Post on 02-Jan-2016
An Introduction to Principles of Patient
SafetyCentral Pennsylvania NANT Chapter
Spring Conference – April 15, 2012Gary Merica, R.Ph, MBA/HCM
Director, Patient Safety, WellSpan Health
Objectives
Participants will be able to: Describe the frequency with which patients suffer
unintended harm in hospitals Define a culture of patient safety, and describe
how to measure it Describe 3 significant interventions hospitals can
take to improve their culture of patient safety
Why?Numbers……………..
44,000 – 98,000 1 in 7 16 every quarter 1.7 million 99,000
……………and Names
Josie King David Milne Ben Kolb Michael Colombini
The passing of a hero in Canada
An admonition from the public
Regulatory/legal “Stuff”
Pa Act 13 Licensed practitioners required to report medical
errors and adverse events to their organization Organization must report events to the state Written disclosure letters to patients/families for
Serious Events
CMS Hospital Acquired Conditions
FOREIGN OBJECT RETAINED AFTER SURGERY
AIR EMBOLISM BLOOD
INCOMPATIBILITY PRESSURE ULCER
STAGES III AND IV FALLS AND TRAUMA
CAUTI CLABSI MANIFESTATIONS OF
POOR GLYCEMIC CONTROL
SSI DVT/PE AFTER HIP OR
KNEE REPLACEMENT
CMS Hospital Acquired Conditions
Since 10/1/08, hospitals do not receive the higher payment when: One of these conditions is present as a secondary diagnosis at
discharge And was not present on admission And results in a higher MS-DRG
In March 2011, 8 of the HACs were publicly reported on the CMS Hospital Compare website
Beginning in FFY 2015, hospitals in the worst performing quartile of HAC rates per 1000 eligible discharges will be subject to a 1% reduction in Medicare reimbursement.
Pa Act 1 of 2009: Preventable Serious Adverse Events Act
General rule: A health care provider may not knowingly seek
payment from a health payor or patient:1. For a PSAE, or
2. For any services required to treat the problem created by the PSAE when the event occurred under their control
What is a “Culture of Patient Safety”
Culture The predominating attitudes and behaviors that
characterize the functioning of an organization…or
The collective behaviors, practices, and operational standards, driven by our shared values and beliefs…or
The way we do things around here Safety
Freedom from unintended harm
Attributes of a Culture of Patient Safety
Patient centered, patient first Mutual respect Open communication Highly functioning teams Reporting and learning “Just Culture” approach to safety Peer accountability Crucial Conversations High reliability organization/practitioners
Patient CenteredMutual Respect
1. The American College of Physician Executives (ACPE) physician behavior survey:
• 38.9 percent of the respondents agreed that "physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue.”
2. “There is a difference between hospitals that take care of patients and hospitals that take care of doctors.”
3. ISMP Intimidation Survey:• 40% of clinicians failed to intervene for patient safety due to
fear of a negative encounter
Open Communication
2010 AHRQ Survey on Patient Safety Communication openness (62%)
staff will freely speak up if they see something that may negatively affect patient care (76%) Or…..24 of 100 won’t
staff feel free to question the decisions/actions of those with more authority (47%) Or….. 53 out of 100 don’t
staff are afraid to ask questions when something does not seem right (63%) Or…..37 out of 100 are
Open Communication
Crucial Conversations What makes a conversation “crucial”?
Stakes are high Opinions vary Emotions run strong
Highly Functioning Teams
Crew Resource Management SBAR Briefings/Time-outs/Debriefings Critical language Assertion Situational Awareness Checklists
Pre-procedure Briefing
Team introductions Discuss patient, case – concerns Team accountability Set stage for open communication
Procedural Time-out
Immediately before incision or start of the procedure Entire team is engaged, all activities cease (except
life support) Team positively affirms:
Correct patient Correct procedure Correct site
Note: 16 wrong site surgeries in Pennsylvania per quarter
Post-procedure De-briefing
Clinical/technical – counts, specimens, etc. How did we do? Any changes need to be made?
Peer Accountability
Peer Accountability
In the worst companies, poor performers are first ignored and then transferred
In good companies, bosses eventually deal with problems
In the best companies, everyone holds everyone else accountable – regardless of level or position
High Reliability Organizations
HROs have a preoccupation with the possibility of failure Systems fail People fail HRO’s have a “healthy” recognition of these
potential failures, and actively look to identify and mitigate them prior to patient harm
Just Culture
Why?
The single greatest impediment to error prevention is that “we punish people for making mistakes.”
Lucian Leape, MD
1/25/00 Congressional Testimony
What Does the Data Show?
2010 AHRQ Survey on Patient Safety: Non-punitive environment (44%)
staff feel like mistakes held against them (51%) Or…..49 out of 100 feel this way
feels like person being written up, not event (46%) Or….54 out of 100 feel this way
staff worry that mistakes are kept in their file (35%) Or…. 65 out of 100 worry about this
Who Supports This?
Organizations that advocate for adoption of a Just Culture: National Quality Forum – 2009 Safe Practices for Better
Healthcare: “A just culture should be fostered in which frontline personnel feel comfortable disclosing errors – including their own – while maintaining professional accountability.”
HAP – “HAP recommends that Pa hospitals and health systems strongly consider working with Outcome Engineering to implement a Just Culture model.” (12/05/08)
Who Supports This?
• Organizations that advocate for adoption of a Just Culture:• Pa Patient Safety Authority• Institute for Safe Medication Practices• Joint Commission
• Leadership Standard 03.01.01• Leaders create and maintain a culture of safety and quality throughout
the hospital• The focus of attention is on the performance of systems and
processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated.
Just Culture
Unacceptable to punish all errors and unsafe acts
Equally unacceptable to give blanket immunity to all actions that contributed to an error – evolve from “blameless”, or “non-punitive” culture
Adjust the pendulum
Reporting and Learning
Principles: Predicated on having a reporting environment in which staff
feel comfortable and safe in reporting an observed risk or a mistake.
Looks to create a well established system of accountability Recognizes that human beings are fallible, however also
recognizes that in most circumstances we have control over our behavioral choices
Just Culture
Principles (cont.): Based on “shared accountability” Two inputs into good patient care:
Good system design (management responsibility) Good behavioral choices (staff responsibility)
Measuring Patient Safety:Process, Structure, Outcome
Survey patient safety culture – process & structure National Quality Forum – Safe Practices for Better
Healthcare:
“Healthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk”
Measuring Patient Safety:Process, Structure, Outcome
Observational methodology - process Hand Hygiene – how good are we, and how do
we know? Crew Resource Management – are we just going
through the motions? ISO 9000 auditing requirements - It is considered
healthier for internal auditors to audit outside their usual management line, so as to bring a degree of independence to their judgments.
Measuring Patient Safety:Process, Structure, Outcome
AHRQ Patient Safety Indicators (PSI), CMS Hospital Acquired Conditions – outcome Preventable complications of hospital care
Iatrogenic pneumothorax HAI Blood incompatibility PE/DVT
Change?Never doubt that a small group of thoughtful,
committed citizens can change the world. Indeed, it is the only thing that ever has.
Margaret Mead