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Patient Safety Strategies for Improving Quality

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Title: Patient Safety Strategies for Improving Quality Author: SDPS Last modified by: Leigh Created Date: 6/23/2010 2:17:26 AM Document presentation format – PowerPoint PPT presentation

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Title: Patient Safety Strategies for Improving Quality


1
Patient Safety Strategies for Improving Quality
  • Kelly Shipley, RHIA
  • QI Director
  • ESRD Network of Texas

2
Objectives
  • Distinguish the relationship between quality and
    patient safety
  • Describe the steps in implementing a patient
    safety program
  • Apply patient safety improvement tools in a
    dialysis environment

3
Definition of Healthcare Quality
  • Quality of care is the degree to which health
    services for individuals and populations increase
    the likelihood of desired outcomes and are
    consistent with current professional knowledge.

Institute of Medicine
4
Quality Patient Safety
  • Hippocrates As to diseases make a habit of two
    things - to help, or at least, to do no harm.
    Epidemics I

Quality to Help
Safety Do No Harm
5
A Business Case for Patient Safety
  • Cost of Quality
  • Cost of Errors

Formulas to show how actions can pay off Formulas to show how actions can pay off
AC AVERAGE COST sum of event costs/number of events
BCR BENEFIT-COST RATIO cost avoided/cost of intervention
CER COST-EFFECTIVENESS RATIO cost of intervention/ of prevented events
CS COST SAVINGS ( of avoided events) X (average cost per event) (cost of intervention)


VHA, Root Cause Analysis i Improvement in
the Healthcare Sector, ASQ
6
Deadly Results
Medical Errors may be fifth leading cause of
death 1
Medical Errors Third leading cause of death 2
Institute of Medicine/CDC 1997 1 JAMA, 2000 2
7
Recommendations to Pursue Patient Safety
Initiatives that Prevent Medical Injury
Tactics Accountability
Support teamwork through Crew Resource Management Educators, medical staff, nursing and health care leaders
Encourage appropriate adherence to clinical guidelines to improve quality reduce liability risk Medical staff health care leaders, medical processional societies, health care purchasers payers

Continue to leverage pt. safety initiatives via regulatory/oversight bodies Accrediting, licensing regulatory bodies, PSOs, purchasers payers
Leverage the creation of cultures of patient safety in health care org. Administrators, medical and nursing leaders
P4P strategies provide incentives to focus on improvements in pt. safety health care quality CMS and private-sector healthcare purchasers and payers
Health Care at the Crossroads Strategies for
Improving the Medical Liability System and
Preventing Patient Injury, Joint Commission
8
Improvement Efforts Must Be..
Crossing the Quality Chasm A New Health System
for the 21st Century, IOM
9
Patient Safety Culture
  • Just Culture vs Blame or No Blame Culture
  • People make errors, which lead to accidents.
    Accidents lead
  • to deaths. The standard solution is to blame the
    people
  • involved. If we find out who made the errors and
    punish
  • them, we solve the problem, right?
  • Wrong. The problem is seldom the fault of an
  • individual it is the fault of the system. Change
  • the people without changing the system and the
  • problems will continue. Don Norman, The Design
    of Everyday Things

The Just Culture Community, Natl Patient Safety
Foundation
10
Patient Safety Culture Where do we stand?
  • Health Safety Survey to Improve Patient Safety
    in ESRD
  • (RPA)
  • Patients
  • Professionals
  • Hospital Survey on Patient Safety Culture - an
    assessment
  • tool from Agency for Healthcare Research and
    Quality
  • (AHRQ)
  • Joint Commission, Leapfrog Survey, NQF
  • Discussing Reporting Events
  • Near Miss, Close Calls, Sentinel Events,
  • Adverse Events
  • Mandatory versus voluntary reporting
  • Disclosure

11
Health and Safety Survey to Improve Patient
Safety in ESRD
RPA, March 2007
12
Patient Safety Culture
SECTION C Communications How often do the
following things happen in your work area/unit?
Mark your answer by filling in the circle.
Think about your hospital work area/unit Never? Rarely? Some-times? Most of the time? Always?
1. We are given feedback about changes put into place based on event reports ? ? ? ? ?
2. Staff will freely speak up if they see something that may negatively affect patient care ? ? ? ? ?
3. We are informed about errors that happen in this unit ? ? ? ? ?
4. Staff feel free to question the decisions or actions of those with more authority ? ? ? ? ?
5. In this unit, we discuss ways to prevent errors from happening again ? ? ? ? ?
6. Staff are afraid to ask questions when something does not seem right ? ? ? ? ?
13
CMS Conditions for Coverage for ESRD
Facilities 494.110 Condition Quality
assessment and performance improvement.
  • (a) Standard Program scope.
  • (1) The program must include, but not be limited
    to, an ongoing program that achieves measurable
    improvement in health outcomes and reduction of
    medical errors by using indicators or performance
    measures associated with improved health outcomes
    and with the identification and reduction of
    medical errors.

14
CMS Conditions for Coverage for ESRD Facilities
494.110 Condition Quality assessment and
performance improvement.
  • (2) The dialysis facility must measure, analyze,
    and track quality indicators or other aspects of
    performance that the facility adopts or develops
    that reflect processes of care and facility
    operations. These performance components must
    influence or relate to the desired outcomes or be
    the outcomes themselves. The program must
    include, but not be limited to, the following
  • (vi) Medical injuries and medical errors
    identification.

15
CMS Conditions for Coverage for ESRD Facilities
494.110 Condition Quality assessment and
performance improvement.
  • (c) Standard Prioritizing improvement
    activities. The dialysis facility must set
    priorities for performance improvement,
    considering prevalence and severity of identified
    problems and giving priority to improvement
    activities that affect clinical outcomes or
    patient safety. The facility must immediately
    correct any identified problems that threaten the
    health and safety of patients.

16
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17
Planning for Patient Safety
  • Assess
  • Leadership Commitment
  • Current environment
  • Have to or want to?
  • System
  • Who, What, When, Where, How
  • Flowchart
  • Data Management
  • Reporting, Responding, Proactive vs Reactive
    Analysis
  • Improvement
  • Communication
  • Training, Education
  • Patient Involvement
  • Disclosure

18
Communication
  • Resources
  • Patient involvement examples
  • Disclosure

19
Patient Safety Analysis
  • Concepts
  • Sharp end vs Blunt end
  • Swiss Cheese Model
  • Human Behavior Model
  • Analysis
  • Root Cause Analysis (RCA)
  • Failure Modes Effects Analysis (FMEA)
  • Hardwiring for safety
  • Reminder Systems vs Equipment Design
  • Checklists
  • CQI Tools

20
Sharp End vs Blunt End
Sharp-Active
  • Error Categories
  • Active Errors or Failures
  • Point of contact with patient
  • Generally readily apparent
  • Involve frontline staff
  • Sharp End errors
  • Latent Errors or Conditions
  • Less apparent failures that contribute to error
    downstream
  • Removed from direct patient care processes
    that support care
  • Blunt End errors

Blunt-Latent
21
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22
Medication Administration
  • Sharp End Active Failures
  • nurse administers wrong med
  • nurse administers med to wrong patient
  • anesthesiologist administers wrong drug through
    unlabeled syringe

Sharp End Immediate Cause(s)
Contributing Factors
  • Blunt End Latent Failures
  • incomplete pt info
  • unclear communication of drug order
  • no independent double checks
  • lack of computer warnings
  • drug storage issues
  • unclear policies procedures

Blunt End Root Cause(s)
23
Complex System Latent Failure Model
Incomplete procedures
Deferred maintenance
Inadequate Training Supervision
LATENT FAILURES
Propaganda Missions?
Attention distractions
Triggers
Timepressures
Broken Monitor
Challenge Authority?
Responsibility shifting
The World
Accident
Team
Institution
Individual
Technical
Organization
Profession
DEFENSES
24
Reason, J., Managing the Risks of Organizational
Accidents
25
Root Cause Analysis
  • Process for identifying the basic or causal
    factors that underlie variation in performance,
    including the occurrence or possible occurrence
    of sentinel events
  • A root cause is the most fundamental reason for
    the failure of a process
  • The goal of RCA is to find out
  • What happened?
  • Why did it happen?
  • What do you do to prevent it from happening
    again?

26
Characteristics of an acceptable RCA
  • Focuses primarily on systems processes, not
    individual performance
  • Progresses from special causes in clinical
    processes to common causes in organizational
    processes
  • Repeatedly digs deeper by asking Why Then, when
    answered, asks Why? again and again
  • Identifies changes that could be made in systems
    processes that would reduce the risk of such
    events occuring in the future
  • Is thorough and credible

27
The Quest for Why?
  • Problem Statement
  • You are on your way home from work and your car
    stops in the middle of the road.
  • Why did your car stop?
  • Because it ran out of gas
  • Why did it run out of gas?
  • Because I didnt buy gas on my way to work
  • Why didnt you buy gas in the morning?
  • Because I didnt have any money
  • Why didnt you have any money?
  • Because I lost it all last night in a poker game
  • Why did you lose your money in last nights poker
    game?
  • Because Im not very good at bluffing when I
    dont have a good hand

28
Root Cause Analysis
  • Insert graph from JC of most common root causes

29
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30
RCA Tool
  • RCA reporting tool
  • Dialysis sent event or near miss case scenarios
  • (Audience participation)

31
  • Action plan is key!

32
FMEA Failure Modes Effects Analysis
A systematic, structured approach to process
improvement in the design and process development
stage through identifying ways that a process can
fail, why it might fail, and how it can be made
safer.
33
What is a FMEA?
  • Origin - aerospace industry in 1960s
  • Key tool for improving safety
  • Goals prevent defects, enhance safety,
    increase customer satisfaction.
  • Standardized approach
  • Proactive approach vs. reactive response
  • Another tool to add to your
  • PI toolkit

34
FMEA Steps Select a Process
  • Criteria
  • High Risk
  • High Cost
  • Problem Prone
  • Low Volume
  • Staff Physician input, Committees
  • Sources Sentinel Event Alert, ISMP
  • Industry news Cedars-Sinai Hospital, Christus
    Spohn Hospital South

35
FMEA Steps Select a Process
Number of reported Sentinel Events related to Anticoagulants 1997 2007 Number of reported Sentinel Events related to Anticoagulants 1997 2007 Number of reported Sentinel Events related to Anticoagulants 1997 2007 Number of reported Sentinel Events related to Anticoagulants 1997 2007
Drug Involved Cause Of Event
Heparin 21 Wrong Drug 3
Warfarin 6 Wrong Dose 7
Enezapron 3 Improper Monitoring 9
Unknown 2 Pump Malfunction/Error 5
Outcome of Patients Given without order 2
Death 28 Not reordered 2
Loss of Function 6 Unknown 4
Joint Commission SE database
36
FMEA Steps Assemble Team
  • Facilitator
  • Team members closest to the process
  • Content expert member(s), ad-hoc

37
FMEA Step Identification of Failure Mode, Cause
Effect
  • Failure Mode -ways in which a process could
    break down or fail to perform
  • Cause why the failure mode occur
  • Effect what could happen if a failure mode
    occurred

FAILURE MODE EFFECT
Wrong drug/route/form of administration on physician order Inaccurate clinical data B, T, D, ADR
Wrong administration times selected in Rx Delayed therapy omission
Misprogram pump Overdose subtherapeutic dose B, T, D, ADR
38
FMEA Step Evaluate Risk or Criticality
  • Assign Severity rating the consequence of the
    failure should it occur.
  • Assign Occurrence rating the probability or
    frequency of the failure occurring.
  • Assign Detection rating the probability of
    the failure being detected before the impact of
    the effect is realized.

39
FMEA Worksheet
Processes Sub-processes Failure Modes Causes Effects Severity Rating Occurrence (Probability) Rating Detection Rating Critical Index
A. Prescribing A. Prescribing A. Prescribing A. Prescribing A. Prescribing A. Prescribing A. Prescribing A. Prescribing
Physician prescribes order failure to initiate standard order set/preprinted order no pre-existing order set, not followed/ dont agree w/protocols, numerous modifications therapy may not meet the standard of care B,T,ADR, D 10 6 6 360
pre-printed orders incomplete no standard process for making selections on forms, human factors therapy may not meet the standard of care, wrong drug/dose ferquency 10 3 2 60
40
FMEA Step Prioritize Failure Modes
  • Criticality Index (CI) score used
  • (severity rating x occurrence rating x
    detection rating)
  • Evaluation of Failure Modes with High CI
  • Order Failure Modes
  • Preparing Drug
  • Pump Failure Modes (programming, rate
  • changes, equipment design)
  • Administration Documentation Verification

41
FMEA Step Identify Risk Reduction Strategies
Implement
42
Resources
43
Do you have all your ducks in a row?
44
Questions
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