7 steps to Patient Safety.ppt

8/10/2019 7 steps to Patient Safety.ppt

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Patient Safetyand Quality of Care

Rapat Kordinasi Instalasi RSK Mojowarno


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Seven steps to patient safety

1. Build a safety culture2. Lead and support your staff (Professional

Development)3. Integrate your risk management activity4. Clinical performance & audit5. Involve patients and the public6. Learn and share safety lessons7. Implement solutions to prevent harm



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Step 1Build a safety culture Action points

For you r o rgan i sat i on : ensure your policies state what staff should do following an incident, how it should be investigated , and what support should be given topatients, families and staff; ensure your policies describe individual roles and accountability for when things go wrong; assess your organisations reporting and learning culture using a safety assessment survey (see Resources from the NPSA on page 10).

For you r t eam:

ensure your colleagues feel able to talk about their concerns and report when things go wrong; demonstrate to your team the measures your organisation takes toensure reports are dealt with fairly and that the appropriate learningand action takes place .


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1. Build a safety culture

Operations

Demonstrate top leadership commitment to safety

Communications

Multidisciplinary teamwork



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Operations

Trust-beyond blame

Incident Report Check list Cross / double check

Update and socialize procedure Inspecting system Identification label



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Operations

Signage

Practicing standard precaution (hand hygiene practices)

Implementation for PPM (Plan Preventive Maintenance) forBio-Medical Equipments



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Operations

Staff Competency the right man for the right task Identification Label

Design & Safety Layout Alarm System



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Step 2Lead and support your staffAction points

For you r o rgan i sa ti on : ensure there is an executive board member with responsibility for patient safety; identify patient safety champions in each directorate, division or department;

put patient safety high on the agenda of board or management team meetings; build patient safety into the training programmes for all your staff and ensure this training is accessible and measure its effectiveness.

For you r t eam:

nominate your own champion or lead for patient safety; explain the relevance and importance of patient safety to your team, and the benefits it brings; promote an ethos where all individuals within your team are respected and feel able to challenge when they think something may be goingwrong.


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2. Lead and support your staff(Professional Development)

Operations

Evidence based skills training Postgraduate training Hospital credentialing policy

Indemnity Nurse training in collaboration with ECU



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2. Lead and support your staff(Professional Development)

Operations Staff training

Safety & quality training

Appraisal system (reward & punishment) Rotation within departments Daily briefings Staff counseling Career ladder



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2. Lead and support your staff

(Professional Development)

ExpectedOutcomes

Clinician credentialing and re-credentialing Improved professional development and skills

training for workforce Improved performance management Improved staff satisfaction

Improved patient outcomes



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3. Integrate your risk management activity

Operations Sentinel events reporting (Miss / Near Miss) Clinical incident investigation & training

Quality improvement committee reports Medication safety clinical pharmacologist Clinical microbiologist Planned Preventive Maintenance (Bio-Medic) Risk management officer in every department

Scheduled risk management officer meeting Regular MOU checking & update Infection control program & committee Medico legal advisor



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3. Integrate your risk management activity

ExpectedOutcomes

Improved monitoring and reporting of incidents and

adverse events Improved investigation of clinical incident andadverse events

Improved risk management processes Reduced health care costs through reduced

number and severity of adverse events Improved patient outcomes



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Step 4Promote reportingAction points

For your o rgan i sa t ion : complete a local implementation plan (see below) which describes how and when your organisation will begin reporting nationally to the NPSA.

For you r t eam: encourage your colleagues to actively report patient safety incidents that happen and those that have been prevented from happening butthat carry important lessons.



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4. Clinical performance & audit

Operations

Mortality report & audit

Clinical Indicators Internal clinical guidelines Collaborations with overseas centers of

excellence Working with GPs and Specialist in the

surrounding area Quality indicator Nursing care quality audit Latest equipment provision



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4. Clinical performance & audit

Agreed pathways for clinical practice

Reduced variation in clinical practice Improved patient outcomes Reduced health care costs through reduced

adverse event



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Step 5Involve and communicate with patients and the public

Action points For your o rgan i sa t ion :

develop a local policy covering open communication about incidents with patients and their families; ensure patients and their families are informed when things have gone

wrong and they have been harmed as a result; provide your staff with the support, training and encouragement they need to be open with patients and their families.

For you r t eam: ensure your team respects and supports the active involvement of patients and their families when something has gone wrong; prioritise the need to tell patients and their families when incidents occur, and to provide them with clear, accurate and timely information; make sure patients and their families receive an immediate apology where it is due, and are dealt with in a respectful and sympathetic way.



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5. Involve patients and the public

Operations

Consumer participation training

Informed consent

Complaint management

Customer information center



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Operations

Seminars for public & medical professionals

Patient liaison

Parentcraft, Post natal care education

Patients gathering

Stroke club

Pastoral careRapat Kordinasi Instalasi RSK Mojowarno


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Greater consumer participation in health

service delivery and management Enhanced patient and consumer knowledge Improved patient outcomes



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Step 6Learn and share safety lessons

Action points For your o rgan i sa t ion :

ensure relevant staff are trained to undertake appropriate incident investigations that will identify the underlying causes; develop a local policy which describes the criteria for when your

organisation should undertake a Root Cause Analysis (RCA) orSignificant Event Audit (SEA). These criteria should include all incidentsthat have lead to permanent harm or death.

For you r t eam: share lessons from the analysis of patient safety incidents within your team; identify which other departments might be affected in future, and shareyour learning more widely.


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6. Learn and share safety lessons

Operations

Infection control nurse training

Adapting overseas safety & quality policies

Socializing adapted safety & quality policies

Intensivist training

Training for external participants

Benchmarking



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6. Learn and share safety lessons

ExpectedOutcomes

Decreasing the number of infection Improvement on safety & quality policies

Improving the quality of patient care



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Step 7Implement solutions to prevent harmAction points

For your o rgan i sa t ion :

use the information generated from incident reporting systems, risk assessments, and incident investigation, audit and analysis to identifylocal solutions. This could include re-designing systems and processes,and adapting staff training or clinical practice; assess the risks for any changes you plan to make;

measure the impact of your changes; draw on solutions developed externally. These could be solutions developed at a national level by the NPSA or best practice identifiedelsewhere in the NHS; provide staff with feedback on any actions taken as a result of reported incidents.

For you r t eam: involve your team in developing ways to make patient care better and safer; review changes made with your team to ensure they are sustained; ensure your team receives feedback on any follow -up to reported

incidents.


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7. Implement solutions to prevent harm

Operations

Rapid diagnostics

X-Ray Result has to be finished in 15 minutes

Lab Clinical Pathology 2 hours

Appointment system at OPD Pharmacy

No compound medicine Drugs interaction is controlled by clinicalpharmacologist In-patient pharmacist

Out-patient pharmacist



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Operations

True partnership with our consumers Full time specialist in all disciplines Consumer involvement from Doctors, Patients andtheir family

Active medical advisory board Accreditation & ISO certification Improvement in patient care Genuine empowerment

Bottom-up process Top / down guidance, direction and support

Specialist on-call system Building confidence & new capabilities in Doctors & Staff 24 hours general & maintenance support Preparation for further accreditation under Americanstandard ( JCIA )



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Expected

Outcomes


Improvement in patient care

Building confidence & new capabilities in doctors & staff

Implementation of evidence based practice

New culture of change and optimism

Bringing together consumers and staff from all levels tosolve many of very difficult problems in healthcare.

Sense of excitement from a tired and often cynical staffbecause someone is finally listening to them and doingsomething.



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7 steps to Patient Safety.ppt

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Transcript of 7 steps to Patient Safety.ppt