Keeping Patients and Staff Safe

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Keeping Patients and Staff Safe Dr. Arati
Verma Sr VP-Medical Quality Co Chair, NABH
Technical Committee
Healthy Gujarat -Setting an Agenda for Actions
Gandhinagar, 3rd Dec, 2013
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The Vision
The Challenge
The Roadmap for improvement
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The Vision
The Challenge
The Roadmap for improvement
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Quality Healthcare for all
Healthcare Infrastructure
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Gujarat leading the way..Congratulations!

• A Success Story Quality Improvement Programme-
  Gujarat, India
• I
• ndias 1st NABH / NABL Accredited Govt.
  Facilities-
• Dist. General Hospital Gandhinagar
• Primary Health Centre Gadboriad,
• Dist Vadodara
• Medical College Hospital Labs Bhavanagar
• Blood Bank (BJMC Ahmadabad)
• Food Drug laboratory Badodara
• Mental Hospital Badodara
• Community Health Center, Bardoli-Surat

And we applaud the ongoing initiatives!
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Quality Benefits all Stakeholders

• Deliver the Highest Quality of Care to all our
  Patients
• Service Delight Timeliness, efficient, clean
• No harm/complications
• Cure/control of disease
• Ethical Trustworthy
• Feel safe
• Staff Satisfaction and Health
• Meet Financial Objectives
• Affordable
• Low operating costs
• Value for money
• Realization of the Vision

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Patient Centered Care
Coordination and integration of care (Team
Medicine)
Optimum Health Outcome
Information, communication and education
No harm
Shared Decision making
Transition and continuity
Value for money
Safety
Involvement of family and friends
Respect for patients values, preferences and
needs.
Physical comfort
Emotional support
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Improve at all Levels
Outcome
What is achieved
Patient staff satisfaction, Low infection
rates, good clinical outcomes
Protocols, Procedures, Treatments, Policies,
Training, Efficiency, low waste, Appropriate use
Process
What is done
Structure
Availability of Beds, OPDs, Staff, Building,
Space Equipment, Supplies, Resources, Basic
Monitoring of patients
What is needed
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Floor to Ceiling Outcomes
Aim for HUNDRED
Disease or Procedure Based Outcomes Benchmarked
with Evidence Based Practices Eg Outcomes of
Acute MI Stroke Management etc Patient
Reported Outcome Measures (PROM) Mobility,
Health Outcomes, Pain, Longevity, Functionality,
Experience etc
Ceiling
Safety and Complications Patient falls,
Hospital Acquired Infections, Pressure Sores,
Adverse Drug Events, Other Adverse Events
Floor
Aim for ZERO
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The Vision
The Challenge
The Roadmap for improvement
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Why is patient safety important?

• 1 in 10 patients admitted to hospitals will
  experience some form of unintended harm (limited
  data from low-income countries)
• An estimated 50 are preventable
• Global problem no country has solved it

Error/Event
Surgical problems
Medication Errors
Medical Errors
Patient Falls
Hospital Acquired Infections
Source World Health Organization
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1999 Institute of Medicine Report
How Hazardous Is Health Care?
9 billion in annual costs
Lucian Leape, 2/2001
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Why is Staff Safety Important?
The health care industry is one of the worldwide
largest segments of the global workforce

• World Health Organization estimates
• 9.2 million physicians
• 19.4 million nurses and midwives
• 1.9 million dentists and other dentistry
  personnel
• 2.6 million pharmacists and other
• 1.3 million community health workers

World health statistics 2011
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Healthcare Workers are exposed to many Hazards

• Common to all Clinical areas
• Bloodborne pathogens
• Airborne pathogens
• Ergonomic
• Slips, trips, falls
• Sharps
• Latex
• Fire/Electrical
• Stress

• Lab Workers
• Infectious diseases
• Chemical agents
• (formaldehyde,
• toluene, xylene)

• CSSD
• Compressed
• gases
• Anesthetic
• gases
• Chemical
• agents
• (sterilizers,
• cleaners)
• Burns, cuts

• OT
• Anesthetic gases
• Compressed
• gases
• Lasers

Radiology Radiation

• Pharmacy
• Drug absorption

• Laundry
• Contaminated laundry
• Noise
• Heat
• Lifting
• Fire hazard

• Kitchen Staff
• Food borne diseases
• Heat
• Moving machinery
• Slips, trips, falls

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What makes Healthcare Hazardous
Low Control, high uncertainty, less than ideal
work flows, Low culture of Safety Low
threshold small breakdowns may lead to
catastrophic harm
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Example Frequency and Distribution of Hospital
Acquired Infections

• A prevalence survey in 55 hospitals of 14
  countries representing (Europe, Eastern
  Mediterranean, South-East Asia and Western
  Pacific)
• Average of 8.7 of hospital
• patients had nosocomial infections
• At any time, over 1.4 million people
• worldwide suffer from infectious
• complications acquired in hospital

Increase in hospitalization 8 days Increase in
Cost, Length of stay, morbidity, mortality
Source World Health Organization
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Negative Impact

• Families
• Want justice punishment of the guilty
• Loss of trust
• Sudden Bereavement
• Earning Member
• Agony, Violence and aggression
• Cannot deal with loss
• Want compensation

• Patients/Staff
• Annoyance / Disappointment did not
• deliver on perceived promise
• Harm
• Permanent - Disability
• Death
• Additional Costs hospitalization/medicines
• Discomfort prolonged stay/distress
• Loss of ability to work/earn

• Clinicians
• Shattering Experience
• Low morale
• Loss of organizational/peer respect
• Loss of reputation
• Loss Of Career
• Criminal Charges
• Life Long Distress

• Organization
• Media Scandals
• Lose Trust of Community / Society
• Loss of reputation
• Service Disruption reduced patient flows
• Discounts
• Litigation and costs

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Adverse Events versus Errors

• Not all Adverse events are due to errors
• Not all adverse events are preventable
• Not all medical errors lead to harm

Adverse events
Errors
Mortality
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The Swiss Cheese Model of Accident Causation
(Reason, 1990)

• Excessive cost cutting staffing reduction
• Equipment shortages
• Communication
• Staff Motivation
• Divided or confused accountability

Latent Errors

• Poor compliance to policies
• Poor Coordination Communication

Policies/ Procedures
Available Resources

• Deficient training program
• Inexperienced X-Ray Tech

Barriers to Accidents
Communication

• Failed to review allergies
• Wrong X-ray marker used
• Wrong procedure performed

• Accident Injury
• Wrong Site Surgery
• Medication Error
• Fall
• Sharps injury

Failures in the System
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The Vision
The Challenge
The Roadmap for improvement
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• Culture The way we do things around here

Safety Culture Definition The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. Source Organising for Safety Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England HSE Books, 1993.
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The ultimate goal is to manage quality, but you
cannot manage it until you have a way to measure
it, and you cannot measure it until you can
monitor it.

• Florence Nightingale

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INCIDENT REPORTING Do not identify more than 10
of adverse events

• Aim is to have active surveillance to learn and
  improve
• Root Cause Analysis
• Corrective Action
• Preventive Action
• Disclosure Risks
• Blame and Punitive Threat
• Legal Immunity
• Peer Pressure Reputation, Teamwork
• Thin line between Accident, Error, Negligence
• Family Disclosure
• Media scandals

HARM
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Incident Reporting Learning from the Animal
Kingdom
What is Instinctive Behavior?
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• Protect
• Watch out
• Sense
• Report
• Guide
• Learn
• Share
• Team Behavior

Instinctive behavior is a process whereby animals
"know (without having to think about it) when to
search for food, drink water, seek safety, and
seek shelter when there is inclement weather.
Culture of Safety
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Critical success factors

• Active Participation of Doctors and Nurses
• Transparency
• Mutual trust within clinicians and staff
• Unbiased
• Culture of safety and of continuous improvement
• Openness to change
• No Blame games
• Must show improvement over time

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The Future Beckons

• Learnings from Complaints
• Adverse Event Reports Analysis
• Clinical Specialty Specific Outcomes

Powerful Drivers of Change
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• Mission, vision, values, safety goals
• High Visibility to Safety Committee Open
  support
• Accountability down the line rules and
  obligations who is meant to do what
• Allocate Resources
• Safety Culture No Blame, report
• Action Plans SOPs, Train, Monitor, Improve

• Active participation in Committees, empower
• Training
• Policies, rules,
• Obligations Speak up, raise concerns, report,
  to listen, to be aware,
• mindfulness, to work as a team player

• Articulate at every possible forum
• Candid and open feedback on incidents, data,
  survey results
• Memos, newsletters, Brochures, posters,
  conferences

• Reporting of Incidents and Near Misses
• Perform observational rounds, surveys
• Root Cause Analysis of Incidents and
  improvements
• Safe Infrastructure, equipment, medicines

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• The cycle of continuous improvement

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Let us aim to make each new day safer than
yesterday