Issue link: https://beckershealthcare.uberflip.com/i/931991
20 Executive Briefing age 65. Clinicians strongly underestimated this difference, believing the risk was one half or one quarter what it really is. This can lead to a form of bias in which incorrect knowledge about the prevalence of a disease can make them slow to suspect sepsis. Another finding is related to the source of infection. A little over half of clinicians thought the most common infection source for sepsis was the urinary tract. Actually the source in 50% of cases is the lungs, with the urinary tract implicated in just 10% of cases. In sepsis, finding and eliminating the source of infection quickly is critical. That includes knowing where to start looking. Q: The findings indicated wide variance in the type and amount of misinformation among clinicians. How does this relate to clinical variation in healthcare organizations? BB: Brent James, MD, former chief quality officer of Intermountain Healthcare and the inspirational leader in the movement that produced the landmark book To Err is Human: Building a Safer Health System, helped us in the early days at Intermountain in developing the mission and scope of this effort. Something he said early on has proven accurate— aggregated data in complex healthcare environments has a very high propensity to hide the problem. If you use a bar graph to represent data across all 23 healthcare organizations, they look like they all have about the same level of problems, but if you drill down within a single unit on the same floor of the same hospital, there are significant disparities in knowledge between individual clinicians. Something this platform provides that others don't, is groundbreaking analytics that transform data into patterns that matter and action items that benefit individual clinicians. One of the most common and correctable causes of patient harm and financial loss is confidently held misinformation in the minds of clinicians. The purpose of the healthcare alliance is to find and fix that problem at a granular level. To be clear, the information that we expect physicians to hold in their brains is overwhelming. They are real heroes on the front lines, and we have an obligation to provide them with highly focused and targeted knowledge engineering tools to help them succeed. Analytics can also reveal systemic problems. Another training we did found that a single care location performed very poorly in one area. The data looked so anomalous that we sent someone to see what was going on. Sure enough, we found that they were cleaning a piece of equipment following instructions for the wrong machine. Their confidently held misinformation was actually a signal for a systemic or environmental problem that was easy to fix once identified by the system. Q: What actions can infection control leaders take to improve sepsis outcomes? BB: The biggest thing that is missing—the reason why this alliance exists in the first place—is the infection control leader must acknowledge they're dealing with variations of misinformation and knowledge in individual caregivers. You have to start with that assumption and deploy training and clinical knowledge engineering efforts that are adaptive to individuals who may struggle on one topic while performing beautifully on another. We have to deploy knowledge engineering initiatives that are adaptable at the individual level, which lets us aggregate data, which then leads to actionable interventions. You see systems spending a lot of money to solve sepsis, but they're treating it as if it's a single problem across the organization, and that's not how humans work. One provider needs a completely different intervention than another. What our alliance does and what we tell new members when they come in is that the first step is realizing that you're dealing with a diverse set of problems linked to knowledge gaps unique to each individual. Your clinical knowledge engineering has to start with that assumption. Q: Are these findings transferable to other healthcare problems? BB: At the aggregate level the findings are highly transferable, but the clinical findings in this study are unique to sepsis. We have about 60 clinical interventions comparable to the sepsis initiative. At Intermountain, we've built CAUTI and CLABSI interventions. We're finalizing a C.diff intervention at Partners HealthCare with Mass General. We've rolled out a safe injection practices course through the Duke Infection Control Outreach Network. The findings are all unique. For example, the findings for safe injection practices suggest that on-the- job training propagates misinformation about injections from one person to the next in a very scattered and unpredictable way. The consistent variable here is that this type of clinical intervention is highly applicable to virtually every clinical topic. A year ago we had two interventions; now we have 60 and all of them are built by the member health systems. The overall approach is intensely scalable. A growing alliance To help address the myriad clinical and fiscal challenges facing the American healthcare system in the era of value-based care, Amplifire's leadership and founding members decided to expand the reach of the organization for the purpose of advancing efforts to combat clinical misinformation. "We've made the decision to open up the alliance nationwide, so at this point any health system in the country is welcome to participate in these clinical knowledge engineering initiatives," Mr. Burgin said. "This is the only alliance of its kind and the broader the footprint we have across the country, the better." The sepsis intervention white paper and sample findings are available as a free download at http://info.amplifire.com/ national-sepsis-study-findings. n Amplifire is the leading e-learning platform built from discoveries in brain science. With over a billion learner interactions, it verifiably helps people learn faster, retain longer, and perform better. Healthcare, education, and Fortune 500 companies use Amplifire's patented learning algorithms, knowledge analytics and diagnostic capabilities to drive business outcomes at a significant return on their investment. https://amplifire.com/ HEALTHCARE ALLIANCE