UNIVERSITY OF MISSISSIPPI HEALTH CARE PATIENT SAFETY PLAN

Transcription

1 UNIVERSITY OF MISSISSIPPI HEALTH CARE PATIENT SAFETY PLAN

2 PATIENT SAFETY PLAN 2011 PROGRAM GOALS The goal of the Patient Safety Program at University of Mississippi Health Care (UMHC) is to promote an organizational culture that will develop our hospital system into the safest environment possible for our patients, staff, and visitors. The purpose of the Patient Safety Plan is to articulate an organizational plan of action to eliminate avoidable deaths and preventable injuries. Patient safety at UMHC is defined as the freedom from unintended injury associated with the provision of healthcare services. Ensuring patient safety involves the establishment of operation systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them, so patient harm will not occur. Human error cannot be avoided, but harm can be minimized with sound systems and processes. OBJECTIVES The following are the long-term objectives of the Patient Safety Plan: Eliminate harm, injuries, and death caused by preventable medical errors Create an environment where unsafe equipment, information technology, practices, situations, as well as near-misses and errors are identified, openly communicated, addressed and integrated into organizational learning. Create an environment where gender, race, or hierarchical barriers to communication, coordination, and improvement are eliminated Establish and maintain an infrastructure and capacity for proactive patient safety improvement, education and research Involve patients in decisions about their health care and promote open communication about any adverse outcomes Establish employee competencies in patient safety SCOPE OF THE PATIENT SAFETY PLAN The scope of the Patient Safety Plan encompasses patients, visitors, students, volunteers, and staff including medical staff. The program addresses maintenance and improvement of patient safety in every department throughout the facility. The Patient Safety Plan includes an ongoing assessment, using internal and external knowledge and experience, to prevent error occurrence and to maintain and improve patient safety. 2

3 STRUCTURE, AUTHORITY, AND RESPONSIBILITY FOR PATIENT SAFETY The organizational structure to support patient safety includes the Institutional Quality Board and the Environmental Health and Safety Committee. See Appendix A. Patient Safety Officer The role of the Patient Safety Officer is to lead the oversight of development, implementation, and coordination of the patient safety initiatives at the organizational level in collaboration with Hospital Administration. The Patient Safety Officer is involved in the facilitation of clinical quality improvement projects, serves as a resource for the National Patient Safety Goals, and ensures that a continuous focus is maintained on safe patient care. FRAMEWORK FOR SUCCESS An underlying framework exists of organizational strategy, organizational structure, and execution of culture and outcomes which must be aligned to exceed the expectations of our customers patients, visitors, staff, and physicians. (See Appendix B). The Patient Safety Plan is organized using these three concepts. 1. Include safety as a strategic goal of the organization. Organizational Strategy a. Senior operations group continues to commit to including safety of patients as a strategic goal of the organization. This strategic goal will be included in unit action plans. b. Partner in the mortality reduction initiative with mortality review process. 2. Pursue the development of a safe and just culture. a. Increase reporting of sentinel events, near-misses, and unsafe acts. b. Develop effective safety and operational management. i. Integrate Unsafe Acts Algorithm for management of employees involved in events, especially sentinel events. ii. Implement TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety). c. Continue structured leadership WalkRounds to include a focus on patient safety. d. Continue dissemination and use of the Patient Safety Guide among nurses. 3. Involve and engage physicians and senior-level administrators in patient safety initiatives. a. Commitment from physician leaders and senior-level administrators to regularly scheduled & structured patient safety WalkRounds with PSO. Action items feed into the Quality Boards as an agenda item. b. Physicians will serve as champions for all safety improvement process changes that involve physicians. c. Propose integration of IHI modules as well as didactic experience related to quality and safety into medical school curriculum. d. Propose requirement of IHI modules completion during residency for all residents at UMHC unless modules have been previously completed through another program. e. Propose didactic teaching experience for residents via an undetermined forum including the following topics related to quality of care and patient safety: Performance Improvement/ Core Measures, Risk Management/Legal, Infection Prevention, Patient Safety, Clinical Documentation. 3

4 4. Develop and implement a safety communication plan. a. Include critical language to call a stop to any potentially unsafe situation without repercussions. i. CUUS (Concerned-Uncomfortable-Unsafe-Scared) b. Develop resources to improve hand-off communication at all levels. c. Utilize current SBAR acronym for the development of communication tools. d. Patient Safety Officer will communicate lessons learned, unsafe acts, etc., to organization, as appropriate. e. Continue use of Red Rules: i. Central line insertion. ii. Use of critical language. f. Communication of Patient Safety Plan and prioritized initiatives: i. Annual presentation to organizational leadership ii. Scheduled presentations: Leadership Forum, Leadership Meeting Organizational Structure 1. Organizational planning will include budgeting of human and fiscal resources for patient safety initiatives. 2. Risk Management and Quality Administration will create a communication plan to include: a. Sentinel event reporting and follow-up b. Shared information from electronic reporting system c. Shared information regarding root cause analyses to leadership Execution Culture 1. Implement team resource training throughout the organization. (TeamSTEPPS will begin in Wiser Hospital.) 2. Develop an accountability process for managing the disclosure process. 3. Implement Family Activated Rapid Response house-wide. 4. Integrate patient involvement with the creation of a Patient Safety Community Forum. 5. Design and implement a caregiver communication plan to improve hand-off communication and communication among caregivers. 6. Annually administer patient safety survey to include those questions recommended by AHRQ (Agency for Healthcare Research and Quality). a. Report unit aggregated data b. Facilitate development of action plans based on survey results 1. Develop patient safety scorecard to reflect Are we a safe organization? Execution Outcomes a. Outcome measure How often do we harm patients? i. Measure of health-care acquired infections using standardized definitions and measurement techniques (Example: CLBSI) b. Process measure How often do we provide the interventions that patients should receive? i. Measure the proportion of patients that receive evidence-based interventions using either previously validated process of care measures or a validated methodology to develop new measures (Example: Proportion of pts receiving elevation of head-of-bead and prophylaxis for peptic ulcers and DVT) c. Structural measure How do we know we learned from defects? i. What proportion of months does each patient care area/unit learn from mistakes? (Example: Proportion of months in which at least one sentinel event was reviewed and a policy was created/revised and/or staff awareness or use of that policy was measured). d. Contextual measure How well have we created a culture of safety? 4

5 i. Annual assessment of safety culture at the unit level within UMHC (Example: Percent of patient care areas in which 80% of staff report positive safety and teamwork climate). 2. Continue to generate patient safety scorecard to include measures reflective of The Joint Commission s National Patient Safety Goals 5

6 Appendix A 6

7 Appendix B Alignment to Meet Patient Safety Expectations Organizational Strategy Organizational Structure Execution of Culture & Outcomes 7