Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation. Odet Sarabia...

Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.

Odet Sarabia González M.D.

Advisor to the Vice Ministry of Quality and Innovation

Ministry of Health MexicoAugust 22nd 2007.

SIXTH ANNUAL QUALITY SIXTH ANNUAL QUALITY COLLOQUIUM AT HARVARD COLLOQUIUM AT HARVARD

PATIENT SAFETY PATIENT SAFETY

LESSONS FROM MEXICOLESSONS FROM MEXICO


MEXICAN HEALTH SYSTEM

Private + Public

Government Provider

4000 Hospitals

3000 Public= 75% beds

1000 Private= 25% beds


WHAT DO WE WANT TO CHANGE?WHAT DO WE WANT TO CHANGE?

It seldom happens at

my hospital

Guiltiness

Finger-pointing

We are infallible

1. Not showing concerns.1. Not showing concerns.2. Not reporting incidents.2. Not reporting incidents.3. Not studying and 3. Not studying and

therefore, not knowing therefore, not knowing our reality.our reality.

4. Not taking measures for 4. Not taking measures for improvement.improvement.

Continue Continue harming harming the the patient.patient.

Lack of budget

Attitude


PATIENT SAFETYPATIENT SAFETY

• Internationally bursting movement that questions

about the kind of healthcare we provide.

• Involves all actors within the healthcare system.

• Regarded as a potentially severe and preventable

problem, with huge economic and social impact.


• National Crusade for Quality in Health Care

• Patient Safety Crisis Management Manual

• Pilot Sensitization Workshop-Course in Morelos

• Sensitization workshop course

• Logotype

• 10 Actions on patient safety

• Knowledge spreading: tri-monthly patient safety bulletins

• Patient safety indicators

• National Sentinel Event Reporting and Learning System

• Research Protocols

• Inclusion in the National Healthcare Program

2001

2003

2005

2007

New government

ACTIONS ON PATIENT SAFETYACTIONS ON PATIENT SAFETY


EIGHT STEPS FOR THE ORGANIZATIONAL CHANGE

1. Instill the sense of urge.

2. Create an oriented coalition.

3. Develop a vision and a strategy.

4. Communicate the vision of change.

5. Empower for action a wide base.

6. Generate quick triumphs.

7. Consolidate the gains and generate more changes.

8. Implant the new approaches on the culture.John P. Kotter

WORKSHOP ESTRUCTUREWORKSHOP ESTRUCTURE


MORELOS PILOT STUDY

• Global rating of the patient safety climate 62.61 (SD 21.01, CI 3.57 – 92.85) to 71.89 (SD 21.14, CI 10.71-100) (p = 0.01).

• Individuals with a satisfactory perception of the patient safety climate increased from 37.5 to 60.66% (p = 0.01).

55

60

65

70

75

Sco

re

Phase

Improvement in Patient Safety Climate

Phase 1Phase 2

0

20

40

60

80

Perc

enta

ge

Phase

Improvement in Satisfactory Patient Safety Climate

Phase 1Phase 2

62.61% to 71.89%

37.50% to 60.66%

ACTION LINESACTION LINES


WORKSHOP-COURSE ON PATIENT SAFETY

• 32 COUNTRY STATES

• ISSSTE. (Government employees).

• SEDENA. (Defense Secretary).

• MARINA.(Navy).

• PEMEX. (Oil Agency).

• 2 Federal Reference Hospitals.

• 1 National Institute.

SIC 46 hospitals / 565 attendance

TT 207 (Train the Trainers)

Cascade reproduction 189 hospitals

20,070 total attendance

WORKSHOP-COURSE ON PATIENT SAFETYEXTENDED TO 32 STATES AND PUBLIC

HEALTH SECTOR


2004

2006


2005


Triangular shaped:

International warning sign

Co responsibility between

Healthcare Institutions, Medical Staff and Patient

Patient

Medical Staff

Safety pin


2005


*Based on the Joint Commission Patient Safety Goals

*


http://innovacionycalidad.salud.gob.mx/10pasos.php

2005

2007




• Reports until July 24th 2007: 875

• States : 11

• Exponential reporting (Last month 150

reports)

2005

2007



Adverse Events Comparison Between HospitalsHospital

AHospital

B

% %

Shift where the adverse events occurred

Morning 75.30% 58.15%

Afternoon 12.05% 23.67%

Others 12.65% 17.88%

Services where the AE took place

ICU 24.70% 16.27%

ER 7.83% 40.36%

Surgery 22.89% 12.65%

Internal Medicine 10.84% 20.48%

Others 33.74% 10.24%

Sort of Adverse Event

In hospital infections 57.83% 4.83%

Sentinel Events 16.27% 43.96%

Others 25.90% 51.21%

SinRAECe-Example:Follow up

Two Years at Two General Hospitals

2004

2006


Adverse Event Comparison Between HospitalsHospit

al AHospit

al B

% Adverse events causing lengthening of hospital stay 63.86%

28.02%

Average of additional days In hospital stay9.19% 4.33%

% Adverse events experienced at working age (18 to 65 ) 74.10%

64.25%

% Patients or relatives not informed that an adverse event took place

87.95%

71.98%

Sentinel Events-Medication Errors 13.86%

20.09%

% Cases where the hospital took measures to prevent the adverse event from happening again

48.80%

97.10%

SinRAECe-Example:Follow up

Two Years at Two General Hospitals



2006

•Study with the CONAMED (Medical Arbitration Commission)

•Align actions with the CSG (General Health Council)

•Reinforce accreditation focusing on Patient Safety

•Prevalence study of adverse events at two general hospitals

2007

Inclusion in the National Health Program 2007-2012



World Alliance for Patient Safety, WHO,

Health and Consumption Ministry of Spain

• Measurement study of the prevalence of

adverse events in five countries of the Middle

and South America Region.

• Get to know the problem’s magnitude.

• Sensitization about the problem with hard data.

1. Argentina

2. Colombia

3. Costa Rica

4. México

5. Perú

IBEAS STUDY

2007

INTERNATIONAL ACTION LINESINTERNATIONAL ACTION LINES


2006

2007

•Start of the IBEAS study at 6 hospitals

•IBEAS study extended to:

1 hospital per State (previously trained on patient safety)



WHO World Alliance for Patient Safety in America

First World Challenge “Clean Care is Safer Care”

Signing of the statement between Health Ministry and WHO

Canada (October 2006)

USA (November 2006)

Costa Rica (March 2007)

México (September 2007)

2 Regional signatures:

México (Mexico and Central America)

Uruguay (South America)



1. The commitment should be from the highest hierarchy down to the patient himself.

2. To sensitize the healthcare personnel of all levels is a priority.

3. Basic education and training in patient safety must be started over periodically.

4. Team training (CEO´s, management team) has demonstrated better results than isolated individuals.

LESSONS LEARNTLESSONS LEARNT


5. Even when actions that lead to patient safety initially imply additional workload (change of procedures, verification of routines, learning), once the people has realized that benefits of the “safety attitude” are real, they become enthusiast promoters of the subject themselves.

6. A project that involves cultural change like patient safety, sooner or later delivers positive results when the seed has been sowed widely among the healthcare providers.

7. Successful Hospitals are those who have given continuity to training, for instance, facing staff’s rotation they have to be trained before assuming their new posts (even the director).



8. The communication line must be clear, functional and well established, from the responsible of the patient safety program at the national level down to the operative levels of each hospital unit.

9. No matter where we are, or who are we talking to, our enthusiasm and conviction must always be evident, even when discussing the hardships of the project or recognizing the difficulties of a particular task.




10. Resources are greatly needed, not so much in the form of expensive, state of the art equipment and gizmos, but rather in preventive maintenance, basic structure, education and continuous support for training, policy making and promotion campaigns.

11. There ought to be a well planned and labeled budget for Patient Safety.

12. The structure that supports the Patient Safety Strategy has to be rational according to the expected outcomes.

13. It is desirable to count with a patient safety office on each and every hospital unit.



14. Authorities ought to be extra careful assigning responsibilities and leading posts.

15. Healthcare providers should speak out when they have concerns regarding Patient safety and listen when their peers have them as well.

16. Involving medical, nursing students and residents, has been of great help, since they possess great enthusiasm and are the system’s future.



17. A non punitive adverse event reporting system is necessity if we are to learn from the errors within our healthcare institutions. Even when the flow of reports might be slow at first, one has to patiently wait in order to gain trust and confidence from healthcare professionals.

18. The outcome of the waiting time (maturation process), is always a flow of precious data that enables the healthcare system to know how to deal with bad habits or get rid of the institution’s flaws that have been unnoticed for long.

19. Improvement efforts should focus on fixing the system’s failures, not in blaming healthcare providers.

20. All of us have a responsibility within the system where we work at.


A CHAIN IS JUST AS STRONG AS ITS WEAKEST A CHAIN IS JUST AS STRONG AS ITS WEAKEST

LINKLINK


THANK YOUTHANK YOU

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Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation. Odet Sarabia...

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