Texas Center for Quality and Patient Safety Patient Safety and Quality Improvement: The Essentials

Dennis Cook, MSN, RN, CPPS Senior Director, Texas Center for Quality and & Patient Safety Texas Hospital Association

Objective The participant will be able to describe the essential components of an effective healthcare quality and patient safety evaluation and improvement system.

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Patient Safety

Why is Patient Safety So Important?

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Patient Safety Movement

“To Err is Human”

IOM Report DoD MedTeams ® ED Study JCAHO National Patient Safety Goals Institute for Healthcare Improvement 100K lives Campaign Executive Memo from President National Implementation of TeamSTEPPS T eam STEPPS Patient Safety and Quality Improvement Act of 2005 Adoption by Military Health System from 2007-2011

1995 1999 2001 2003 2004 2005 2006 2008 2011

IOM Report – 2001 What should be the foundation of health care quality and patient safety?

STEEEP

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Standardization of Hospital Quality Measures

NPSGs Patient ID, Communication, Medication Safety, Infection Prevention, Suicide Prevention, Correct Surgery HACs ADEs, CAUTI, CLABSI, Falls, OB injury, Pressure Ulcers, SSI, VTE, VAP Core Measures AMI, Pneumonia, HF, SCIP 6

Process Improvement Strategies

PDCA RCA FMEA Six Sigma

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Impact

Accreditation Joint Commission Det Norske Veritas (DNV) Consumer Awareness Leapfrog Hospital Compare Media Financial Incentive 8

Error Theory - Swiss Cheese Model

Distractions Inadequate Communication Mixed Messages Inadequate Technology Event Occurs 9

Contributing Factors to Error • • • • • • • • • • • • Behavioral assessment process Physical assessment process Patient identification process Patient observation procedures Care planning process Continuum of care Staffing levels Orientation & training of staff Competency assessment/credentialing Supervision of staff Communication with patient/family Communication among staff members • Availabilityof information • Adequacy of technological support • Equipment maintenance and management • Physical environment • Security systems and processes • Medication management • Human Factors • Disruptive behavior • Policy & procedure • Process variation • Documentation • Leadership

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Communication Error??

“Please send me a patient safety check by noon”

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Communication Error??

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Communication

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Root Cause Analysis (RCA)  A structured retrospective process for identifying the causal or contributing factors underlying adverse events.

 RCA follows defined process for identifying specific contributing factors rather than attributing the incident to the first error one finds or to preconceived notions a person might have about the event.

 The goal is to create an action plan for improvement which will prevent the error or incident from occurring in the future.

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Failure Mode Effect Analysis (FMEA)  A prospective assessment that identifies and improves steps in a process thereby reasonably ensuring a safe and clinically desirable outcome.

 A systematic approach to identify and prevent product and process problems before they occur.

 Allows us to identify ways in which a process, current or future, could potentially break down or fail to perform its desired function

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The Value of Near Miss Reporting

Actual Event Near Miss Near Miss Near Miss Near Miss Near Miss Near Miss Near Miss Near Miss

The Mishap Diamond

The Mishap Pyramid

Case Study Can you identify the failures?

Discussion: Organizational Culture and Patient Safety

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Serving Texas Hospitals/Health Systems

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