FOCUS Presentation at the ASA Meeting

by Bruce Spiess, M.D.

The FOCUS Initiative is a part of the program of the ASA Annual Meeting. Join us on Sunday, October 17 at 10:00 am -12:00 noon pacific time at the San Diego Convention Center, room Upper 1A for the presentation, “Patient Safety in the Complex Environment of the Cardiac Operating Room. “

Panelists for the presentation include Joyce A. Wahr, MD, Jeffrey Cooper, MD, Elizabeth A. Martinez, MD, Alan F. Merry, MD and Bruce D. Spiess, MD.

FOCUS previewed in American Heart Association newsletter

The Vol 8., No. 1 spring 2010 issue of the American Heart Association newsletter, Connections, features an excerpt from the article Spiess, BD, Wahr, JA, Nussmeier, NA. Bring Your Life into FOCUS! Anesth Analg. 110:283-7, 2010.

Pronovost Interviewed by New York Times

Dr. Peter J. Pronovost, 45, is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, which means he leads that institution's quest for safer ways to care for its patients. He also travels the country, advising hospitals on innovative safety measures. The Hudson Street Press has just released his book, "Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out," written with Eric Vohr. An edited version of a two-hour conversation follows.
http://www.nytimes.com/2010/03/09/science/09conv.html?em

Anesthesia & Analgesia Spotlights the FOCUS Initiative

January 26, 2010

John Melleky, SCA Foundation Executive Director

Anesthesia & Analgesia Spotlights the FOCUS Initiative

An introduction and update on the FOCUS initiative appears in two special articles, “Bring Your Life Into FOCUS “and “The Society of Cardiovascular Anesthesiologists' FOCUS Initiative: Locating Errors Through Networked Surveillance (LENS) Project Vision” in the February 2010 issue of Anesthesia & Analgesia, the official journal of the International Anesthesia Research Society (IARS) and the SCA.

"Preventing humans from making mistakes may be nearly impossible, but the SCA FOCUS initiative is predicated on the strong belief that making an error-free medical environment can be achieved," comments Dr. Steven L. Shafer of Columbia University, Editor-in-Chief of Anesthesia & Analgesia.

Read the full article in Anesthesia & Analgesia.

FOCUS Sets Priorities

December 1, 2009

FOCUS Sets Priorities

By Bruce Spiess, M.D. and Joyce A. Wahr, M.D.

In 2009, the first year of the FOCUS research project, Dr. Peter Pronovost and the Quality and Safety Research Group (QSRG) at Johns Hopkins Hospital (JHU). completed an extensive review of the cardiac patient safety literature and reviewed the National Heath Service (United Kingdom) error reporting database, focusing on cardiac surgical errors. From this rich background, QSRG developed an in-depth, two-day observational process to research operating room factors that contribute to human errors. This observational process was conducted in cardiac operating rooms at five separate hospitals. At each of the five sites, surgeons, anesthesiologists, nurses, perfusionists, surgical technicians and hospital executive management personnel participated. Each individual completed extensive surveys on motivation and patient safety culture, and observations were conducted over several days at each site. The surveys and observations have been coded into a database and used to create a taxonomy of errors and to develop interventions. The data collected are both informative and distressing. For example, errors were made in nearly every skin preparation procedure, and in nearly every programming of the “smart” intravenous pumps. These errors were made despite the high level of motivation to provide flawless care by the OR staff who were surveyed. The data are currently being analyzed and will be presented in a series of publications over the next 6-12 months.

Although the full analysis of the observations will not be complete for some time, the FOCUS Steering Committee and QSRG have identified three priorities for interventions to improve patient safety.

1. Develop a learning collaborative within the cardiac surgical teams to enhance patient safety. This process will use the Michigan Keystone model developed by Dr. Pronovost and the QSRG team that has been so successful in eliminating catheter based infections in the ICU setting. The FOCUS learning collaborative will use reduction in wound infections as the metric that will inform us of how we are doing.

2. Develop a peer-to-peer assessment tool that can be used by operating room teams to assess their own safety performance, or be used by an invited visiting team to provide feedback regarding areas for improvement in safety. This non-judgmental, for-internal-use-only peer-to-peer assessment tool will be based on the highly successful WANO (World Association of Nuclear Operators) process that has made the nuclear industry a “highly reliable” industry.

3. Design the operating room of the future. Tackle the issues of equipment and OR design to improve the interfaces between humans and the machines they use to deliver patient care in the operating room.

The FOCUS committee is looking for more sites and individuals to get involved in the project, whether it is on a committee, on a workgroup of the three priorities above, or as a site for one of the workgroups. Committees that you can be involved in include Data, Fundraising/Grants, Public and Society Relations, Patient Safety Initiatives Liaison, Publications, Site Selection, Speaker’s Bureau, and Summit Planning. To get involved and for more details, contact the SCA Foundation at foundation@scahq.org or call John Melleky, Executive Director at 804-565-6324.

A FOCUS Update

By Bruce Spiess, M.D.

The FOCUS Initiative is making strong progress through the summer months. At the SCA Annual Meeting in San Antonio, the curtains were pulled back for a slight peek into the initial data regarding human errors in the cardiac operating rooms. At that meeting the data was described as “robust”, meaning a number of problems had been uncovered. We are happy to report that since the Annual Meeting, the remainder of site visits and follow-up questionnaires have all been completed. The Johns Hopkins University Center for Innovation in Quality Patient Care (JHUIQPC) is now hard at work collating the data and inputting it into computers for analysis. That process is huge. As part of their analysis, JHUIQPC has undertaken a review of the data using the National Reporting and Learning System from the United Kingdom, which is the largest known error reporting system in the world.

FOCUS will convene a meeting in Baltimore at JHUIQPC on August 13, 2009 for an initial review of data. At this meeting a number or representatives from the FOCUS leadership, data management committee and consultants will be present as well as the JHUIQPC team. Importantly, leadership from the Society of Thoracic Surgeons and AORN are expected to attend. Enthusiasm from other associations is growing so that we can all work together to improve patient care. Letters and phone contacts have been completed to AMSECT and we hope to solicit their participation/sponsorship of FOCUS in the future.

The committees within the FOCUS Initiative have been formed and their charges have been given to them. Notably, the publications committee is moving forward with a written process with regards to authorship and participation in publications from FOCUS data. This process should be available to all for review through our FOCUS web site. Once our August meeting is complete, we will develop our next steps based on the data obtained at our initial sites. To become involved as a volunteer with FOCUS, you can contact the SCA Foundation via email at foundation@scahq.org.

FOCUS – Our Next Steps

By Dr. Bruce Spiess

FOCUS is very excited to announce that all the initial hospital sites have been visited and observed. The human factors research team employs a number of tools (called “LENS’) that have undergone validation and testing prior to being used as research tools in the present project. FOCUS is very proud to partner with the JHU Center on Quality Patient Care not only because of their and Dr. Pronovost’s international reputation, but also because it allowed both groups to further refine these human factors investigational tools. The tools employ survey instruments distributed prior to site visitation, extensive interviews with the entire operating room team (anesthesiology, surgery, perfusion and nursing) as well as the administration, on-site observation of cases, and post visitation surveys and interviews. The on-site team in a 2 day visit, examines communications, breaks in flow, ergonomics of equipment, and other systems constructs, all with a FOCUS upon how a team performs in a highly complex environment. The data from the various LENS’ are now being coded and collated. In discussions with the JHU team we are told: “The data is very rich, and full of possibilities for interventions that to improve patient safety – ones that can be done relatively easily and soon, and some that will take more earnest work”. What that means we cannot tell at this time, but suffice it to say that there will be directions and conclusions that can be drawn form this original first look inside the cardiac operating rooms.

What are the next steps?

Clearly we must finish what we have set out to accomplish, the first gathering of data and its analysis. As stated throughout the formation of FOCUS, this will be a scientific, data driven medical and sociological intervention. Until the data is analyzed, it is hard to say what interventions should proceed or in what order we should invoke changes. Although there is much data collected already, only five, albeit carefully selected and representative, sites have been studied. The FOCUS steering committee envisions that more sites should be studied (5-20 more), and that the beginning of a self-study program should be initiated. The form of the self-study tools will grow out of the data through a combined effort of the JHU human factors experts and the FOCUS Data Analysis Committee. It could well be that in the next 12 months we see the first recommendations from FOCUS come forward to be implemented and field tested at cardiac sites around the country. The on-going success of the FOCUS program itself is feeding back towards improving/reducing human error. By the existence and success of the initial site visits, national and even international curiosity is peaking. The FOCUS project is gaining exposure with reporting on the programs for educational meetings not only within the SCA but in other societies. The recent 14^th Annual Update on Cardiopulmonary Bypass was held at Whistler, Canada March 14-20, 2009. At that meeting a session on patient safety was well received and the attendees asked for more and expanded sessions, workshops and team building training for future meetings all with the end goals of reducing human error in the cardiac operating rooms. So, in a small way the FOCUS program has already succeeded by creating buzz, discussion, and insight by the rank and file into how we go about delivering such complex care.

FOCUS has only begun – join us!