FOCUS Update

FOCUS (Flawless Operative Cardiovascular Unified Systems) is making tremendous progress. On Sunday, April 19, 2009 at 11:00 am, as part of the upcoming SCA Annual Meeting in San Antonio, Texas, a one hour session will be devoted to the FOCUS initiative. The First Data from the LENS of FOCUS will showcase the first peek behind the curtain to look at the data will be presented by Dr Peter Pronovost of Johns Hopkins University Center on Quality Patient Care. Dr Spiess will then conjecture on what future direction FOCUS will take and describe the Next Steps to Continue Our Focus on Human Error. In some respects those directions will be like entering a traffic circle. Any number of branching points and spokes could/should be taken from the original entry point (our original data gathering). Which ones will be traveled are hard to predict until the data is fully analyzed and recommendations are created. But, the session should provide feedback to the membership and reward for not only their support but hard work over the four years to get to this point. We are sure that enthusiastic members who have undergone the site visitation may well provide participation from the floor on what it was like to participate in this process. All the membership is encouraged not only to attend the FOCUS session at the annual meeting but to watch for ways in which they can participate and help. Calls have gone to the membership for participation in committees of FOCUS. Please look for more requests for volunteerism as well as your personal philanthropic donations to move FOCUS forward.

The FOCUS team has held past and on-going discussions with the Society of Thoracic Surgeons on a very high level. Our goal is to involve all the stake-holders in the care of cardiac surgical patients. Eventually it is envisioned that FOCUS will be an example for all of medicine as a method of self study and self improvement with reduction in human error. Communications will be forthcoming from FOCUS to AMSECT, AORN and other surgical, nursing, critical care and allied health societies to see if they will band with SCA Foundation in driving FOCUS to it ultimate goal (improved patient safety).

The FOCUS Initiative

Executive Summary
Human error in medicine has been widely heralded as a major cause of morbidity and mortality. The Institute of Medicine published a blockbuster study in the 1990’s estimating approximately 100,000 deaths per year occur in the United States from human error in health care delivery. Government agencies, insurance carriers, legal groups, and medical societies are working to address the public’s and lay presses’ call to action.

In 2008, the Society of Cardiovascular Anesthesiologists Foundation (SCA Foundation) launched the Flawless Operative Cardiovascular Unified Systems (FOCUS) project. FOCUS is a groundbreaking research/practice effort to study human error in cardiac operating rooms.

Cardiac Surgery
Cardiac operating care takes place in a demanding and technologically advanced environment. Teams of highly trained medical professionals must perform complex tasks in concert. The potential for miscommunication and errors is immense. Yet, high rates of success and positive outcomes demonstrate teams’ mastery of modern medicine and technological achievement. Members of SCA are proud of our participation in this success—we believe that we can do even better.

FOCUS looks to the commercial aviation field and its high rate of success controlling human error through cockpit resource management (CRM) as we develop similar protocols in the operating theatre. CRM has become synonymous with human error reduction. John Nance, an Alaska Airlines Senior Pilot and commercial aviation consultant for ABC News recently said, “Individuals can and will forever commit errors, but teams have the ability to be flawless.”

Nance’s statement stresses the importance of a team’s ability to interact in healthy and productive ways. While CRM and mimicking the success of aviation protocol are not the entire answer to improving cardiac operating room success, they are excellent guides as our study uncovers more opportunities for successful change in surgery teams.

FOCUS is an on-going, multi-year (>20 year) project of research, self-study, innovation, and implementation. Dr. Peter Pronovost is leading the Quality and Safety Research Group at Johns Hopkins University (JHU) for our initial research. They administer questionnaires, interviews, and live observations in a technique known as Locating Errors through Network Surveillance (LENS). A variety of trained scientists are involved, including:
organizational sociologists,
human factors engineers,
industrial psychologists,
applied organizational psychologists,
clinical medical specialists, and
biostatisticians.
The JHU team has received wide acclaim for the successful application of this methodology in Michigan and elsewhere. SCA Foundation is proud to have them leading the FOCUS research.

Staging
A competitive, world-wide selection process weighed many aspects of health care and a large number of applicants to identify the finest research organizations with patient safety research experience . With the cooperation of these institutions, we will collect initial data from a range of possible practice scenarios and a broad geographic area. FOCUS is currently in its initial data collection phase.

This first round data will be gathered and analyzed to guide expansion of the project. Additional sites will be added to the study and practice recommendations made. Alpha and Beta tests will be conducted before changes are implemented.

We expect to create self-study guides in a few years that will enable other hospitals to conduct independent human error studies. Ideally, such data should circle back to the project to facilitate the overall goal of human error reduction in the cardiac operating rooms. FOCUS intends to serve as a leader in error reduction for not only cardiovascular care, but all of medicine.

Guiding Principles
Protect the privacy of institutions and individuals.
De-identify all data.
Maintain the highest scientific standards.
Maintain the ideologic spirit of the project.
Change medicine and create “flawless” patient care.
We cannot hope to change medicine unless we find areas for change in our daily practice first. From its inception, the vision for FOCUS has been to study cardiac anesthesia. It is impossible to understand cardiac anesthesia without understanding the entire cardiac environment:
surgery,
nursing,
perfusion,
anesthesia, and
the institutional matrix in which they exist.
Our success depends upon everyone’s cooperation. We are fortunate to have the benefit of input from advisors in each of these disciplines.
JHU has worked closely with their surgeons, perfusionists, and nurses to make sure the techniques are effective. The FOCUS Steering committee believes that this project will evolve into a unified whole through contributions from each of the major disciplines contributed through their society representatives.

We have a great deal of work ahead of us first. The current alpha phase will provide initial data, testing of research methods, and a demonstration of both the capabilities and implications of human error reduction research. We have carefully briefed government agencies and the World Health Organization on FOCUS. We’ve begun the work.

The Primary Investigator from each site has the research protocol, documents, JHU IRB approval, and other pertinent documents. We at the SCA Foundation and the FOCUS Steering Committee are available to answer any questions you may have. Communication is the key to success. Our goal is to be open and accessible.

We realize that participation in this sociologic study will be a unique departure from daily routine in many institutions. That being said, we took efforts to make planning for site visits as easy as possible. We wish to be as minimally intrusive as can. The JHU research team’s experience in studies like this has proven invaluable. We extend our gratitude to the institutions’ Primary Investigators who continue to facilitate communication and assure the success of this vital project. A successful start is important to the collection of meaningful data.

Thank you for your willingness to contribute to FOCUS. On behalf of all of our future patients, the JHU research team, your PI, and the SCA FOCUS Steering Committee, I thank you for your time and thoughtful contribution to this very important project.

Bruce D. Spiess, MD, FAHA
Chair, FOCUS Steering Committee

Initiation of FOCUS

The SCA Foundation is pleased to announce initiation of the FOCUS project and is asking for cardiac anesthesia programs that would like to participate.

This project, Flawless Operative Cardiovascular Unified Systems, is a national research program to improve the safety of our patients undergoing cardiac surgery. John Nance, the lead FOCUS speaker at the 2007 SCA Annual Meeting, noted that “although individuals may make mistakes, it is possible for teams to be flawless”. The FOCUS research project was conceived with the goal to change patient care and to substantially decrease the incidence and severity of human error in the cardiac operating room through a scientific analysis leading to culture change. Following definition of the goal of the FOCUS initiative, a Request for Proposals was developed and 60 institutions submitted proposals. Through an extensive review and site visit process, the FOCUS Steering Committee has selected Dr. Peter Pronovost and his team at Johns Hopkins University to perform the research.

About Us

The Society of Cardiovascular Anesthesiologists (SCA) is the preeminent international educational organization for this sub-specialty, leading the way in treatment innovations through care, investigation, and knowledge. The SCA funds research and educational activities to enhance the care of patients with cardiovascular disease.

Public funding is not keeping pace with the advances in cardiovascular surgery. The absence of continuous advancement in medicine breeds stagnation–progress requires research. Currently studies that can improve patient quality of life often go unfunded in large part because of continuing reductions in research funding from the National Institutes of Health and other sources.

While major corporations have long recognized the importance of continuing to fund proprietary research, we need more investigation that is not driven by profitable product development or constrained by decreasing government sponsorship.