Making a Patient Safety Program Work

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Making a Patient Safety Program Work

• Karen Frush, MD
• Chief Patient Safety Officer
• Duke University Health System
• August 21, 2005

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Making a Patient Safety Program Work A
Practical Approach

• Transformation of current culture safety is at
  the center of all efforts
• Fundamental responsibility of healthcare
  providers understand risk, accept
  responsibility for harm, lead efforts to prevent
  harm
• Commitment and participation of all employees and
  staff is necessary to continuously improve and
  excel in safety performance

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Duke University Health SystemPatient Safety
Program

• A National Imperative
• 1999 IOM Report prompted an increased national
  focus on patient safety
• Response externally driven by media, regulators
  and consumers
• Not specific to the institution
• Strong sense of denial and invulnerability
  remained intact

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Our Defining Event The Transplant
Mismatch How could this happen at Duke?
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Duke University Health System Patient Safety
Program

• Institutional Imperative
• February 2003 transplant mismatch provided a true
  organizational imperative for change
• Patient Safety Program to act as a catalyst for
  the development of a culture of safety at all
  levels of patient care, from frontline providers
  to executive leadership (IOM, November, 1999)

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What is Patient Safety?

• In its simplest form, patient safety is
  prevention of harm to patients.

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What is Quality?

• Degree to which health care services increase the
  likelihood of a desired outcome
• Appropriateness of care
• Expected health benefits exceed expected health
  risks
• Reasonable chance of nontrivial benefit
• Improper not to provide the care
• Adherence to professional standards
• Measured in terms of performance indicators

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Background Relationship Between Quality and
Patient Safety
Patient safety is a component under the umbrella
of clinical quality.
CLINICAL QUALITY
Patient
Patient
Centeredness
Centeredness
Institute of Medicine I (1999)
Institute of Medicine II (2001)
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Duke University Health SystemPatient Safety
Program

• Most errors are made by good but fallible
  people, working in a challenged and imperfect
  system.

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Isnt it easier just to get a CT?
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Making a Patient Safety Program WorkUnderstand
the Urgency

• It wasnt one doctor, one nurse or one decimal
  pointit was a huge systems breakdown.
• 
  Sorrel King
• American healthcare operates with levels of
  unreliability, injury, wasteand poor service
  that long ago became unacceptable in many other
  industries.
• 
  Donald Berwick, MD
• There is a massive gap between where we are and
  where we could be.
• Brent James, MD
• R. Langreth Fixing
  Hospitals. Forbes, June 20, 2005. pg 68-76.

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Making a Patient Safety Program WorkEstablish a
Culture of Safety

• Acknowledge the ubiquity of risk, and take
  responsibility for reducing risk
• View the recognition of errors as opportunities
  for reducing risk
• Create a non-punitive environment for reporting
  errors actively encourage reporting of adverse
  events and near-misses
• Develop a method to share stories and lessons
  learned

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Making a Patient Safety Program WorkBuild an
infrastructure

• Identify safety leaders throughout all levels of
  the organization
• Establish multi-disciplinary local safety teams
  to identify risk and develop solutions
• Perform safety walkrounds with executives to
  close the gap between front line and leadership
  What is the next thing that is going
  to
• hurt a patient in this area?

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The Johns Hopkins Comprehensive Unit-based Safety
Program

• Evaluate culture of safety
• Educate staff on science of safety
• Identify defects
• Assign executive to adopt unit
• Learn from one defect per month
• Evaluate culture
• www.safetyresearch.jhu.edu

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Safety WalkRoundsAllan Frankel, M.D.

• A carefully choreographed discussion between
  Frontline Staff and hospital leaders, patient
  safety specialist, a scribe, and other (Managers,
  Pharmacists, Students).
• Lasting about one hour and regularly repeated
• As frequently as weekly, but at a minimum monthly
• Located wherever frontline staff do their work
• Fully supported by back office quality analysis
• Fully integrated into Operations committees
• Requiring rigorous application to detail in every
  step

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Safety WalkRoundsAsking the right questions

• How will the next patient be harmed in your
  area?
• How does the environment fail you?
• The last patient who was hurt as a result of how
  we delivered care what happened?
• ...goal is openess and transparency

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Making a Patient Safety Program WorkDesign
improvements into the system

• Avoid reliance on memory
• Simplify and standardize whenever possible
• Use constraints and forcing functions
• Promote effective team functioning, communication
• Include patients and patient advocates in safety
  efforts and initiatives
• Measure results, monitor progress

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Making a Patient Safety Program WorkImprove
communication and team work

• Promote formal teamwork training
• Standardize Communication (SBAR)
• Crew Resource Management
• Assertion, psychological safety
• Develop checklists
• Hand-offs, procedures
• Initiate teamwork training in professional
  schools, residency programs

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Making a Patient Safety Program WorkInclude
patients and families

• Establish patient advocacy groups to advise
  leaders
• Include patients and families on safety teams, in
  safety walk rounds
• Empower patients and families to actively
  participate in care

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Making a Patient Safety Program WorkMeasure
results and monitor progress

• CMS Quality Metrics
• AHRQ Patient Safety Indicators
• JCAHO National Patient Safety Goals
• IHI 100,000 Lives Campaign

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The Centers for Medicare and Medicaid Services

• www.hospitalcompare.hhs.gov
• Quality measures
• Heart Attack (AMI) Care
• Heart Failure Care
• Pneumonia Care

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JCAHO National Patient Safety Goals

• Improve the safety of using medications
• Computerized physician order entry
• Clinical pharmacists
• Medication reconciliation (IHI)
• Reduce the risk of health care-associated
  infections
• Central line-associated bloodstream infections
  (IHI)
• Ventilator-associated pneumonia (IHI)
• Surgical site infections (IHI)

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Making a Patient Safety Program WorkFocus on a
few performance measures

• External metrics
• CMS, AHRQ, JCAHO, IHI
• Internal metrics
• BSC based on strategic agenda
• Meaningful indicators for local teams
• Actionable

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Making a Patient Safety Program WorkImplement
change via local safety teams

• Review risk data
• Local and aggregate
• Implement improvement strategies
• Best practice
• Customized strategies for local culture
• Include patients and patient advocates in safety
  efforts and initiatives

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Making a Patient Safety Program
WorkOutcomes-based Measures

• Reduce Mortality
• Rapid Response Teams
• Reduce ADEs (Severity Index)
• Objective data (automated surveillance, chart
  review)
• Eliminate Nosocomial Infections
• VAP bundle in ICUs
• BSI in ICUs
• Eliminate Perioperative Injuries
• Wrong site surgery (Time out)
• Surgical Site Infections

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Making a Patient Safety Program Work

• All hospitals and healthcare agencies should
  establish a Patient Safety Program, to act as a
  catalyst for the development of a culture of
  safety at all levels of patient care, from
  frontline providers to executive leadership (IOM,
  November, 1999)

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Making a Patient Safety Program Work

• Transformation of current culture safety is at
  the center of all efforts
• Fundamental responsibility of healthcare
  providers understand risk, accept
  responsibility for harm, lead efforts to prevent
  harm
• Commitment and participation of all employees and
  staff is necessary to continuously improve and
  excel in safety performance