Quality and Medical Safety Programs

Quality and Medical Safety Program

Employee education competency module 2009 DMC Quality Department Detroit Medical Center © Revised: December, 2008 Page 1 of 26

Quality and Medical Safety Programs

Commitment to Quality and Safety

 The Detroit Medical Center is committed to providing safe, high quality medical care.

 This is part of our mission and it is also reflected by our certification and accreditation with regulatory agencies and participation with local, state, and national quality and safety improvement projects.

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Quality and Medical Safety Programs

Quality and Environmental Management Systems

 The DMC has incorporated the requirements of a Quality Management System (QMS) as outlined in the ISO 9001-2000 standards and an Environmental Management System (EMS) as outlined in ISO 14001: 2004 standards into its quality program.

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Quality and Medical Safety Programs

Foundation for Medical Safety

 Our commitment to Medical Safety is reflected in our:  Environmental Statement  Quality Statement

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Quality and Medical Safety Programs

ENVIRONMENTAL STATEMENT

The Detroit Medical Center is dedicated to the health and safety of its patients, employees, customers, community and environment. We are committed to: •the prevention of pollution, •compliance with environmental regulations and other requirements, and •continuous improvement.

THINK GREEN

Environmental Hotline 1-800-8ETHICS

THINK CLEAN Page 5 of 26

Quality and Medical Safety Programs

QUALITY STATEMENT

Quality at the DMC includes:  Continuous improvement  Prevention of medical/health system errors  Provision of high quality medical care

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Quality and Medical Safety Programs

Improving Quality and Safety

Most events or errors occur due to process issues

 Multiple events at multiple levels lead to the event – almost never just one process failure.

 Rarely a “person” failure

By improving our systems and processes, we improve healthcare quality and safety.

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Quality and Medical Safety Programs

What is Performance Improvement?

It’s an ongoing effort to find new and better ways of doing things.

 It’s about:  Getting better results • Involving the whole organization • Improving work processes Foundation for Performance Improvement: • PDCA  Plan  Do  Check  Act

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Quality and Medical Safety Programs

Performance Improvement

   

Plan

 What are the goals you want to achieve?

Do

 Measure progress towards goals by collecting data.

Check

 Look closely at (analyze) your data to answer these questions: • How well are we performing? • Why are we performing well (or not well)?

• Which areas should we focus on first to improve our process?

Act

 Make Improvements!

 Celebrate success!

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Quality and Medical Safety Programs



Medical Safety

What does Medical Safety mean?

 It means we constantly look for ways to make the care or service we provide safer for our patients and employees.

 How can we do this?

    By identifying conditions that are hazardous and changing them. By acting quickly and appropriately when an incident occurs.

By making medical safety a regular part of our performance improvement activities.

By making concerns for safety part of everything we do.

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Quality and Medical Safety Programs

Medical Safety = Quality Care



The DMC is committed to adopting the

Institute of Medicine’s

6 aims for improving the quality and safety of healthcare Page 11 of 26

Quality and Medical Safety Programs

Institute of Medicine 6 aims of improving care

Healthcare needs to be: 1. Safe

: avoiding injuries to patients from the care that is intended to help them.

2. Effective:

providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

3. 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.

4. Timely:

reducing waits and sometimes harmful delays for both those who receive and those who give care.

5. Efficient:

energy. avoiding waste, including waste of equipment, supplies, ideas, and

6. Equitable:

providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. A health care system that achieves major gains in these six areas would be far better at meeting patient needs.

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Quality and Medical Safety Programs

Healthcare Safety Statistics

40 to 50 Patient Injuries per 100 Hospital Admissions

37 Million Admissions X 40 Injuries per 100 Admissions =

15 Million Injuries per Year

What can we do to change this?

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Quality and Medical Safety Programs

Institute for Healthcare Improvement (IHI) “Protecting 5 Million lives from Harm” campaign

   AIM:  Care that is standardized and systematized Zero defects Innovative System Redesign

The DMC has committed to participate with the IHI to protect patients from harm Everyone is responsible for the quality and safety of healthcare

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Quality and Medical Safety Programs

     

Proven Interventions

The 5 Million Lives Campaign challenges American hospitals to adopt 12 changes in care that save lives and reduce patient injuries:

Deploy Rapid Response Teams

…at the first sign of patient decline

Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction

…to prevent deaths from heart attack

Prevent Adverse Drug Events (ADEs)

…by implementing

medication reconciliation Prevent Central Line Infections

…by implementing a series of interdependent, scientifically grounded steps

Prevent Surgical Site Infections

…by reliably delivering the correct perioperative antibiotics at the proper time

Prevent Ventilator-Associated Pneumonia

…by implementing a series of interdependent, scientifically grounded steps

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    

Quality and Medical Safety Programs



Proven Interventions con’t.

The 5 Million Lives Campaign challenges American hospitals to adopt 12 changes in care that save lives and reduce patient injuries:

Prevent Harm from High-Alert Medications

... starting with a focus on anticoagulants, sedatives, narcotics, and insulin

Reduce Surgical Complications

... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project ( www.medqic.org/scip )

Prevent Pressure Ulcers

... by reliably using science-based guidelines for their prevention

Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection

…by reliably implementing scientifically proven infection control practices

Deliver Reliable, Evidence-Based Care for Congestive Heart Failure

... to avoid readmissions

Get Boards on Board

… by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care

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Quality and Medical Safety Programs

Promoting and Maintaining a Safe Medical Climate



Staff Responsibilities:

 Take action to provide necessary care and protect patients in the event of a unsafe event or error.

 Report all errors, near misses and hazardous conditions (web based incident reporting system).

    Complete yearly, educational competencies.

Participate in departmental improvement efforts.

Be part of interdepartmental, multidisciplinary improvement teams. Share ideas to improve employee or patient safety with supervisor or quality department  SPEAK UP if you see an opportunity to avoid an unsafe practice or violation of policy  Instruct patients and families to report safety concerns.

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Quality and Medical Safety Programs

Promoting and Maintaining a Safe Medical Climate



Patient Responsibilities:



Encourage patients to:

• Provide accurate and complete information about present complaints, past illnesses, hospitalizations and medications.

• Ask questions when they do not understand what they have been told or what they are expected to do.

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Quality and Medical Safety Programs

Accreditation

 Accreditation means that an organization has met requirements related to the delivery of safe, quality care.

 The DMC is surveyed and accredited by many different agencies.

 The Joint Commission is one of these agencies and comes to our hospitals at least once every 3 years.

What is Joint Commission?

 The Joint Commission is an accreditation agency who’s objective is to improve the quality of healthcare provided to the public by establishing clinical standards; evaluating health care organizations; rendering accreditation; and providing education and consultative support to healthcare professionals.

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Quality and Medical Safety Programs

Hospital Transparency

   Hospital “transparency” is providing information to the public on patient safety & quality, cost, and performance indicators Transparency assists hospitals to become more efficient, rewards those hospitals that provide high quality care, and allows consumers to make informed decisions The DMC provides information on safety and quality that is publicly reported

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Quality and Medical Safety Programs



Quality Improvement

The DMC participates in many local, state and national Quality Improvement projects some of which are:  The National Quality Forum (NQF)  Leapfrog  Institute for Healthcare Improvement (IHI)  Michigan Hospital Association (MHA – Keystone project)  Greater Detroit Area Health Coalition (GDAHC – Save Lives-Save Dollars campaign)  Blue Cross Blue Shield of Michigan

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Quality and Medical Safety Programs

Consumer Centered Hospital Data

   In recent years, there has been an increased emphasis on hospital quality and transparency Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores It is important to remember that all DMC employees play a role in ensuring that our patients leave with a satisfying experience

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Quality and Medical Safety Programs

Healthcare Quality Websites

     The Joint Commission  www.jointcommission.org

Provides information regarding hospital accreditation and compliance AHRQ Report Card  www.ahrq.gov

Features information on the quality of hospitals, medical groups, health plans, and nursing homes CMS/Hospital Compare www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp

 Provides consumers with hospital-reported information on quality, performance, and customer satisfaction Leapfrog Group  www.leapfroggroup.org

Provides consumers with hospital information based on its yearly survey of quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk procedures, and NQF Safety Goals Michigan Hospital Inform  http://www.mihospitalinform.org/ State of Michigan healthcare quality website

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Quality and Medical Safety Programs

Quality of Care

    As employees of the DMC, it is everyone’s responsibility to ensure safe, quality care for our patients.

Also, as an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.

If you have concerns, first speak to your supervisor. If you are not satisfied, you may contact the Quality Department or use the compliance hotline.

If still your concerns are not addressed, you have the right to contact the Joint Commission at [email protected]

or call 1-800-994-6610.

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Quality and Medical Safety Programs

Quality and Medical Safety Programs Summary

Both the Quality Management System (QMS) and Environmental Management System (EMS) are part of our integrated quality program.

Medical Safety means we constantly look for ways to make the care or service we provide safer for our patients and employees.

The DMC publicly reports it’s quality and safety data.

Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores.

As an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.

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Quality and Medical Safety Programs

Summary

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