; and finally to attempt shared goal setting and decision making Intervention Control ward – no intervention

27. 13*60 “Staff did not really consider my opinions” 23*57 “I felt not involved in decision making” 10*43 “It upset me that I did not know what was happening” 20*57 “I did not receive explanations about alternatives” 3*53 “Relative’s problems were not explained” 10*53 “I felt uncomfortable with asking questions” 17*60 “I was not asked to participate in decisions” 17*43 “I felt alone and without support” 7*27 “I felt pressured to make decisions” Control Intervention Percent of relatives agreeing with negative statements

28. Is the X-ray interpretation by the junior staff on duty correct? Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham Departments of Surgery, Radiology, and Center for Quality & Safety Emerging methods for quality evaluation

30. Frontal bone fracture Hip fracture

31. Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Chest (n=54) 92 (65-100) 93 (82-98) 79 (52-94) 97 (88-100) Neck (n=19) 100 (5-100) 100 (85-100) 100 (5-100) 100 (85-100) Pelvis (n=27) 60 (18-93) 100 (87-100) 100 (37-100) 92 (75-99) CT’s (n=75) 94 (81-99) 95 (85-99) 94 (81-99) 95 (85-99) Validity of X-ray Interpretations in Trauma mean & 95% CI (confidence interval)

32. Reliability of X-ray Interpretation on Duty mean & 95% confidence intervals Inter-observer variability Resident vs. Specialist Percent agreement Kappa Coefficient Surgery77% 0.60 (0.4-0.8) Pulmonary Embolism 95% (0.7-1.0) 0.84 (0.7-1.0)

33. A Senior Resident in Radiology Concluded: “We need to look at ourselves”

34. Students ProjectsStudents Projects Institution-wide ProjectsInstitution-wide Projects Educational ActivitiesEducational Activities National ImpactNational Impact Summary & Conclusion Diverse projects attempt to make healthcare at Hadassah more patient-centered, more evidence- based and more system-minded. Increased accountability by department heads for quality and safety may be a key to further successes.

35. How would an open disclosure policy about mistakes affect hospital image in public’s eyes? Damage Image No Change Improve Image MD student Zivan Beer

36. How would an open disclosure policy about mistakes affect hospital image in public’s eyes? p<0.001 Damage Image No Change Improve Image MD student Zivan Beer N=570 N=115

37. Risk management: Extreme honesty may be the best policy (The V.A. Experience) Annals of Internal Medicine ‘99 New position statement by the Ethics Board of the Israeli Medical Association supports transparency (May 2004) “Tell the truth and tell it fast” N. Augustine. Crisis Management Harvard Business Review (2000)

38. “The physician has an obligation to disclose to the patient that a mishap has happened” IMA Ethics Board Position Paper