Creating a Culture of Patient Safety

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Creating a Culture of Patient Safety

• WVU Department of Family Medicine
• RCB HSC- Eastern Division
• Konrad C. Nau, MD

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We work in a complex environment
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We value quality medical care

• UHA STATEMENT OF VALUES
• We will provide high-quality service and
  responsiveness to our patients and to each other
  that exceed expectations

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We know that error happens
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We know that patient safety is the bedrock of
quality care

• Institute of Medicine Quality Care

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IOM elements of Quality

• Safe avoiding injuries to patients from the care
  that is intended to help them
• Timely reducing waits and sometimes harmful
  delays for both those who receive and those who
  give care
• Effective providing services based on scientific
  knowledge to all who could benefit and refraining
  from providing services to those not likely to
  benefit (avoiding underuse and overuse)
• Efficient avoiding waste, in particular waste of
  equipment, supplies, ideas, and energy
• Equitable providing care that does not vary in
  quality because of personal characteristics such
  as gender, ethnicity, geographic location, and
  socioeconomic status
• Patient-Centered providing care that is
  respectful of and responsive to
• individual patient preferences, needs, and
  values and ensuring that patient values guide all
  clinical decisions
• STEEEP Framework outlined by the Institute of
  Medicine (IOM)

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We preach quality but can we say we have a true
culture of safety

• Culture
• The way we do things around here
• Safety
• Avoiding injuries from care intended to help
  patients

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Can everyone in our clinic name five ways to
improve patient safety ?
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AHRQ Five Steps to Safer Health Care

• 1. Ask questions if you have doubts or concerns.
• 2. Keep and bring a list of ALL the medicines you
  take.
• 3. Get the results of any test or procedure.
• 4. Talk to your doctor about which hospital is
  best for your health needs..
• 5. Make sure you understand what will happen if
  you need surgery.

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Delivering on our Promise of Quality Medical Care
Quality Care
Patient Safety
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Patient Safety Quality Medical Care
Two fundamental questions guide us, as a
world-class academic family medicine center, and
in this order 1.How can we help the patient?
2.In doing so, what can we learn?
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Patient Safety CampaignWVU Dept Family
Medicine-East Div

• Patient Safety Kickoff
• System of Reporting and Analyzing Error
• Regular Patient Safety Grand Rounds
• Create a Culture of Safety

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Patient Safety Kickoff

• Entire office assembled off-site for lunch
  meeting January 2005
• Present Epidemiology of Medical Error
• Present Creating a Culture of Patient Safety

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System to Report and Analyze Error

• Electronic Occurrence Reporting System
• Quantros/Dr Quality/ORM
• Web based
• We encourage ALL staff to file reports online
• Patient injury
• Adverse drug reactions
• Near-misses
• Non-putative, can be filed anonymously

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https//qxpert.quantros.com/orm/jsp/JeffersonLogin
.jsp
Click here to report an occurrence (a.k.a.
variance or incident) anonymously. You do not
need a User ID or Password to do this. Please
assist us in creating a safer healthcare
environment for the customers we serve
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Resident PhysiciansReporting and Analyzing Error

• All residents are REQUIRED to self report their
  own medical errors.
• Electronic format is confidential and Peer Review
  protected.
• Encourages reflection and honesty expected in
  physicians
• Non-putative focus on systems-based analysis
• Will formulate basis of Patient Safety Grand
  Rounds topics

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Patient Safety Grand Rounds

• Bimonthly residents, faculty, students, invited
  clinic staff
• Based on residents self reported medical error
  or near miss
• Clinical case presented
• Systems-based analysis of the error
• Present patient safety literature that supports
  recommendations
• Case Report and analysis is written up and
  reviewed with Chair prior to required submission
  to AHRQ MM

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Create a Culture of Patient Safety

• Enhance clinic library with Patient Safety
  materials
• Journal of Patient Safety
• Patient Safety Quality Healthcare Journal
• Seminal textbooks
• Crossing the Quality Chasm
• To Err is Human
• Enhance clinic technology for Patient Safety
• Clinic wide Lexicomp/Drug Interaction software on
  all computers and handhelds
• Redesign Clinic Web Page
• Medication Charts
• Office Visit preparation/safety tips

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Create a Culture of Patient Safety

• AHRQ Patient Safety Culture Survey
• http//www.ahrq.gov/qual/hospculture/
• Outpatient format available in PDF or Word
• Results display template on PowerPoint
• Involve entire clinic in patient safety culture
  survey
• Patient focus groups to inform clinic about
  patient stakeholder perspectives
• Clinic leadership makes Patient Safety Rounds

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Patient Safety Culture Survey
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Overall Perceptions of Safety
Sample culture Survey result slide

Strongly Disagree/ Neither
Strongly Agree/ Disagree
Agree
Survey Items

• 1. Patient safety is never sacrificed to get
  more
• work done. (A15)
• 2. Our procedures and systems are good at
• preventing errors from happening. (A18)
• R3. It is just by chance that more serious
• mistakes dont happen around here. (A10)
• R4. We have patient safety problems in this
• unit. (A17)

R Indicates reversed-worded items. NOTE The
item letter and number in parentheses indicate
the items survey location.
Page
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Quality Primary Care for the 21st Century

• Safe Patient Care
• Consistent Best Practices
• Great Patient Service

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Ambulatory Patient Safety Culture

• Create a Culture of Safety
• Culture the way we do things around here
• Culture of Safety Requirements
• Visualize a safe system
• Non-punitive environment
• Leadership support

Quality Care
Patient Safety
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Ambulatory Patient Safety

• Capture errors that occur
• Analyze errors
• Follow-up on analysis
• Safety projects will emerge
• Medication
• EMR
• Communications
• Team work
• Test results
• Pt education about safety

Quality Care
Patient Safety
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First Class Patient Safety will require
everyones best efforts
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We need creativity
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We need enthusiasm
We need you.