Transcript Health Access Deprivation Index:

Creating a Culture of
Patient Safety
WVU Department of Family Medicine
RCB HSC- Eastern Division
Konrad C. Nau, MD
1
We work in a complex environment
2
We know that error happens
4
We know that patient safety is the
bedrock of quality care
Institute of Medicine: Quality Care
5
IOM elements of “Quality”
• Safe: avoiding injuries to patients from the care that is intended to help
them
• Timely: reducing waits and sometimes harmful delays for both those
who 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 to
benefit (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 of
personal 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 that
patient values guide all clinical decisions
“STEEEP” Framework outlined by the Institute of Medicine (“IOM”)
6
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
Can everyone in our clinic name
five ways to improve patient
safety ?
8
AHRQ
Five Steps to Safer Health Care
• 1. Ask questions if you have
doubts or concerns.
• 2. Keep and bring a list of ALL
the medicines you take.
• 3. Get the results of any test or
procedure.
• 4. Talk to your doctor about
which hospital is best for your
health needs..
• 5. Make sure you understand
what will happen if you need
surgery.
9
Delivering on our Promise of
Quality Medical Care
Quality Care
Patient Safety
10
Patient Safety &
Quality Medical Care
Two fundamental questions guide us, as a world-class
academic family medicine center, and in this order:
1.How can we help the patient?
2.In doing so, what can we learn?
11
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
12
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
13
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
14
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
15
Resident Physicians
Reporting and Analyzing Error
• All residents are REQUIRED to self report their
own “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 Grand
Rounds topics
16
Patient Safety Grand Rounds
• Bimonthly – residents, faculty, students, invited clinic
staff
• Based on resident’s 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
17
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
18
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 culture
survey
• Patient focus groups to inform clinic about
patient stakeholder perspectives
• Clinic leadership makes “Patient Safety Rounds”
19
Patient Safety Culture Survey
20
Sample culture Survey result slide:
Overall Perceptions of Safety
Survey Items
• 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 don’t happen around here. (A10)
•R4. We have patient safety problems in this
• unit. (A17)
R
% Strongly Disagree/
Disagree
5
% Neither
25
15
20
% Strongly Agree/
Agree
70
25
60
30
80
50
15
Indicates reversed-worded items.
NOTE: The item letter and number in parentheses indicate the item’s survey location.
21
Page
5
Quality Primary Care for the
21st Century
•Safe Patient Care
•Consistent Best Practices
•Great Patient Service
22
Ambulatory Patient Safety Culture
Quality Care
• Create a Culture of Safety
• Culture = the way we do
things around here
• Culture of Safety
Requirements
– Visualize a safe system
– Non-punitive environment
– Leadership support
Patient Safety
23
Ambulatory Patient Safety
Quality Care
• Capture errors that occur
• Analyze errors
• Follow-up on analysis
• Safety projects will emerge
– Medication
– EMR
– Communications
– Team work
Patient Safety
– Test results
– Pt education about safety
24
We need creativity
26
We need enthusiasm
We need you.
27