Fall Meeting AAOS Orthopaedic Surgery Safety Update 2012 William J Robb III MD Chair AAOS Orthopaedic Surgery Safety Summit AAOS Patient Safety Committee.

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  • Slide 1
  • Fall Meeting AAOS Orthopaedic Surgery Safety Update 2012 William J Robb III MD Chair AAOS Orthopaedic Surgery Safety Summit AAOS Patient Safety Committee
  • Slide 2
  • Disclosure Consultant – Blue Cross Blue Shield Association Consultant – Blue Cross Blue Shield Association TJR - Centers of Distinction Program Consultant (Unpaid) - Smith and Nephew Consultant (Unpaid) - Smith and Nephew Investor – emmi Solutions Investor – emmi Solutions Chair – AAOS Orthopaedic Surgery Safety Summit Chair – AAOS Orthopaedic Surgery Safety Summit Chair – AAOS Patient Safety Committee Chair – AAOS Patient Safety Committee
  • Slide 3
  • Is there an Orthopaedic Surgery Safety Problem 2012? Media ABC News Report - Maryland 2012 Report on Surgical Errors Report on Surgical Errors CMS - only 14% errors reported in hospitals CMS - only 14% errors reported in hospitals Advised patients ask about checklists Advised patients ask about checklists Report Report SSIs shoulder surgery SSIs shoulder surgery Wrong site pediatric eye surgery Wrong site pediatric eye surgery
  • Slide 4
  • Is there an Orthopaedic Surgery Safety Problem 2012? HealthGrades - 2010 >350,000 patient safety errors/year 2006-2008 >350,000 patient safety errors/year 2006-2008 Cost $9B Cost $9B 1/10 safety errors results deaths 1/10 safety errors results deaths >100,000 surgical error deaths/year >100,000 surgical error deaths/year Top 5% Hospitals – only 43% reduction safety incidents Top 5% Hospitals – only 43% reduction safety incidents Wrong Site Surgery (WSS) rates - 1/20,000 surgeries Wrong Site Surgery (WSS) rates - 1/20,000 surgeries Hospital SSI rates 2-3% Hospital SSI rates 2-3% NO evidence safety/quality improvement 2000-2010 NO evidence safety/quality improvement 2000-2010
  • Slide 5
  • Is there an Orthopaedic Surgery Safety problem 2012? JC 2009-2010 Wrong Site/Procedure/Patient Surgery (WSS) Wrong Site/Procedure/Patient Surgery (WSS) Mandatory State –bsed WSS Reporting Mandatory State –bsed WSS Reporting Minnesota (48 - WSS) Minnesota (48 - WSS) Pennsylvania (58 - WSS) Pennsylvania (58 - WSS) 35.4 WSS/wk. in US (estimated) 35.4 WSS/wk. in US (estimated)
  • Slide 6
  • JC Sentinel Events Data Base 2007-2011 54 Orthopaedic WSS
  • Slide 7
  • Is there a Orthopaedic Surgery Safety Problem 2012? Hospital Data JC - 2011 >7 wrong site/side/level/implant/procedure/patient surgeries /day >7 wrong site/side/level/implant/procedure/patient surgeries /day System errors – NOT Surgeon errors System errors – NOT Surgeon errors Most frequent causes: Most frequent causes: inadequate/missing surgical information inadequate/missing surgical information scheduling discrepancies/errors scheduling discrepancies/errors irregularities in pre-op holding process irregularities in pre-op holding process inadequate/absent surgical site marking inadequate/absent surgical site marking poor communication poor communication distractions in OR distractions in OR inadequate/absent OR process/time-out inadequate/absent OR process/time-out Mark Chassin MD, MPP, MPH
  • Slide 8
  • Is there an Orthopaedic Surgery Safety problem 2012? ABOS Certification/Recertification Data Base – 2011 ABOS Certification/Recertification Data Base – 2011 WSS Rate - 1/30,000 orthopaedic surgeries WSS Rate - 1/30,000 orthopaedic surgeries NO CHANGE 2000-2011 NO CHANGE 2000-2011
  • Slide 9
  • Surgical Safety/Quality/Value Timeline 1997 - AAOS - Program - (safety) 1997 - AAOS - Sign Your Site Program - (safety) 1999 - IOM Report - To Error is Human: Building a Safer Health System – (safety) (44-88,00 deaths in hospitals/year from medical errors) 2001 - IOM Report – Crossing the Quality Chasm: A New Health System for the 21 st Century (quality) 2003 - VA National Directive to reduce Risk WSS (safety) 2004 - JCAHO – Universal Protocol (safety/quality) 2004 - SCOAP** (safety/quality) voluntary hospital-based surgical safety/quality – Washington voluntary hospital-based surgical safety/quality – Washington
  • Slide 10
  • Surgical Safety/Quality/Value Timeline 2007 - SCIP* (quality) mandated national surgical quality standards mandated national surgical quality standards 2007 - WHO Safe Surgery-Saves Lives (safety/quality) 2009 - Checklist Manifesto –Atul Gwande MD (safety and quality) 2010 - Berwick*** CMS Administrator (safety/quality/value) CMS payments - financial penalties for Never Events CMS payments - financial penalties for Never Events CMS/PQRS payments – financial incentives for quality reporting CMS/PQRS payments – financial incentives for quality reporting 2012 – CMS Public Quality Data Reporting Program (safety/quality/value) Hospital SSI Rates Hospital SSI Rates Surgical Re-admission Rates Surgical Re-admission Rates * Surgical Care Outcome Assessment Program – Washington State Hospital Association * Surgical Care Outcome Assessment Program – Washington State Hospital Association ** Surgical Care Improvement Program – US Department of Health and Human Services ** Surgical Care Improvement Program – US Department of Health and Human Services *** Former President and CEO, Institute for Healthcare Improvement (IHI) *** Former President and CEO, Institute for Healthcare Improvement (IHI)
  • Slide 11
  • Evidence Surgical Safety/Quality/Value Programs are Effective 2006 – Central Line Checklists – Peter Pronovost MD Reduction central line infections - 40% to
  • Results Positive Findings >90% use Universal Protocol (UP) in Hospital ORs >90% use Universal Protocol (UP) in Hospital ORs 82% Believe UP Improves Surgical Safety/Quality 82% Believe UP Improves Surgical Safety/Quality No differences in utilization/understanding UP by: No differences in utilization/understanding UP by: Years in practice Years in practice Sub-specialty Sub-specialty
  • Slide 19
  • Results Negative Findings Surgical errors reported ALL orthopaedic settings Surgical errors reported ALL orthopaedic settings Most undereducated safety science Most undereducated safety science
  • Safety Summit No! No! cultural change resistance cultural change resistance other industries safety change > decade other industries safety change > decade Options Options embrace change – improve care embrace change – improve care resist change – accept regulatory mandates/financial penalties resist change – accept regulatory mandates/financial penalties Safety Summit designed to Safety Summit designed to expand safety practices introduced by AAOS in 1997 expand safety practices introduced by AAOS in 1997 build new orthopaedic specific safety tools build new orthopaedic specific safety tools affirm orthopaedic leadership/commitment affirm orthopaedic leadership/commitment
  • Slide 59
  • Safety Summit Summary Overview Participant Recognition: Prioritize Safety for ALL orthopaedic settings Participant Recognition: Prioritize Safety for ALL orthopaedic settings 6 sub-specialty work groups : PILOT new orthopaedic safety programs 6 sub-specialty work groups : PILOT new orthopaedic safety programs Safety collaboration - CMS, AHRQ, JCAHO, ACS, SCOAP Safety collaboration - CMS, AHRQ, JCAHO, ACS, SCOAP Unify Orthopaedic community : Unify Orthopaedic community : UNIFIED Orthopaedic Safety Information Statement UNIFIED Orthopaedic Safety Information Statement BOS and AAOS collaboration new safety programs /products BOS and AAOS collaboration new safety programs /products
  • Slide 60
  • Summit Safety Outcomes Summary Unified Position Statement on Orthopaedic Surgical Safety Unified Position Statement on Orthopaedic Surgical Safety Develop funding support for Work Group pilot safety programs Develop funding support for Work Group pilot safety programs Continue communication CMS, JCAHO, AHRQ Continue communication CMS, JCAHO, AHRQ Explore partnering with ACS/SCOAP for surgical safety data Explore partnering with ACS/SCOAP for surgical safety data Explore ongoing support and coordination of the Orthopaedic Safety programs Explore ongoing support and coordination of the Orthopaedic Safety programs ? new BOS Safety Committee ? new BOS Safety Committee Collaborate with AAOS Surgical Safety TeamSTEPPS Communication Program (80 Centers/3 years) Collaborate with AAOS Surgical Safety TeamSTEPPS Communication Program (80 Centers/3 years)
  • Slide 61
  • Safety Recommendations Trauma Work Group Recommend to AAOS - SSI Prevention Guideline Recommend to AAOS - SSI Prevention Guideline Develop SSI Prevention Checklist (Bundle) Develop SSI Prevention Checklist (Bundle) Antibiotic managementHbA1C/Hypergylcemia Management Antibiotic managementHbA1C/Hypergylcemia Management Surgical warming (>35c.)Albumin/Nutritional management Surgical warming (>35c.)Albumin/Nutritional management Smoking CessationBlood manageent Smoking CessationBlood manageent Pilot a Standardized Hip Fracture Patient Care Pathway Pilot a Standardized Hip Fracture Patient Care Pathway Standardized Order Sets Standardized Order Sets Pre-op Pre-op Post-op Post-op Discharge Discharge Hip Fracture PIM Hip Fracture PIM Goals: decreased LOS, decreased costs and improved Fx outcomes Goals: decreased LOS, decreased costs and improved Fx outcomes
  • Slide 62
  • Safety Recommendations Sports Work Group Develop a Surgical Safety Program for Ambulatory Surgery Centers Develop a Surgical Safety Program for Ambulatory Surgery Centers Collaborate with JCAHO, ASCA Collaborate with JCAHO, ASCA Develop training modules Develop training modules Collaborate with AAOS TeamSTEPPS training program Collaborate with AAOS TeamSTEPPS training program Currently only 50% of orthopaedic surgicenters use Universal Protocol Currently only 50% of orthopaedic surgicenters use Universal Protocol
  • Slide 63
  • Safety Recommendations Spine Work Group Recommend to AAOS - SSI Infection Prevention Guideline Recommend to AAOS - SSI Infection Prevention Guideline Pilot - Wrong Level Spine Surgery Checklist Pilot - Wrong Level Spine Surgery Checklist Define imaging requirements Define imaging requirements Define wrong level surgery Define wrong level surgery Define exception/outlier management – obesity, retained implants Define exception/outlier management – obesity, retained implants
  • Slide 64
  • Safety Recommendations Pediatric Work Group Pilot a Family/Patient Focused Peri-operative Checklist Pilot a Family/Patient Focused Peri-operative Checklist Pre-op Pre-op Care team review Care team review Consent, Consent, Team huddle Team huddle Surgical Surgical Post-op surgeon review Post-op surgeon review Post-op Post-op Care plan review Care plan review Discharge Discharge Follow-up appointment Follow-up appointment 10-15 pilot centers identified 10-15 pilot centers identified Potential funding sources identified Potential funding sources identified
  • Slide 65
  • Safety Recommendations Hip/Knee/Tumor Work Group Recommend to AAOS - SSI Prevention Guideline Recommend to AAOS - SSI Prevention Guideline Develop SSI Prevention education products Develop SSI Prevention education products OKO OKO PIM PIM With AHRQ pilot Pre-op Optimization SSI Prevention With AHRQ pilot Pre-op Optimization SSI Prevention Checklist (Bundle): Checklist (Bundle): Obesity (BMI>40 counseling) Obesity (BMI>40 counseling) Smoking Cessation (Pre-op counseling/cessation) Smoking Cessation (Pre-op counseling/cessation) Diabetic Management (Optimize Pre-op HbA1C
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    • Slide 1
  • Fall Meeting AAOS Orthopaedic Surgery Safety Update 2012 William J Robb III MD Chair AAOS Orthopaedic Surgery Safety Summit AAOS Patient Safety Committee
  • Slide 2
  • Disclosure Consultant – Blue Cross Blue Shield Association Consultant – Blue Cross Blue Shield Association TJR - Centers of Distinction Program Consultant (Unpaid) - Smith and Nephew Consultant (Unpaid) - Smith and Nephew Investor – emmi Solutions Investor – emmi Solutions Chair – AAOS Orthopaedic Surgery Safety Summit Chair – AAOS Orthopaedic Surgery Safety Summit Chair – AAOS Patient Safety Committee Chair – AAOS Patient Safety Committee
  • Slide 3
  • Is there an Orthopaedic Surgery Safety Problem 2012? Media ABC News Report - Maryland 2012 Report on Surgical Errors Report on Surgical Errors CMS - only 14% errors reported in hospitals CMS - only 14% errors reported in hospitals Advised patients ask about checklists Advised patients ask about checklists Report Report SSIs shoulder surgery SSIs shoulder surgery Wrong site pediatric eye surgery Wrong site pediatric eye surgery
  • Slide 4
  • Is there an Orthopaedic Surgery Safety Problem 2012? HealthGrades - 2010 >350,000 patient safety errors/year 2006-2008 >350,000 patient safety errors/year 2006-2008 Cost $9B Cost $9B 1/10 safety errors results deaths 1/10 safety errors results deaths >100,000 surgical error deaths/year >100,000 surgical error deaths/year Top 5% Hospitals – only 43% reduction safety incidents Top 5% Hospitals – only 43% reduction safety incidents Wrong Site Surgery (WSS) rates - 1/20,000 surgeries Wrong Site Surgery (WSS) rates - 1/20,000 surgeries Hospital SSI rates 2-3% Hospital SSI rates 2-3% NO evidence safety/quality improvement 2000-2010 NO evidence safety/quality improvement 2000-2010
  • Slide 5
  • Is there an Orthopaedic Surgery Safety problem 2012? JC 2009-2010 Wrong Site/Procedure/Patient Surgery (WSS) Wrong Site/Procedure/Patient Surgery (WSS) Mandatory State –bsed WSS Reporting Mandatory State –bsed WSS Reporting Minnesota (48 - WSS) Minnesota (48 - WSS) Pennsylvania (58 - WSS) Pennsylvania (58 - WSS) 35.4 WSS/wk. in US (estimated) 35.4 WSS/wk. in US (estimated)
  • Slide 6
  • JC Sentinel Events Data Base 2007-2011 54 Orthopaedic WSS
  • Slide 7
  • Is there a Orthopaedic Surgery Safety Problem 2012? Hospital Data JC - 2011 >7 wrong site/side/level/implant/procedure/patient surgeries /day >7 wrong site/side/level/implant/procedure/patient surgeries /day System errors – NOT Surgeon errors System errors – NOT Surgeon errors Most frequent causes: Most frequent causes: inadequate/missing surgical information inadequate/missing surgical information scheduling discrepancies/errors scheduling discrepancies/errors irregularities in pre-op holding process irregularities in pre-op holding process inadequate/absent surgical site marking inadequate/absent surgical site marking poor communication poor communication distractions in OR distractions in OR inadequate/absent OR process/time-out inadequate/absent OR process/time-out Mark Chassin MD, MPP, MPH
  • Slide 8
  • Is there an Orthopaedic Surgery Safety problem 2012? ABOS Certification/Recertification Data Base – 2011 ABOS Certification/Recertification Data Base – 2011 WSS Rate - 1/30,000 orthopaedic surgeries WSS Rate - 1/30,000 orthopaedic surgeries NO CHANGE 2000-2011 NO CHANGE 2000-2011
  • Slide 9
  • Surgical Safety/Quality/Value Timeline 1997 - AAOS - Program - (safety) 1997 - AAOS - Sign Your Site Program - (safety) 1999 - IOM Report - To Error is Human: Building a Safer Health System – (safety) (44-88,00 deaths in hospitals/year from medical errors) 2001 - IOM Report – Crossing the Quality Chasm: A New Health System for the 21 st Century (quality) 2003 - VA National Directive to reduce Risk WSS (safety) 2004 - JCAHO – Universal Protocol (safety/quality) 2004 - SCOAP** (safety/quality) voluntary hospital-based surgical safety/quality – Washington voluntary hospital-based surgical safety/quality – Washington
  • Slide 10
  • Surgical Safety/Quality/Value Timeline 2007 - SCIP* (quality) mandated national surgical quality standards mandated national surgical quality standards 2007 - WHO Safe Surgery-Saves Lives (safety/quality) 2009 - Checklist Manifesto –Atul Gwande MD (safety and quality) 2010 - Berwick*** CMS Administrator (safety/quality/value) CMS payments - financial penalties for Never Events CMS payments - financial penalties for Never Events CMS/PQRS payments – financial incentives for quality reporting CMS/PQRS payments – financial incentives for quality reporting 2012 – CMS Public Quality Data Reporting Program (safety/quality/value) Hospital SSI Rates Hospital SSI Rates Surgical Re-admission Rates Surgical Re-admission Rates * Surgical Care Outcome Assessment Program – Washington State Hospital Association * Surgical Care Outcome Assessment Program – Washington State Hospital Association ** Surgical Care Improvement Program – US Department of Health and Human Services ** Surgical Care Improvement Program – US Department of Health and Human Services *** Former President and CEO, Institute for Healthcare Improvement (IHI) *** Former President and CEO, Institute for Healthcare Improvement (IHI)
  • Slide 11
  • Evidence Surgical Safety/Quality/Value Programs are Effective 2006 – Central Line Checklists – Peter Pronovost MD Reduction central line infections - 40% to
  • Results Positive Findings >90% use Universal Protocol (UP) in Hospital ORs >90% use Universal Protocol (UP) in Hospital ORs 82% Believe UP Improves Surgical Safety/Quality 82% Believe UP Improves Surgical Safety/Quality No differences in utilization/understanding UP by: No differences in utilization/understanding UP by: Years in practice Years in practice Sub-specialty Sub-specialty
  • Slide 19
  • Results Negative Findings Surgical errors reported ALL orthopaedic settings Surgical errors reported ALL orthopaedic settings Most undereducated safety science Most undereducated safety science
  • Safety Summit No! No! cultural change resistance cultural change resistance other industries safety change > decade other industries safety change > decade Options Options embrace change – improve care embrace change – improve care resist change – accept regulatory mandates/financial penalties resist change – accept regulatory mandates/financial penalties Safety Summit designed to Safety Summit designed to expand safety practices introduced by AAOS in 1997 expand safety practices introduced by AAOS in 1997 build new orthopaedic specific safety tools build new orthopaedic specific safety tools affirm orthopaedic leadership/commitment affirm orthopaedic leadership/commitment
  • Slide 59
  • Safety Summit Summary Overview Participant Recognition: Prioritize Safety for ALL orthopaedic settings Participant Recognition: Prioritize Safety for ALL orthopaedic settings 6 sub-specialty work groups : PILOT new orthopaedic safety programs 6 sub-specialty work groups : PILOT new orthopaedic safety programs Safety collaboration - CMS, AHRQ, JCAHO, ACS, SCOAP Safety collaboration - CMS, AHRQ, JCAHO, ACS, SCOAP Unify Orthopaedic community : Unify Orthopaedic community : UNIFIED Orthopaedic Safety Information Statement UNIFIED Orthopaedic Safety Information Statement BOS and AAOS collaboration new safety programs /products BOS and AAOS collaboration new safety programs /products
  • Slide 60
  • Summit Safety Outcomes Summary Unified Position Statement on Orthopaedic Surgical Safety Unified Position Statement on Orthopaedic Surgical Safety Develop funding support for Work Group pilot safety programs Develop funding support for Work Group pilot safety programs Continue communication CMS, JCAHO, AHRQ Continue communication CMS, JCAHO, AHRQ Explore partnering with ACS/SCOAP for surgical safety data Explore partnering with ACS/SCOAP for surgical safety data Explore ongoing support and coordination of the Orthopaedic Safety programs Explore ongoing support and coordination of the Orthopaedic Safety programs ? new BOS Safety Committee ? new BOS Safety Committee Collaborate with AAOS Surgical Safety TeamSTEPPS Communication Program (80 Centers/3 years) Collaborate with AAOS Surgical Safety TeamSTEPPS Communication Program (80 Centers/3 years)
  • Slide 61
  • Safety Recommendations Trauma Work Group Recommend to AAOS - SSI Prevention Guideline Recommend to AAOS - SSI Prevention Guideline Develop SSI Prevention Checklist (Bundle) Develop SSI Prevention Checklist (Bundle) Antibiotic managementHbA1C/Hypergylcemia Management Antibiotic managementHbA1C/Hypergylcemia Management Surgical warming (>35c.)Albumin/Nutritional management Surgical warming (>35c.)Albumin/Nutritional management Smoking CessationBlood manageent Smoking CessationBlood manageent Pilot a Standardized Hip Fracture Patient Care Pathway Pilot a Standardized Hip Fracture Patient Care Pathway Standardized Order Sets Standardized Order Sets Pre-op Pre-op Post-op Post-op Discharge Discharge Hip Fracture PIM Hip Fracture PIM Goals: decreased LOS, decreased costs and improved Fx outcomes Goals: decreased LOS, decreased costs and improved Fx outcomes
  • Slide 62
  • Safety Recommendations Sports Work Group Develop a Surgical Safety Program for Ambulatory Surgery Centers Develop a Surgical Safety Program for Ambulatory Surgery Centers Collaborate with JCAHO, ASCA Collaborate with JCAHO, ASCA Develop training modules Develop training modules Collaborate with AAOS TeamSTEPPS training program Collaborate with AAOS TeamSTEPPS training program Currently only 50% of orthopaedic surgicenters use Universal Protocol Currently only 50% of orthopaedic surgicenters use Universal Protocol
  • Slide 63
  • Safety Recommendations Spine Work Group Recommend to AAOS - SSI Infection Prevention Guideline Recommend to AAOS - SSI Infection Prevention Guideline Pilot - Wrong Level Spine Surgery Checklist Pilot - Wrong Level Spine Surgery Checklist Define imaging requirements Define imaging requirements Define wrong level surgery Define wrong level surgery Define exception/outlier management – obesity, retained implants Define exception/outlier management – obesity, retained implants
  • Slide 64
  • Safety Recommendations Pediatric Work Group Pilot a Family/Patient Focused Peri-operative Checklist Pilot a Family/Patient Focused Peri-operative Checklist Pre-op Pre-op Care team review Care team review Consent, Consent, Team huddle Team huddle Surgical Surgical Post-op surgeon review Post-op surgeon review Post-op Post-op Care plan review Care plan review Discharge Discharge Follow-up appointment Follow-up appointment 10-15 pilot centers identified 10-15 pilot centers identified Potential funding sources identified Potential funding sources identified
  • Slide 65
  • Safety Recommendations Hip/Knee/Tumor Work Group Recommend to AAOS - SSI Prevention Guideline Recommend to AAOS - SSI Prevention Guideline Develop SSI Prevention education products Develop SSI Prevention education products OKO OKO PIM PIM With AHRQ pilot Pre-op Optimization SSI Prevention With AHRQ pilot Pre-op Optimization SSI Prevention Checklist (Bundle): Checklist (Bundle): Obesity (BMI>40 counseling) Obesity (BMI>40 counseling) Smoking Cessation (Pre-op counseling/cessation) Smoking Cessation (Pre-op counseling/cessation) Diabetic Management (Optimize Pre-op HbA1C
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