Presentaci

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SIXTH ANNUAL QUALITY COLLOQUIUM AT HARVARD
PATIENT SAFETY LESSONS FROM MEXICO
Odet Sarabia González M.D. Advisor to the Vice
Ministry of Quality and Innovation Ministry of
Health Mexico August 22nd 2007.
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MEXICAN HEALTH SYSTEM Private Public
Government Provider 4000 Hospitals 3000 Public
75 beds 1000 Private 25 beds
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WHAT DO WE WANT TO CHANGE?
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PATIENT SAFETY

• Internationally bursting movement that questions
  about the kind of healthcare we provide.
• Involves all actors within the healthcare system.
• Regarded as a potentially severe and preventable
  problem, with huge economic and social impact.

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ACTIONS ON PATIENT SAFETY

• National Crusade for Quality in Health Care
• Patient Safety Crisis Management Manual
• Pilot Sensitization Workshop-Course in Morelos
• Sensitization workshop course
• Logotype
• 10 Actions on patient safety
• Knowledge spreading tri-monthly patient safety
  bulletins
• Patient safety indicators
• National Sentinel Event Reporting and Learning
  System
• Research Protocols
• Inclusion in the National Healthcare Program

2001 2003 2005 2007
New government
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WORKSHOP ESTRUCTURE

• EIGHT STEPS FOR THE ORGANIZATIONAL CHANGE
• Instill the sense of urge.
• Create an oriented coalition.
• Develop a vision and a strategy.
• Communicate the vision of change.
• Empower for action a wide base.
• Generate quick triumphs.
• Consolidate the gains and generate more changes.
• Implant the new approaches on the culture.
• John P. Kotter

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ACTION LINES

• MORELOS PILOT STUDY
• Global rating of the patient safety climate 62.61
  (SD 21.01, CI 3.57 92.85) to 71.89 (SD 21.14,
  CI 10.71-100) (p 0.01).
• Individuals with a satisfactory perception of the
  patient safety climate increased from 37.5 to
  60.66 (p 0.01).

37.50 to 60.66
62.61 to 71.89
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ACTION LINES
WORKSHOP-COURSE ON PATIENT SAFETY EXTENDED TO 32
STATES AND PUBLIC HEALTH SECTOR

• WORKSHOP-COURSE ON PATIENT SAFETY
• 32 COUNTRY STATES
• ISSSTE. (Government employees).
• SEDENA. (Defense Secretary).
• MARINA.(Navy).
• PEMEX. (Oil Agency).
• 2 Federal Reference Hospitals.
• 1 National Institute.

2004
SIC 46 hospitals / 565 attendance TT 207 (Train
the Trainers) Cascade reproduction 189
hospitals 20,070 total attendance
2006
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ACTION LINES
2005
Medical Staff
Triangular shaped International warning sign Co
responsibility between Healthcare Institutions,
Medical Staff and Patient
Patient
Safety pin
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ACTION LINES

2005
Based on the Joint Commission Patient Safety
Goals
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ACTION LINES
http//innovacionycalidad.salud.gob.mx/10pasos.php
2005
2007
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ACTION LINES
2005

• Reports until July 24th 2007 875
• States 11
• Exponential reporting (Last month 150 reports)

2007
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ACTION LINES
SinRAECe-Example Follow up Two Years at Two
General Hospitals
Adverse Events Comparison Between Hospitals Adverse Events Comparison Between Hospitals Hospital A Hospital B

Shift where the adverse events occurred Morning 75.30 58.15
Shift where the adverse events occurred Afternoon 12.05 23.67
Shift where the adverse events occurred Others 12.65 17.88
Services where the AE took place ICU 24.70 16.27
Services where the AE took place ER 7.83 40.36
Services where the AE took place Surgery 22.89 12.65
Services where the AE took place Internal Medicine 10.84 20.48
Services where the AE took place Others 33.74 10.24
Sort of Adverse Event In hospital infections 57.83 4.83
Sort of Adverse Event Sentinel Events 16.27 43.96
Sort of Adverse Event Others 25.90 51.21
2004
2006
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ACTION LINES
SinRAECe-Example Follow up Two Years at Two
General Hospitals
Adverse Event Comparison Between Hospitals Hospital A Hospital B
Adverse events causing lengthening of hospital stay 63.86 28.02
Average of additional days In hospital stay 9.19 4.33
Adverse events experienced at working age (18 to 65 ) 74.10 64.25
Patients or relatives not informed that an adverse event took place 87.95 71.98
Sentinel Events-Medication Errors 13.86 20.09
Cases where the hospital took measures to prevent the adverse event from happening again 48.80 97.10
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ACTION LINES

• Study with the CONAMED (Medical Arbitration
  Commission)
• Align actions with the CSG (General Health
  Council)
• Reinforce accreditation focusing on Patient
  Safety
• Prevalence study of adverse events at two general
  hospitals

2006
Inclusion in the National Health Program
2007-2012
2007
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INTERNATIONAL ACTION LINES
IBEAS STUDY

• World Alliance for Patient Safety, WHO, Health
  and Consumption Ministry of Spain
• Measurement study of the prevalence of adverse
  events in five countries of the Middle and South
  America Region.
• Get to know the problems magnitude.
• Sensitization about the problem with hard data.
• Argentina
• Colombia
• Costa Rica
• México
• Perú

2007
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INTERNATIONAL ACTION LINES
2006

• Start of the IBEAS study at 6 hospitals
• IBEAS study extended to
• 1 hospital per State (previously trained on
  patient safety)

2007
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INTERNATIONAL ACTION LINES
WHO World Alliance for Patient Safety in
America First World Challenge Clean Care is
Safer Care Signing of the statement between
Health Ministry and WHO Canada (October
2006) USA (November 2006) Costa Rica (March
2007) México (September 2007) 2 Regional
signatures México (Mexico and Central
America) Uruguay (South America)
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LESSONS LEARNT

1. The commitment should be from the highest
   hierarchy down to the patient himself.
2. To sensitize the healthcare personnel of all
   levels is a priority.
3. Basic education and training in patient safety
   must be started over periodically.
4. Team training (CEOs, management team) has
   demonstrated better results than isolated
   individuals.

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LESSONS LEARNT

1. Even when actions that lead to patient safety
   initially imply additional workload (change of
   procedures, verification of routines, learning),
   once the people has realized that benefits of the
   safety attitude are real, they become
   enthusiast promoters of the subject themselves.
2. A project that involves cultural change like
   patient safety, sooner or later delivers positive
   results when the seed has been sowed widely among
   the healthcare providers.
3. Successful Hospitals are those who have given
   continuity to training, for instance, facing
   staffs rotation they have to be trained before
   assuming their new posts (even the director).

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LESSONS LEARNT

1. The communication line must be clear, functional
   and well established, from the responsible of the
   patient safety program at the national level down
   to the operative levels of each hospital unit.
2. No matter where we are, or who are we talking to,
   our enthusiasm and conviction must always be
   evident, even when discussing the hardships of
   the project or recognizing the difficulties of a
   particular task.

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LESSONS LEARNT

• Resources are greatly needed, not so much in the
  form of expensive, state of the art equipment and
  gizmos, but rather in preventive maintenance,
  basic structure, education and continuous support
  for training, policy making and promotion
  campaigns.
• There ought to be a well planned and labeled
  budget for Patient Safety.
• The structure that supports the Patient Safety
  Strategy has to be rational according to the
  expected outcomes.
• It is desirable to count with a patient safety
  office on each and every hospital unit.

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LESSONS LEARNT

• Authorities ought to be extra careful assigning
  responsibilities and leading posts.
• Healthcare providers should speak out when they
  have concerns regarding Patient safety and listen
  when their peers have them as well.
• Involving medical, nursing students and
  residents, has been of great help, since they
  possess great enthusiasm and are the systems
  future.

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LESSONS LEARNT

1. A non punitive adverse event reporting system is
   necessity if we are to learn from the errors
   within our healthcare institutions. Even when the
   flow of reports might be slow at first, one has
   to patiently wait in order to gain trust and
   confidence from healthcare professionals.
2. The outcome of the waiting time (maturation
   process), is always a flow of precious data that
   enables the healthcare system to know how to deal
   with bad habits or get rid of the institutions
   flaws that have been unnoticed for long.
3. Improvement efforts should focus on fixing the
   systems failures, not in blaming healthcare
   providers.
4. All of us have a responsibility within the system
   where we work at.

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A CHAIN IS JUST AS STRONG AS ITS WEAKEST LINK
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THANK YOU osarabia_at_salud.gob.mx