Joanne Disch, PhD, RN, FAAN Clinical Professor University of Minnesota School of Nursing

A world-wide issue

   Adverse drug events and medication errors in Australia (IJQHC, 2003) 

Of coded adverse events leading to death, 27% involved an adverse drug event

Transplant Tourism: Outcomes of United States Residents Who Undergo Kidney Transplantation Overseas (Transplantation, 2006) 

6 infections in 4 patients, l rejection

Medication errors in primary care in Riyadh city, Saudi Arabia (EMHJ, 2011) 

Prescribing errors in 18.7%

IOM Six Aims for Improving Health Care Safety and Quality AIM

Safe Timely Effective Efficient Equitable

Description

Avoiding injury and harm to patients Reducing waits Care based on evidence Avoiding waste Quality does not vary because of gender, ethnicity, socioeconomic factors or geographic status Patient centered Respectful and responsive care based on patient values

High Reliability Organizations (HRO) HRO

Organizations that have cultures of safety, foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improving the safety and quality of care are considered to be high reliability organizations

High Reliability Organizations (HRO):Characteristics

Characteristics of HROs include:     having a safety and quality-centered culture direct involvement of top and middle leadership safety and quality efforts aligned with the strategic plan an established infrastructure for safety and continuous improvement and active engagement of staff across the organization

Components of a HRO

A health care setting is composed of a large set of interacting systems, often referred to as the Macrosystem . The smaller units are known as Microsystems.   admissions emergency department     inpatient units ambulatory units and operating room dietary environmental services, etc.

Macrosystem Microsystem

Microsystems

- are a small group of people who work together on

a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems, and as such they must do the primary work associated with core aims, meet the needs of internal staff, and maintain themselves over time as clinical units.

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High-performing front-line clinical units

(Nelson et al, 2002) From leaders of 43 clinical units in 20 orgs Constancy of purpose Investment in improvement Alignment of role and training for efficiency, staff satisfaction Interdependence of the care team to meet patient needs Integration of information and technology Ongoing measurement of outcomes Supportiveness of the larger organization Connection to the community to enhance care delivery and extend influence

The Microsystem Model

Culture Performance patterns Organizatio nal support Process improveme nt Patient focus Information & IT Interdepende nce of care teams Leadership Staff focus

Organizational factors associated with high performance

(Keroack et al, 2011)     79 academic medical centers, 2003-2004 Factors assessed: safety, mortality, clinical effectiveness, equity of care Six institutions studied: 3 top, 3 average Top levels of performance could result in 150 fewer deaths per year

Key findings

  Shared sense of purpose    ‘Patient care comes first’ Leaders are dissatisfied with status quo Service excellence part of focus on quality, safety Accountability system for service, quality, safety (SQS)    Prioritizing, developing measures and setting goals are centralized, while tactics are decentralized Chairs accept responsibility for SQS in departments Accountability, innovation and redundancy at the unit

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Key findings (cont)

Collaboration    The basic relationship among administration, nurses, physicians and other staff Frequent recognition of employee contributions at all levels Employees [and physicians] value each other’s critical knowledge when problem solving Leadership style     CEO is passionate re: service, quality, safety (SQS) Everyday events are connected via stories to SQS Governance structures minimize conflicts among missions Institution is led as an alliance between executive leadership team and clinical chairs

Key findings (cont)

 Focus on results     Relentless effort to improve Results outweigh the approach to performance improvement Focus on human behavior and work redesign Technology is accelerator, not substitute for work redesign

Culture of Safety

Within a healthcare setting, each discipline can have a different culture, as can each patient care area…so can each individual person In a culture of safety, the focus is on effective teamwork to accomplish the goal of safe, high quality patient care.

Elements of a Culture of Safety

   establishing safety as an organizational priority teamwork patient involvement   openness/transparency accountability   non-punitive responses to adverse events and errors  shared core values and goals adequate education and training

Elements of a Culture of Safety

A safety culture requires strong, committed leadership, and engagement and empowerment of all employees. It entails periodic assessment of the culture and relationship between the organization culture and the quality and safety within the organization

IOM: How to Improve Patient Safety?

The IOM described 9 categories that provide opportunities to improve patient safety:

1. User-centered Design

Approaches include making things visible so the user is able to see actions possible at any time, affordance, constraints and forcing-functions.

2. Avoid Reliance on Memory

Standardizing and simplifying procedures and tasks decreases the demand on memory, planning, and problem-solving.

3. Attend to Work Safety

Work hours, work loads, staffing ratios, distractions, and counterclockwise shift changes all affect patient safety.

4. Avoid Reliance on Vigilance

Checklists, well-designed alarms, rotating staff and breaks decrease the need for remaining vigilant for long periods.

5. Training Concepts for Teams

Training programs for effective interprofessional communication and collaboration include transitions in care and hand-offs.

6. Involve Patients in Their Care

Patients and families should be in the center of the care process.

7. Anticipate the Unexpected

Reorganization and organization-wide changes result in new patterns and processes of care.

8. Design for Recovery

Errors will occur despite the best of planning. Designing and planning for recovery will allow reversal or make it hard to carry out irreversible critical functions.

9. Improve Access to Accurate, Timely Information

Information for decision making needs to be available at the point of care.

In summary -

High reliability organizations have:      A shared sense of purpose Focus on results Accountability systems for service/quality/safety Collaboration Effective leadership