creating a culture of patient safety
TRANSCRIPT
-
7/29/2019 Creating a Culture of Patient Safety
1/25
1
Creating a Culture of
Patient SafetyWVU Department of Family Medicine
RCB HSC- Eastern DivisionKonrad C. Nau, MD
-
7/29/2019 Creating a Culture of Patient Safety
2/25
2
We work in a complex environment
-
7/29/2019 Creating a Culture of Patient Safety
3/25
4
We know that error happens
-
7/29/2019 Creating a Culture of Patient Safety
4/25
5
We know that patient safety is the
bedrock of quality care
Institute of Medicine: Quality Care
-
7/29/2019 Creating a Culture of Patient Safety
5/25
6
IOM elements of Quality
Safe: avoiding injuries to patients from the care that is intended to helpthem
Timely: reducing waits and sometimes harmful delays for both thosewho receive and those who give care
Effective: providing services based on scientific knowledge to all who
could benefit and refraining from providing services to those not likely tobenefit (avoiding underuse and overuse)
Efficient: avoiding waste, in particular waste of equipment, supplies,ideas, and energy
Equitable: providing care that does not vary in quality because ofpersonal characteristics such as gender, ethnicity, geographic location,
and socioeconomic status Patient-Centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring thatpatient values guide all clinical decisions
STEEEP Framew
orkoutlined by the Institute of Medicine (IOM)
-
7/29/2019 Creating a Culture of Patient Safety
6/25
7
We preach quality but can we say
we have a true culture of safety
Culture
The way we do things around here
Safety
Avoiding injuries from care intended to help
patients
-
7/29/2019 Creating a Culture of Patient Safety
7/25
8
Can everyone in our clinic name
five ways to improve patient
safety ?
-
7/29/2019 Creating a Culture of Patient Safety
8/25
9
AHRQ
Five Steps to Safer Health Care 1. Ask questions if you have
doubts or concerns.
2. Keep and bring a list of ALLthe medicines you take.
3. Get the results of any test orprocedure.
4. Talk to your doctor aboutwhich hospital is best for your
health needs.. 5. Make sure you understand
what will happen if you needsurgery.
-
7/29/2019 Creating a Culture of Patient Safety
9/25
10
Delivering on our Promise of
Quality Medical Care
Patient Safety
Quality Care
-
7/29/2019 Creating a Culture of Patient Safety
10/25
11
Patient Safety &
Quality Medical Care
Two fundamental questions guide us, as a world-classacademic family medicine center, and in this order:
1.How can we help the patient?
2.In doing so, what can we learn?
-
7/29/2019 Creating a Culture of Patient Safety
11/25
12
Patient Safety Campaign
WVU Dept Family Medicine-East Div
1.Patient Safety Kickoff
2.System of Reporting and Analyzing Error
3.Regular Patient Safety Grand Rounds
4.Create a Culture of Safety
-
7/29/2019 Creating a Culture of Patient Safety
12/25
13
Patient Safety Kickoff
Entire office assembled off-site for lunch meeting
January 2005
Present : Epidemiology of Medical Error
Present : Creating a Culture of Patient Safety
-
7/29/2019 Creating a Culture of Patient Safety
13/25
14
System to Report and Analyze Error
Electronic Occurrence Reporting System
Quantros/Dr Quality/ORM
Web based
We encourage ALL staff to file reports online
Patient injury
Adverse drug reactions
Near-misses
Non-putative, can be filed anonymously
-
7/29/2019 Creating a Culture of Patient Safety
14/25
15
https://qxpert.quantros.com/orm/jsp
/JeffersonLogin.jsp
Click here to report an occurrence (a.k.a. variance or incident) anonymously. You do
not need a User ID or Password to do this. Please assist us in creating a safer
healthcare environment for the customers we serve
http://check%28%29/ -
7/29/2019 Creating a Culture of Patient Safety
15/25
16
Resident Physicians
Reporting and Analyzing Error
All residents are REQUIRED to self report theirown medical errors.
Electronic format is confidential and Peer
Review protected. Encourages reflection and honesty expected in
physicians
Non-putative focus on systems-based analysis
Will formulate basis of Patient Safety GrandRounds topics
-
7/29/2019 Creating a Culture of Patient Safety
16/25
17
Patient Safety Grand Rounds
Bimonthly residents, faculty, students, invited clinic
staff
Based on residents self reported medical error or near
miss
Clinical case presented
Systems-based analysis of the error
Present patient safety literature that supports
recommendations Case Report and analysis is written up and reviewed with
Chair prior to required submission to AHRQ M&M
-
7/29/2019 Creating a Culture of Patient Safety
17/25
18
Create a Culture of Patient Safety
Enhance clinic library with Patient Safety materials
Journal of Patient Safety
Patient Safety & Quality Healthcare Journal
Seminal textbooks
Crossing the Quality Chasm
To Err is Human
Enhance clinic technology for Patient Safety
Clinic wide Lexicomp/Drug Interaction software on all
computers and handhelds Redesign Clinic Web Page
Medication Charts
Office Visit preparation/safety tips
-
7/29/2019 Creating a Culture of Patient Safety
18/25
19
Create a Culture of Patient Safety
AHRQ Patient Safety Culture Survey
http://www.ahrq.gov/qual/hospculture/
Outpatient format available in PDF or Word
Results display template on PowerPoint
Involve entire clinic in patient safety culturesurvey
Patient focus groups to inform clinic aboutpatient stakeholder perspectives
Clinic leadership makes Patient Safety Rounds
http://www.ahrq.gov/qual/hospculture/http://www.ahrq.gov/qual/hospculture/ -
7/29/2019 Creating a Culture of Patient Safety
19/25
20
Patient Safety Culture Survey
-
7/29/2019 Creating a Culture of Patient Safety
20/25
21
25
30
15
70
50
80
20
15
5 25
5
60
Overall Perceptions of Safety
R Indicates reversed-worded items.
NOTE: The item letter and number in parentheses indicate the items survey location.
Survey Items % Strongly Disagree/ % Neither % Strongly Agree/Disagree Agree
1. Patient safety is never sacrificed to get more
work done. (A15)
2. Our procedures and systems are good at
preventing errors from happening. (A18)
R3. It is just by chance that more serious
mistakes dont happen around here. (A10)
R4. We have patient safety problems in this
unit. (A17)
Page
Sample culture Survey result slide:
-
7/29/2019 Creating a Culture of Patient Safety
21/25
22
Quality Primary Care for the
21st Century
Safe Patient CareConsistent Best Practices
Great Patient Service
-
7/29/2019 Creating a Culture of Patient Safety
22/25
23
Ambulatory Patient Safety Culture
Create a Culture of Safety
Culture = the way we do
things around here
Culture of SafetyRequirements
Visualize a safe system
Non-punitive environment
Leadership support
Patient Safety
Quality Care
-
7/29/2019 Creating a Culture of Patient Safety
23/25
24
Ambulatory Patient Safety
Capture errors that occur
Analyze errors
Follow-up on analysis
Safety projects will emerge
Medication
EMR
Communications
Team work
Test results
Pt education about safety
Patient Safety
Quality Care
-
7/29/2019 Creating a Culture of Patient Safety
24/25
26
We need creativity
-
7/29/2019 Creating a Culture of Patient Safety
25/25
27
We need enthusiasm
We need you.