Transcript Everything I Need to Know About Patient Safety I Learned

An Introduction to Principles of
Patient Safety
Central Pennsylvania NANT Chapter
Spring Conference – April 15, 2012
Gary Merica, R.Ph, MBA/HCM
Director, Patient Safety, WellSpan Health
Objectives

Participants will be able to:



Describe the frequency with which patients suffer
unintended harm in hospitals
Define a culture of patient safety, and describe
how to measure it
Describe 3 significant interventions hospitals can
take to improve their culture of patient safety
Why?
Numbers……………..
44,000 – 98,000
 1 in 7
 16 every quarter
 1.7 million
 99,000

……………and Names




Josie King
David Milne
Ben Kolb
Michael Colombini
The passing of a hero in Canada
An admonition from the public
Regulatory/legal “Stuff ”

Pa Act 13



Licensed practitioners required to report medical
errors and adverse events to their organization
Organization must report events to the state
Written disclosure letters to patients/families for
Serious Events
CMS Hospital Acquired Conditions





FOREIGN OBJECT
RETAINED AFTER
SURGERY
AIR EMBOLISM
BLOOD
INCOMPATIBILITY
PRESSURE ULCER
STAGES III AND IV
FALLS AND TRAUMA





CAUTI
CLABSI
MANIFESTATIONS OF
POOR GLYCEMIC
CONTROL
SSI
DVT/PE AFTER HIP OR
KNEE REPLACEMENT
CMS Hospital Acquired Conditions

Since 10/1/08, hospitals do not receive the higher
payment when:





One of these conditions is present as a secondary diagnosis at
discharge
And was not present on admission
And results in a higher MS-DRG
In March 2011, 8 of the HACs were publicly reported on
the CMS Hospital Compare website
Beginning in FFY 2015, hospitals in the worst performing
quartile of HAC rates per 1000 eligible discharges will be
subject to a 1% reduction in Medicare reimbursement.
Pa Act 1 of 2009: Preventable Serious Adverse
Events Act
General rule:

A health care provider may not knowingly seek
payment from a health payor or patient:

1.
2.
For a PSAE, or
For any services required to treat the problem created
by the PSAE when the event occurred under their
control
What is a “Culture of Patient Safety”

Culture




The predominating attitudes and behaviors that
characterize the functioning of an
organization…or
The collective behaviors, practices, and
operational standards, driven by our shared
values and beliefs…or
The way we do things around here
Safety

Freedom from unintended harm
Attributes of a Culture of Patient Safety









Patient centered, patient first
Mutual respect
Open communication
Highly functioning teams
Reporting and learning
“Just Culture” approach to safety
Peer accountability
Crucial Conversations
High reliability organization/practitioners
Patient Centered
Mutual Respect
1.
•
The American College of Physician Executives (ACPE) physician
behavior survey:
38.9 percent of the respondents agreed that "physicians in my
organization who generate high amounts of revenue are
treated more leniently when it comes to behavior problems
than those who bring in less revenue.”
“There is a difference between hospitals that take care of patients
and hospitals that take care of doctors.”
2.
3.
•
ISMP Intimidation Survey:
40% of clinicians failed to intervene for patient safety due to
fear of a negative encounter
Open Communication

2010 AHRQ Survey on Patient Safety

Communication openness (62%)

staff will freely speak up if they see something that may
negatively affect patient care (76%)


staff feel free to question the decisions/actions of those with more
authority (47%)


Or…..24 of 100 won’t
Or….. 53 out of 100 don’t
staff are afraid to ask questions when something does not seem
right (63%)

Or…..37 out of 100 are
Open Communication


Crucial Conversations
What makes a conversation “crucial”?



Stakes are high
Opinions vary
Emotions run strong
Highly Functioning Teams

Crew Resource Management






SBAR
Briefings/Time-outs/Debriefings
Critical language
Assertion
Situational Awareness
Checklists
Pre-procedure Briefing




Team introductions
Discuss patient, case – concerns
Team accountability
Set stage for open communication
Procedural Time-out



Immediately before incision or start of the procedure
Entire team is engaged, all activities cease (except
life support)
Team positively affirms:




Correct patient
Correct procedure
Correct site
Note: 16 wrong site surgeries in Pennsylvania per
quarter
Post-procedure De-briefing



Clinical/technical – counts, specimens, etc.
How did we do?
Any changes need to be made?
Peer Accountability
Peer Accountability



In the worst companies, poor performers are
first ignored and then transferred
In good companies, bosses eventually deal
with problems
In the best companies, everyone holds
everyone else accountable – regardless of
level or position
High Reliability Organizations

HROs have a preoccupation with the
possibility of failure



Systems fail
People fail
HRO’s have a “healthy” recognition of these
potential failures, and actively look to identify and
mitigate them prior to patient harm
Just Culture
Why?

The single greatest impediment to error
prevention is that “we punish people for
making mistakes.”
Lucian Leape, MD
1/25/00 Congressional Testimony
What Does the Data Show?

2010 AHRQ Survey on Patient
Safety:

Non-punitive environment (44%)

staff feel like mistakes held against them (51%)


feels like person being written up, not event (46%)


Or…..49 out of 100 feel this way
Or….54 out of 100 feel this way
staff worry that mistakes are kept in their file (35%)

Or…. 65 out of 100 worry about this
Who Supports This?

Organizations that advocate for adoption of a Just
Culture:


National Quality Forum – 2009 Safe Practices for Better
Healthcare: “A just culture should be fostered in which frontline
personnel feel comfortable disclosing errors – including their
own – while maintaining professional accountability.”
HAP – “HAP recommends that Pa hospitals and health
systems strongly consider working with Outcome Engineering
to implement a Just Culture model.” (12/05/08)
Who Supports This?
• Organizations that advocate for adoption of a Just
Culture:
• Pa Patient Safety Authority
• Institute for Safe Medication Practices
• Joint Commission
•
Leadership Standard 03.01.01
•
•
Leaders create and maintain a culture of safety and quality
throughout the hospital
The focus of attention is on the performance of systems and
processes instead of the individual, although reckless behavior and a
blatant disregard for safety are not tolerated.
Just Culture



Unacceptable to punish all errors and unsafe
acts
Equally unacceptable to give blanket
immunity to all actions that contributed to an
error – evolve from “blameless”, or “nonpunitive” culture
Adjust the pendulum
Reporting and Learning

Principles:



Predicated on having a reporting environment in which staff
feel comfortable and safe in reporting an observed risk or a
mistake.
Looks to create a well established system of accountability
Recognizes that human beings are fallible, however also
recognizes that in most circumstances we have control
over our behavioral choices
Just Culture

Principles (cont.):


Based on “shared accountability”
Two inputs into good patient care:


Good system design (management responsibility)
Good behavioral choices (staff responsibility)
Measuring Patient Safety:
Process, Structure, Outcome

Survey patient safety culture – process &
structure
National Quality Forum – Safe Practices for Better
Healthcare:
“Healthcare organizations must measure their
culture, provide feedback to the leadership and
staff, and undertake interventions that will reduce
patient safety risk”

Measuring Patient Safety:
Process, Structure, Outcome

Observational methodology - process



Hand Hygiene – how good are we, and how do
we know?
Crew Resource Management – are we just going
through the motions?
ISO 9000 auditing requirements - It is considered
healthier for internal auditors to audit outside their usual
management line, so as to bring a degree of independence to
their judgments.
Measuring Patient Safety:
Process, Structure, Outcome

AHRQ Patient Safety Indicators (PSI), CMS
Hospital Acquired Conditions – outcome

Preventable complications of hospital care




Iatrogenic pneumothorax
HAI
Blood incompatibility
PE/DVT
Change?
Never doubt that a small group of thoughtful,
committed citizens can change the world.
Indeed, it is the only thing that ever has.
Margaret Mead