1© 2010 TMIT

NQF-Endorsed®

Safe Practices for Better Healthcare

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD000000-0000XX 2© 2010 TMIT

Slide Deck Overview

Slide Set Includes:

Section 1: NQF-Endorsed® Safe Practices for Better Healthcare Overview

Section 2: Harmonization Partners Section 3: The Problem Section 4: Practice Specifications Section 5: Example Implementation Approaches Section 6: Front-line Resources

3© 2010 TMIT

NQF-Endorsed®

Safe Practices for Better HealthcareOverview

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

4© 2010 TMIT

2010 NQF Safe Practices for Better Healthcare: A Consensus Report

34 Safe Practices

• Criteria for Inclusion

• Specificity

• Benefit

• Evidence of Effectiveness

• Generalization

• Readiness

5© 2010 TMIT

Culture SP 1

2010 NQF Report

CHAPTER 7: Healthcare-Associated Infections• Hand Hygiene• Influenza Prevention• Central Line-Associated Blood Stream Infection

Prevention • Surgical-Site Infection Prevention• Daily Care of the Ventilated Patient• MDRO Prevention• Catheter-Associated UTI Prevention

Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition- and Site-Specific Practices

Consent & Disclosure

Wrong-siteSx Prevention

Press. Ulcer Prevention

VTE Prevention

Anticoag. Therapy

VAP Prevention

Central Line-Assoc.BSI Prevention

Sx-Site Inf.Prevention

Contrast Media Use

Hand HygieneInfluenza

Prevention

Pharmacist Leadership Structures and Systems

Med. Recon.

Culture

CPOE

Read-Back & Abbrev.

Discharge Systems

PatientCare Info.

LabelingDiag. Studies

Culture Meas.,FB., and Interv.

Structuresand Systems

Risk and HazardsTeam Trainingand Skill Bldg.

Nursing Workforce

ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care

CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]

Culture of Safety Leadership Structures and Systems Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Risks and Hazards

CHAPTER 5: Information Management and Continuity of Care

Patient Care Information Order Read-Back and Abbreviations Labeling Diagnostic Studies Discharge Systems Safe Adoption of Computerized Prescriber Order Entry

CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Leadership Structures and Systems

CHAPTER 8: Condition- and Site-Specific Practices• Wrong-Site, Wrong-Procedure, Wrong-Person

Surgery Prevention • Pressure Ulcer Prevention• VTE Prevention• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention• Organ Donation• Glycemic Control• Falls Prevention• Pediatric Imaging

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver

Consent and Disclosure

Care of Caregiver

MDROPrevention

UTIPrevention

FallsPrevention

OrganDonation

GlycemicControl

PediatricImaging

7© 2010 TMIT

Harmonization Partners

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

8© 2010 TMIT

Harmonization – The Quality Choir

9© 2010 TMIT

The Patient – Our Conductor

© 2006 HCC, Inc. CD000000-0000XX 10© 2010 TMIT

The Objective

Risks and Hazards

Ensure that patient safety risks and hazards are continuously identified and communicated to all levels of the organization, that mitigation activities are aggressively undertaken to minimize harm to patients, and that patient safety information is communicated to the appropriate external organizations.

[Institute for Healthcare Improvement, How to Improve: Medication Systems, N.D.; Pizzi, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, 2001]

11© 2010 TMIT

The Problem

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD000000-0000XX 12© 2010 TMIT

The Problem

13© 2010 TMIT

[http://online.wsj.com/article/SB123491688329704423.html]

14© 2010 TMIT

[http://www.timesonline.co.uk/tol/news/uk/article468980.ece]

15© 2010 TMIT

[http://www.myfoxny.com/dpp/health/091226_near_miss_registry]

16© 2010 TMIT

[http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Jul/Why-Not-the-Best--Results-from-the-National-Scorecard-on-U-S--Health-System-Performance--2008.aspx]

© 2006 HCC, Inc. CD000000-0000XX 17© 2010 TMIT

The Problem

Frequency

Medical errors have been associated with subsequent personal distress, decreased empathy, and increased probability of making another medical error

Risk mitigation is typically not integrated across an organization

Clinicians significantly underreport medical errors A culture of name, blame, and shame behaviors and

the fear of malpractice liability have been major barriers to performance improvement

Zero must be the goal for adverse events[West, JAMA 2006 Sep 6;296(9):1071-8; Kaldjian, J Gen Intern Med 2007 Jul;22(7):988-96; Kaldjian, Arch Intern Med 2008 Jan 14;168(1):40-6; The Joint Commission, 2009 Accreditation Requirements Chapter, 2009]

© 2006 HCC, Inc. CD000000-0000XX 18© 2010 TMIT

The Problem

Severity

The severity of harm due to the absence of coordinated patient safety programs cannot be accurately estimated

However, recent studies have shown that as many as 15% of Medicare beneficiaries experience serious harm in hospitals

Readmission and mortality rates of seniors after acute care hospital admissions may be much higher than previously presumed

[Boutwell, Reducing Re-hospitalizations in a State or Region: Minicourse M1, 2008; Levinson, Office of Inspector General. Adverse events in hospitals: overview of key issues, 2008; Denham, J Patient Saf 2009 Mar;5(1):42-52]

© 2006 HCC, Inc. CD000000-0000XX 19© 2010 TMIT

The Problem

Preventability

Healthcare organizations can identify and mitigate patient safety risks and hazards by using a number of internal methods

Patient safety organizations that provide federal protection of information should increase the sharing of adverse event information and lessons learned

Supply adequate resources to cover the cost of strategies regularly evaluated for effectiveness

[Helmreich, BMJ 2000 Mar 18;320(7237):781-5; Carthey, Qual Health Care 2001 Mar;10(1):29-32; Marx, Qual Saf Health Care 2003 Dec;12 Suppl 2:ii33-8; Wreathall, Qual Saf Health Care 2004 Jun;13(3):206-12; Milch, J Gen Intern Med 2006 Feb;21(2):165-70; Centers for Medicare & Medicaid Services, Hospital Conditions of Participation: Patients’ Rights, 2008]

20© 2010 TMIT

Practice Specifications

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD000000-0000XX 21© 2010 TMIT

Additional Specifications

© 2006 HCC, Inc. CD000000-0000XX 22© 2010 TMIT

Safe Practice Statement

Identification and Mitigation of Risks and Hazards

Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm.

© 2006 HCC, Inc. CD000000-0000XX 23© 2010 TMIT

Additional Specifications

Risk and Hazard Identification Activities

Risks and hazards should be identified on an ongoing basis from multiple sources

The risk and hazard analysis should integrate the information gained from multiple sources to provide organization-wide context

The organizational culture should be framed by a focus on system (not individual) errors and blame-free reporting, and should use data from risk assessment to create a just culture

[Institute of Medicine, Patient Safety: Achieving a New Standard for Care, 2004; Agency for Healthcare Research and Quality, National Healthcare Disparities Report 2008, 2009; Nuckols, Jt Comm J Qual Patient Saf 2009 Mar;35(3):139-45; Pronovost, Clin Chest Med 2009 Mar;30(1):169-79]

© 2006 HCC, Inc. CD000000-0000XX 24© 2010 TMIT

Additional Specifications

Retrospective Identification

Use a number of retrospective measures and indicators to identify risk from historical data

Specific steps should be taken to ensure that the lessons learned are communicated across the organization and applied in other care settings

Some retrospective identification and analysis activities are triggered by adverse events

Retrospective identification of risks and hazards should occur regularly, and progress reports should be generated as frequently as needed

[Nuckols, Jt Comm J Qual Patient Saf 2009 Mar;35(3):139-45]

© 2006 HCC, Inc. CD000000-0000XX 25© 2010 TMIT

Additional Specifications

Real-Time and Near Real-time Identification

Evaluate real-time or near real-time tools for their value in risk identification for the areas of high risk

Consider using trigger, observational, and technology tools

A structured, proactive risk assessment should be undertaken to identify risks and hazards in order to prevent harm and error

Evaluate the prospective or proactive tools and methods in order to identify risks

[Institute of Medicine, Patient Safety: Achieving a New Standard for Care, 2004; Alemi, Qual Manag Health Care 2007 Oct-Dec;16(4):300-10; Hovor, Qual Manag Health Care 2007 Oct-Dec;16(4):349-53; Adler, J Patient Saf 2008 Dec;4(4):245-9; Emily, Risk Anal 2009 Apr;29(4):565-75; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010]

© 2006 HCC, Inc. CD000000-0000XX 26© 2010 TMIT

Additional Specifications

Integrated Organization-Wide Risk Assessment

The systematic integration of information about risks and hazards across the organization should be undertaken to optimally prevent systems failures At least annually, create frequent progress and summary of reports annually for risk management, complaints/customer service, disclosure support, culture measurement, and other informationInformation should be provided to the governance board and senior administrative leadership continually

[Centers for Disease Control and Prevention, Emergency Preparedness and Response, N.D.; Centers for Disease Control and Prevention, Pandemic Influenza Resources; N.D.; APIC, Pandemics, 2008; Boothman, Journal of Health & Life Sciences Law 2009 Jan;2(2):125-59; Chiozza, Clin Chim Acta 2009 Jun;404(1):75-8; McDonald, Full Disclosure and Residency Education, 2008]

© 2006 HCC, Inc. CD000000-0000XX 27© 2010 TMIT

Additional Specifications

Risk Mitigation Activities

Every organization has a unique risk profile and should carefully design performance improvement projects that target prioritized risk areas

Performance Improvement Programs

Organizations should provide documentation of performance improvement programs

[Denham, J Patient Saf 2005 Mar;1(1):41-55; Pronovost, Health Aff (Millwood) 2009 May-Jun;28(3):w479-89; Damiani, Med Sci Monit 2009 Jul;15(7):RA157-66; Denham, J Patient Saf 2009 Sep;5(3):188-96; Wayre, Healthc Financ Manage 2009 Jan;63(1):86-91; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010]

© 2006 HCC, Inc. CD000000-0000XX 28© 2010 TMIT

Additional Specifications

Specific Risk-Assessment and Mitigation Activities

Organizations should document evidence of high performance or actions taken to close common patient safety gaps for the patient safety risk areas, such as:

Falls Malnutrition Pneumatic Tourniquets Aspiration Workforce Fatigue

[Weingart, Jt Comm J Qual Patient Saf 2009 Apr;35(4):206-15; Yeo, JAMA 2009 Sep 23;302(12):1301-8; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook 2010]

29© 2010 TMIT

Example Implementation Approaches

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD000000-0000XX 30© 2010 TMIT

Example Implementation Approaches

© 2006 HCC, Inc. CD000000-0000XX 31© 2010 TMIT

Example Implementation Approaches

Have the organization’s leaders partner with front-line caregivers to design a path for the adoption of this safe practice’s activities

Periodically assess tools used for prospective, near real-time, and retrospective risk identification and mitigation

New risk identification opportunities are presented through the use of evolving trigger tools, such as the Global Trigger Tool

Evaluate the risk areas identified by purchasers to be high priority to them

[Centers for Disease Control and Prevention, Legionellosis Resource Site (Legionnaires' Disease and Pontiac Fever), N.D.; Centers for Medicare & Medicaid Services, CMS Proposes to Expand Quality Program for Hospital Inpatient Services in FY 2009, 2008; Centers for Medicare & Medicaid Services, Hospital-Acquired Conditions Overview, 2008; Mills, Qual Saf Health Care 2008 Feb;17(1):37-46; Percarpio, Jt Comm J Qual Patient Saf 2008 Jul;34(7):391-8; Wu, JAMA 2008 Feb 13;299(6):685-7; Griffin, IHI Global Trigger Tool for Measuring Adverse Events (Second Edition), 2009]

© 2006 HCC, Inc. CD000000-0000XX 32© 2010 TMIT

Example Implementation Approaches

Strategies of Progressive Organizations

Some organizations have declared that governance board members must spend equal time in meetings and activities on financial issues and quality/safety issues

Organizations have embraced patient safety and risk reduction as their primary competitive initiatives

High-performing organizations provide feedback to staff on improvements that resulted from adverse event reporting

[McDonald, Full Disclosure and Residency Education; 2008; Gallagher, JAMA 2009;302(6):669-77; McDonald, Responding to Patient Safety Incidents: The Seven Pillars; 2009]

33© 2010 TMIT

Front-line Resources

Safe Practice 4Risks and Hazards

Chapter 2: Improving Patient Safety by

Creating and Sustaining a Culture of Safety

34© 2010 TMIT

35© 2010 TMIT

The 3 Ts of Leadership Engagement:Truth, Trust, and Teamwork

Charles Denham

36© 2010 TMIT

Poster available in Spanish[http://www.jointcommission.org/PatientSafety/SpeakUp/]

© 2006 HCC, Inc. CD000000-0000XX 37© 2010 TMIT

NQF & TMIT National Webinar Series

Leadership and Leadership Principles forSafety (Safe Practices 1-4)

Charles R. Denham, MD – Leadership and Culture Practices: New Roles for Leaders

Peter B. Angood, MD – Important National Highlights Regarding Leadership and Culture

James Conway, MS – Bringing Boards On-board: Critical Issues in 2009

Dan Ford, MBA – Patient Perspective on Medication Management Safe Practices

Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4942 (July 16, 2009)