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Making a Patient Safety Program Work

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Patient Safety Program Work Karen Frush, MD Chief Patient Safety Officer Duke University Health System August 21, 2005 Making a Patient Safety Program Work: A ... – PowerPoint PPT presentation

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Title: Making a Patient Safety Program Work


1
Making a Patient Safety Program Work
  • Karen Frush, MD
  • Chief Patient Safety Officer
  • Duke University Health System
  • August 21, 2005

2
Making a Patient Safety Program Work A
Practical Approach
  • Transformation of current culture safety is at
    the center of all efforts
  • Fundamental responsibility of healthcare
    providers understand risk, accept
    responsibility for harm, lead efforts to prevent
    harm
  • Commitment and participation of all employees and
    staff is necessary to continuously improve and
    excel in safety performance

3
Duke University Health SystemPatient Safety
Program
  • A National Imperative
  • 1999 IOM Report prompted an increased national
    focus on patient safety
  • Response externally driven by media, regulators
    and consumers
  • Not specific to the institution
  • Strong sense of denial and invulnerability
    remained intact

4
Our Defining Event The Transplant
Mismatch How could this happen at Duke?
5
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6
Duke University Health System Patient Safety
Program
  • Institutional Imperative
  • February 2003 transplant mismatch provided a true
    organizational imperative for change
  • Patient Safety Program to act as a catalyst for
    the development of a culture of safety at all
    levels of patient care, from frontline providers
    to executive leadership (IOM, November, 1999)

7
What is Patient Safety?
  • In its simplest form, patient safety is
    prevention of harm to patients.

8
What is Quality?
  • Degree to which health care services increase the
    likelihood of a desired outcome
  • Appropriateness of care
  • Expected health benefits exceed expected health
    risks
  • Reasonable chance of nontrivial benefit
  • Improper not to provide the care
  • Adherence to professional standards
  • Measured in terms of performance indicators

9
Background Relationship Between Quality and
Patient Safety
Patient safety is a component under the umbrella
of clinical quality.
CLINICAL QUALITY
Patient
Patient
Centeredness
Centeredness
Institute of Medicine I (1999)
Institute of Medicine II (2001)
10
Duke University Health SystemPatient Safety
Program
  • Most errors are made by good but fallible
    people, working in a challenged and imperfect
    system.

11
Isnt it easier just to get a CT?
12
(No Transcript)
13
Making a Patient Safety Program WorkUnderstand
the Urgency
  • It wasnt one doctor, one nurse or one decimal
    pointit was a huge systems breakdown.

  • Sorrel King
  • American healthcare operates with levels of
    unreliability, injury, wasteand poor service
    that long ago became unacceptable in many other
    industries.

  • Donald Berwick, MD
  • There is a massive gap between where we are and
    where we could be.
  • Brent James, MD
  • R. Langreth Fixing
    Hospitals. Forbes, June 20, 2005. pg 68-76.

14
Making a Patient Safety Program WorkEstablish a
Culture of Safety
  • Acknowledge the ubiquity of risk, and take
    responsibility for reducing risk
  • View the recognition of errors as opportunities
    for reducing risk
  • Create a non-punitive environment for reporting
    errors actively encourage reporting of adverse
    events and near-misses
  • Develop a method to share stories and lessons
    learned

15
Making a Patient Safety Program WorkBuild an
infrastructure
  • Identify safety leaders throughout all levels of
    the organization
  • Establish multi-disciplinary local safety teams
    to identify risk and develop solutions
  • Perform safety walkrounds with executives to
    close the gap between front line and leadership
    What is the next thing that is going
    to
  • hurt a patient in this area?

16
The Johns Hopkins Comprehensive Unit-based Safety
Program
  • Evaluate culture of safety
  • Educate staff on science of safety
  • Identify defects
  • Assign executive to adopt unit
  • Learn from one defect per month
  • Evaluate culture
  • www.safetyresearch.jhu.edu

17
Safety WalkRoundsAllan Frankel, M.D.
  • A carefully choreographed discussion between
    Frontline Staff and hospital leaders, patient
    safety specialist, a scribe, and other (Managers,
    Pharmacists, Students).
  • Lasting about one hour and regularly repeated
  • As frequently as weekly, but at a minimum monthly
  • Located wherever frontline staff do their work
  • Fully supported by back office quality analysis
  • Fully integrated into Operations committees
  • Requiring rigorous application to detail in every
    step

18
Safety WalkRoundsAsking the right questions
  • How will the next patient be harmed in your
    area?
  • How does the environment fail you?
  • The last patient who was hurt as a result of how
    we delivered care what happened?
  • ...goal is openess and transparency

19
Making a Patient Safety Program WorkDesign
improvements into the system
  • Avoid reliance on memory
  • Simplify and standardize whenever possible
  • Use constraints and forcing functions
  • Promote effective team functioning, communication
  • Include patients and patient advocates in safety
    efforts and initiatives
  • Measure results, monitor progress

20
Making a Patient Safety Program WorkImprove
communication and team work
  • Promote formal teamwork training
  • Standardize Communication (SBAR)
  • Crew Resource Management
  • Assertion, psychological safety
  • Develop checklists
  • Hand-offs, procedures
  • Initiate teamwork training in professional
    schools, residency programs

21
Making a Patient Safety Program WorkInclude
patients and families
  • Establish patient advocacy groups to advise
    leaders
  • Include patients and families on safety teams, in
    safety walk rounds
  • Empower patients and families to actively
    participate in care

22
Making a Patient Safety Program WorkMeasure
results and monitor progress
  • CMS Quality Metrics
  • AHRQ Patient Safety Indicators
  • JCAHO National Patient Safety Goals
  • IHI 100,000 Lives Campaign

23
The Centers for Medicare and Medicaid Services
  • www.hospitalcompare.hhs.gov
  • Quality measures
  • Heart Attack (AMI) Care
  • Heart Failure Care
  • Pneumonia Care

24
JCAHO National Patient Safety Goals
  • Improve the safety of using medications
  • Computerized physician order entry
  • Clinical pharmacists
  • Medication reconciliation (IHI)
  • Reduce the risk of health care-associated
    infections
  • Central line-associated bloodstream infections
    (IHI)
  • Ventilator-associated pneumonia (IHI)
  • Surgical site infections (IHI)

25
Making a Patient Safety Program WorkFocus on a
few performance measures
  • External metrics
  • CMS, AHRQ, JCAHO, IHI
  • Internal metrics
  • BSC based on strategic agenda
  • Meaningful indicators for local teams
  • Actionable

26
Making a Patient Safety Program WorkImplement
change via local safety teams
  • Review risk data
  • Local and aggregate
  • Implement improvement strategies
  • Best practice
  • Customized strategies for local culture
  • Include patients and patient advocates in safety
    efforts and initiatives

27
Making a Patient Safety Program
WorkOutcomes-based Measures
  • Reduce Mortality
  • Rapid Response Teams
  • Reduce ADEs (Severity Index)
  • Objective data (automated surveillance, chart
    review)
  • Eliminate Nosocomial Infections
  • VAP bundle in ICUs
  • BSI in ICUs
  • Eliminate Perioperative Injuries
  • Wrong site surgery (Time out)
  • Surgical Site Infections

28
Making a Patient Safety Program Work
  • All hospitals and healthcare agencies should
    establish a Patient Safety Program, to act as a
    catalyst for the development of a culture of
    safety at all levels of patient care, from
    frontline providers to executive leadership (IOM,
    November, 1999)

29
Making a Patient Safety Program Work
  • Transformation of current culture safety is at
    the center of all efforts
  • Fundamental responsibility of healthcare
    providers understand risk, accept
    responsibility for harm, lead efforts to prevent
    harm
  • Commitment and participation of all employees and
    staff is necessary to continuously improve and
    excel in safety performance
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