A Systems Approach to Patient Safety at the VA
|
|
- Beverly Thornton
- 6 years ago
- Views:
Transcription
1 BRIGHT IDEAS A Systems Approach to Patient Safety at the VA Erika Hatva The Department of Veterans Affairs (VA) operates the largest integrated healthcare system in the United States, serving 8.76 million veterans at 1,700 medical facilities, including 153 hospitals, 800 outpatient clinics, 180 veterans centers, 136 nursing homes, as well as community living centers, counseling centers, and other facilities within 21 Veterans Integrated Service Networks (VISNs). The VA s Healthcare Technology Management team under the leadership of Kurt Finke, BSE, since May 2011 includes more than 1,000 healthcare technology management (HTM) professionals who work with more than $6.5 billion worth of medical technology and 650,000 devices. These professionals primarily include clinical engineers (CEs) and biomedical equipment technicians (BMETs). Challenge With such a large network, wide range of technologies, and medical devices becoming ever more complex, Finke and his team faced a challenge: How could they enhance patient safety and ensure safe operation of medical devices across all facilities? The solution turned out to be a systems-based, multidisciplinary training initiative. A culture of safety is also the primary concern of the VA s Office of Quality, Safety and Value, said Tandi Bagian, director of human factors engineering with the VA National Center for Patient Safety (NCPS). The goal of the NCPS is the reduction and prevention of inadvertent harm to patients as a result of their care. To this end, the NCPS notes that the patient safety managers at all VA hospitals and the patient safety officers at 21 VISNs participate in the program. Of the more than 1,000 HTM professionals at the VA, approximately 200 CEs are involved in managing a wide range of equipment and budgets, as well as overseeing multiple programs. CEs are often consumed with evaluations, competitive bidding, buying, planning, and running the projects: managing implementation, equipment supply, integration into our electronic medical record system, safety testing, training, and sustainment, said Finke. The CEs have a heavy workload and an understandable tendency to focus on details and short-term goals, Finke said, so he and his team wanted to shine a spotlight on the overarching goal of patient safety. Many of our CEs are extremely busy, so drawing their attention to the bigger picture, focusing on safety, is very important, he said. Most are partially aware or only subconsciously aware that up to 90% of their work directly contributes to a safe environment of care. Many organizations place responsibility primarily on managers and leaders to solve problems quickly. The result can be shortsighted, boundary-directed actions, which may have unintended and adverse consequences. Such organizations focus on short-term goals. Implementing systems At a Glance SUBJECT VA Healthcare Technology Management Team, VA National Center for Patient Safety LOCATION Washington, DC, and Ann Arbor, MI SIZE More than 1,700 medical facilities, including 153 hospitals STAFF More than 1,000 HTM professionals including clinical engineers and biomedical equipment technicians 45
2 About the Author Erika Hatva, PhD, was AAMI s managing editor. She recently moved to London with her husband. Implementing systems thinking shifts responsibility to an entire team or community, fundamentally altering the way problems are viewed and solved, and placing an emphasis on the bigger picture. thinking shifts responsibility to an entire team or community, fundamentally altering the way problems are viewed and solved, and placing an emphasis on the bigger picture. Bagian said it is crucial that team members understand that their decisions and actions are all connected in the modern healthcare environment. We d like VHA to become a healthcare system where every employee is asking themselves what could go wrong, armed with an appreciation that it could happen to any one of us, she said. The pervasive problem of under-reporting of adverse medical device events is an example of a patient safety issue that can be addressed by promoting systems thinking, according to Finke. Reporting adverse events is becoming even more important as medical devices, software such as electronic medical records, or EMRs and IT systems are increasingly connected. Identifying connectivity failures and malware and performing integration testing are critical to ensuring patient safety. Making sure accurate information about such incidents is passed on is vital, he notes, in order to investigate incidents, identify hazards, and if necessary, recall devices. Thinking ahead and assessing the potential for use-issues is the smartest way to minimize them, agreed Bagian. We learn from our unfortunate experiences and close calls, and when we proactively anticipate similar issues, we can avoid having additional unfortunate experiences. Reporting adverse events can be achieved by coding of work orders in a computerized maintenance management system and then querying the system database. The team adds that it is important to carry out root cause analysis (RCA) of those events that score as having the highest potential for harm. An RCA report describes the problem or adverse event, the methods used to determine the causes, all probable causes, and the likelihood of each cause with supporting evidence along with actions to mitigate or eliminate each cause. Bagian noted that as healthcare devices become more complex gaining a true understanding of the root causes of an event becomes more and more challenging. We can only re-engineer healthcare systems to mitigate or eliminate the causes of patient harm if we make it a priority to thoroughly investigate and analyze the harmful events and close calls we experience. We now have patients with glucometers commanding their implanted drug delivery pumps, and it s not clear if misdosing is due to the external device or calibration test strips, the implanted device or meds, or the IT system through which data passes, added Bagian. Integrating a prescription entered in the electronic medical record (EMR) for medication delivery by an infusion pump at the bedside is another medication application being developed that involves a complex system of hardware and software. Solution Part of the solution focuses on new hires. Every year we bring over 20 new CEs into our team, said Finke. These recruits are well educated; they all have engineering degrees and more than half have graduate degrees. They are, however, all new to the VA system and most go through a two-year clinical engineering development program. We devote a conscious effort every year to what I call getting back to basics, Finke said. And one of the tenets of HTM at the VA is patient safety: assuring the safe operation of medical devices. During their training program at the VA, the newly hired CEs participate in a Patient Safety Training Boot Camp. Part of that involves learning to assess device risk prior to purchasing complex devices. The recruits could then train other CEs and eventually develop strong working relationships with their facilities patient safety managers. They conduct their own root cause analyses of adverse medical device events. If we could specifically train our CEs particularly the new ones how to enhance medical device safety, we could instill concepts we wanted them all to be aware of, said Finke. The NCPS staff includes three biomedical 46
3 engineers who research device use-error via the RCA process and work with the manufacturers and chiefs of service in the VA to create a plan to remove the vulnerability from the VA system, said Bagian. We realized that those who purchase and maintain these complex devices would be the best suited to work with the patient safety managers to ensure thorough investigation of adverse events. Thus, a partnership was born, said Bagian, with the VA s HTM team and NCPS working together. However, the venture initially encountered some difficulties. Leadership did not immediately embrace either the idea of devoting NCPS resources to training clinical and biomedical engineers in addition to patient safety managers or that of training biomedical staff rather than nurses in patient safety, particularly given the constraints on federal spending and travel. However, plans were underway in June 2012 for the program. We determined that a group of twelve [CEs] was the maximum that could be approved for a given training session under the dollar limit imposed last year, and October 2012 saw the first NCPS Patient Safety Boot Camp for the Technical Career Field (TCF) Biomedical Engineer (BME) Alpha Class, said Bagian, who was in charge of the program. The main goals of the joint pilot project were to: Train CEs in a systems approach to patient safety, so that adverse events in the field are well understood. Train CEs in how to participate on an RCA team, identifying the root causes of patient safety events. Disseminate this knowledge to engineering colleagues in all 153 VA facilities. Strengthen the partnership between CEs and patient safety managers. Key elements of the new training program developed by the two departments included: Providing NCPS patient safety manager training with focus on HTM tools and concepts. Incorporating NCPS training modules on high reliability organization structure to provide a shared vision of the VA hospital of the future. VA biomedical engineers attend a boot camp on patient safety. Using hands-on human factors exercises for the HTM trainees to illustrate the capabilities and limitations of humans in a system, as well as illustrating how an environment or situation affects the performance of a task. Emphasizing understanding of an event using the RCA process and discussing actions most likely to make a difference in removing or containing the vulnerability. Providing techniques such as proactive healthcare failure mode and effect analysis (HFMEA) to assess complex new technology to be acquired by a facility. Emphasizing case study analysis. The result is not just a view of a device, but of the whole complex, interoperable system, allowing analysts to determine how the device affects patient safety across the country, and to determine system vulnerabilities that would otherwise remain hidden. 47
4 Members of the VA s healthcare technology management team pose for a photo at the AAMI 2012 Conference & Expo in Charlotte, NC. The VA has the luxury of having a 153-facility network where any lesson discovered by a given team on a given shift at a given facility can be learned by all VA employees said Bagian. In particular, because the VA maintains more than 1 million patient safety event reports, many of which involve devices, the unique opportunity exists for extensive analysis of the complexity of the medical device world at a national level. In the field, adverse events are scored, and those with a high score require a root cause analysis, said Bagian. In 2012, we had nearly 108,000 reports. Over 1,150 of these were investigated via RCA, and each one can be used to demonstrate national trends in specific issues. The result is not just a view of a device, but of the whole complex, interoperable system, allowing analysts to determine how the device impacts patient safety across the country, and to determine system vulnerabilities that would otherwise remain hidden. Results The result is not just a view of a device, but of the whole complex, interoperable system, allowing analysts to determine how the device affects patient safety across the country, and to determine system vulnerabilities that would otherwise remain hidden. This holistic view also affects staff interaction, increasing collaboration, knowledge sharing, and skills, said Bagian. NCPS analysts talk to the patient safety officers and patient safety managers, and dive into the database. There is a neat synergy to provide support for frontline engineers and technicians who might see a potential vulnerability, and work with their patient safety manager to improve healthcare systems across the entire VA. I see tangible benefits that have emerged from this initiative, said Finke. I hear reports that RCAs are improving in quality, and that a multidisciplinary team was involved; patient safety managers comment on the talents of our HTM staff talents that were not recognized before; and I hear people asking questions about specifications and requirements for purchasing that tie to ease of use and usability. The program s initial phase of training incoming CEs has been so successful that the VA is in the process of expanding it to seasoned biomedical or clinical engineers. Although the program was implemented only a year ago, data suggests that it has had an enormous impact. In 2011, according to Finke, 11,000 hours of HTM staff time were spent on RCAs. In 2013, that number jumped to 13,400 hours, a 22% increase. Time spent in identifying and reporting issues is critical. For each adverse event, noted Bagian, we have 45 days to make sure VA learns from the event or close call that warranted an RCA. The team describes the device, understands the issue, and talks to manufacturers as well as clinicians who deliver the treatment to the patients. When an issue is understood to be a potential vulnerability for more than the local facility, the NCPS team determines if concrete actions can be taken at a national level to remove or reduce the potential harm, sometimes publishing a Patient Safety Advisory or Patient Safety Alert requiring VA facilities to take action. The more analysis 48
5 that takes place, the more likely it is that a future adverse event can be prevented. Trainees who have attended the program attest to the success of the initiative. I m more cognizant of potentially faulty medical equipment procurement and utilization processes, said Jennifer Wong. Patient safety is dependent on effective policies and processes rather than specific people or devices. For Paige Armstrong, the training program was eye opening: I didn t realize the effect I could have on patient safety within my career field as a biomedical engineer. Kristen Russell, a new CE at the VA, found that the Patient Safety Boot Camp was a tremendous learning opportunity covering a wide variety of safety topics including root cause analysis, failure mode effects analysis, and human factors engineering. The future appears bright for the VA s ongoing partnership between patient safety The future appears bright for the VA s ongoing partnership between patient safety managers and HTM professionals. managers and HTM professionals. This is likely to create a more mission-focused, systems-focused team at every facility, said Bagian. We already are seeing an energized analysis in some of our RCAs involving devices where the RCA team chooses to simulate or replicate their ideas of root causes to confirm their understanding and an increase in proactively detecting and resolving vulnerabilities due to more involvement and detailed reporting from the field. According to Bagian, the HTM department plans to offer two core courses on patient safety to every biomedical engineer. That s not all. Based on the success of the partnership with HTM, NCPS envisions working with other departments, such as pharmacy and radiology, to better understand complex events or close calls. Advance Your Career With... Career Moves This one CD is packed with more than 150 career-related articles and resources. Learn how to: u Prepare for a certification exam u Improve customer service u Become a manager u Sharpen your skills and learn specialties u Keep up-to-date on IT training and much more Career Moves: Advancing Your Career in Healthcare Technology 2013 edition A valuable resource for clinical and biomedical engineers and technicians. Order code: CAREER-CD List $160 AAMI member $85 SOURCE CODE: PB To order your copy today, call or visit 49
Optimizing Medical Device Safety: A Closed Loop Process
Optimizing Medical Device Safety: A Closed Loop Process Session #149, February 22, 2017, 8:30AM Shelly Crisler & Katrina Jacobs US Department of Veterans Affairs 1 Speaker Introduction Shelly Crisler,
More informationPatient Safety Initiatives of the VA National Center for Patient Safety
Patient Safety Initiatives of the VA National Center for Patient Safety At the Quality Colloquium at Harvard University John Gosbee, MD, MS August 27, 2003 National Center for Patient Safety Department
More informationCognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1.
Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall Application Analysis Total 1. CULTURE 2 12 4 18 A. Assessment of Patient Safety Culture 1. Identify work settings
More informationEnd-to-end infusion safety. Safely manage infusions from order to administration
End-to-end infusion safety Safely manage infusions from order to administration New demands and concerns 56% 7% of medication errors are IV-related. 1 of high-risk IVs are compounded in error. 2 $3.5B
More informationHEALTHCARE TECHNOLOGY MANAGEMENT (HTM) Tackling Your Top Challenges
HEALTHCARE TECHNOLOGY MANAGEMENT (HTM) Tackling Your Top Challenges Are you maximizing the talents of your HTM team? Discover and utilize their abilities for the benefit of your organization: 1. Make sure
More informationSelf-Assessment Questionnaire: Establishing a Health Information Technology Safety Program
Self-Assessment Questionnaire: Establishing a Health Information Technology Safety Program Initial assessment by: Date: In consultation with: Date of previous assessment: The success of a health information
More informationGuidance for Medication Reconciliation and System Integration Process
Guidance for Medication Reconciliation and System Integration Process Identifying points of failure within the medication reconciliation process and determining systematic approaches (via health IT) to
More informationBridging the Gap Between Clinicians and HTM Staff
Bridging the Gap Between Clinicians and HTM Staff James H. Philip MEE MD CCE, Professor of Anaesthesia, Harvard Medical School, Anesthesiologist and Medical Liaison for Anesthesia, Department of Biomedical
More informationWalking the Tightrope with a Safety Net Blood Transfusion Process FMEA
Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA AnMed Health AnMed Health, located in Anderson, South Carolina, is one of the largest and most technologically advanced health systems
More informationLEARNING FROM THE VANGUARDS:
LEARNING FROM THE VANGUARDS: STAFF AT THE HEART OF NEW CARE MODELS This briefing looks at what the vanguards set out to achieve when it comes to involving and engaging staff in the new care models. It
More informationQA offers significant economic benefits!
and Safety Systems in the USA J. Tobey Clark, MSEE, CCE, SASHE University of Vermont, USA Definitions Quality assurance Planned and systematic actions that can be demonstrated to provide confidence that
More informationVA Radiotherapy Incident Reporting and Analysis System (RIRAS)
VA Radiotherapy Incident Reporting and Analysis System (RIRAS) Jatinder R Palta PhD Rishabh Kapoor MS Michael Hagan, MD National Radiation Oncology Program(10P11H) Veterans Health Administration Disclosure
More informationUniversity of Michigan Health System Part IV Maintenance of Certification Program [Form 12/1/14]
Report on a QI Project Eligible for Part IV MOC: Improving Medication Reconciliation in Primary Care Instructions Determine eligibility. Before starting to complete this report, go to the UMHS MOC website
More informationImproving the Safe Use of Multiple IV Infusions
QUICK GUIDE Improving the Safe Use of Multiple IV Infusions The AAMI Foundation is grateful to its collaborating partners in the National Coalition for Infusion Therapy Safety: Acknowledgements The AAMI
More informationRisk Management in the ASC
1 Risk Management in the ASC Sandra Jones CASC, LHRM, CHCQM, FHFMA sjones@aboutascs.com IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2014 Accreditation Association for Conflict of Interest Disclosure
More informationComprehensive Analysis Method
Incident Analysis Learning Program - Module Four Comprehensive Analysis Method Jan. 10, 2013 Welcome Ioana Popescu Sandi Kossey Erin Pollock Tina Cullimore Learning Program M3 WHAT WAS LEARNED? WHAT CAN
More information2011 Electronic Prescribing Incentive Program
2011 Electronic Prescribing Incentive Program Hardship Codes In 2012, the physician fee schedule amount for covered professional services furnished by an eligible professional who is not a successful electronic
More informationHendricks Regional Health Patient Safety Strategic Plan
Hendricks Regional Health Patient Safety Strategic Plan Strategic Planning Achieve Excellence in Healthcare Industry Role: Administration, Medical staff leaders and patient safety staff will participate
More informationManaging Technology, Saving Lives...
Managing Technology, Saving Lives... A Career in healthcare technology management make a difference as a technician supporting healthcare technology! if you are looking for a meaningful career that offers
More informationA PRINCIPLED APPROACH TO DELIVERING PATIENT-FOCUSED CARE
A PRINCIPLED APPROACH TO DELIVERING PATIENT-FOCUSED CARE 18 Just as individual practitioners must constantly reflect on their practice in order to learn and grow so must the regulatory College. We do this
More informationTHE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION
THE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION Requirements: Component I Patient Safety Self-Assessment Program Programs must meet the following criteria to be an ABP approved Patient
More informationNSERC Management Response: Evaluation of NSERC s Discovery Program
NSERC Response: Evaluation of NSERC s Discovery Program Discovery Grants are NSERC s leading source of funding for thousands of researchers each year. These grants account for more than one-third of NSERC
More informationHow the Industry Must Take in Stride New CMS and TJC Requirements
Two Steps Forward, One Step Back How the Industry Must Take in Stride New CMS and TJC Requirements Stephen L. Grimes About the Author Stephen L. Grimes, FACCE, FHIMSS, FAIMBE, is chief technology officer
More informationU-M Hospitals and Health Centers Policies and Procedures
U-M Hospitals and Health Centers Policies and Procedures UMHHC Policy 05-02-006 Safe Medical Device Act Policy Issued: 4/00; Last Reviewed: 10/04; Last Revised: 10/04 Return to UMHHC Policies Table of
More informationSTATEMENT. JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration
STATEMENT JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration Institute of Medicine Committee on Patient Safety and Health Information Technology
More informationWHITEPAPER: PERSPECTIVES ON MILITARY HEALTHCARE QUALITY IMPROVEMENT Strategic Collaboration
WHITEPAPER: PERSPECTIVES ON MILITARY HEALTHCARE QUALITY IMPROVEMENT Strategic Collaboration LEVERAGING LEAN SIX SIGMA TO HARNESS THE BEST OF VA & MILITARY HEALTHCARE Introduction Continuous Process Improvement
More informationOHTAC Recommendation. Implementation and Use of Smart Medication Delivery Systems
OHTAC Recommendation Implementation and Use of Smart Medication Delivery Systems July 2009 Background The Ontario Health Technology Advisory Committee (OHTAC) engaged the University Health Network s (UHN)
More informationUNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN 2014 1 PATIENT SAFETY PLAN 2014 PROGRAM GOALS The goal of the Patient Safety Program at University of Mississippi Medical Center (UMMC) is to
More informationThe Solution to Medical Device Security Also Could Save Tens of Thousands of Lives and Millions of Dollars
The Solution to Medical Device Security Also Could Save Tens of Thousands of Lives and Millions of Dollars February 24, 2017 Evolver, Inc. The Solution to Medical Device Security Could Save Tens of Thousands
More informationUsing CAST for Adverse Event Investigation in Hospitals
Using CAST for Adverse Event Investigation in Hospitals Meaghan O Neil March 27, 2014 Motivation As many as 98,000 people, die in hospitals each year as a result of medical errors that could have been
More informationTraining for ICD-10: A Complete Plan Extends Beyond Coders
Training for ICD-10: A Complete Plan Extends Beyond Coders ICD-10 training discussions have primarily centered around medical coders. As providers experienced with MS-DRGs, however, effective clinical
More informationExpanding Role of the HIM Professional: Where Research and HIM Roles Intersect
Page 1 of 6 The Expanding Role of the HIM Professional: Where Research and HIM Roles Intersect by Jessica Bailey, PhD, RHIA, CCS, and William Rudman, PhD Abstract This article examines the evolving role
More informationDefining incident-based peer review
CHAPTER 1 Defining incident-based peer review Learning objectives After reading this chapter, the participant will be able to: Identify three external sources imposing higher nursing standards Discuss
More informationPreventing Medical Errors
Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.
More informationFully Featured Safe and Secure eprescribing from PatientSource. Patient Care Safely in One Place
Fully Featured Safe and Secure eprescribing from PatientSource Patient Care Safely in One Place eprescribing works seamlessly between different teams in different departments PatientSource eprescribing
More informationProactively prevent HAIs with infection surveillance software
Proactively prevent HAIs with infection surveillance software NIP HAIs IN THE BUD Redirect your time to proactively preventing infections instead of just reacting. RL s automated infection surveillance
More informationThe Road to Clinical Transformation
The Road to Clinical Transformation Ann O Brien RN MSN CPHIMS Kaiser Permanente Senior Director Clinical Informatics KPIT & National Patient Care Services Learning Objectives 1. Describe strategies to
More informationAdverse Events: Thorough Analysis
CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES Adverse Events: Thorough Analysis James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP QAPI Specialist/ Quality Surveyor Educators
More informationComponent Description Unit Topics 1. Introduction to Healthcare and Public Health in the U.S. 2. The Culture of Healthcare
Component Description (Each certification track is tailored for the exam and will only include certain components and units and you can find these on your suggested schedules) 1. Introduction to Healthcare
More informationObjectives. Key Elements. ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management 5/20/2014
ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management Matthew Fricker, RPh, MS, FASHP Program Director, ISMP Rebecca Lamis, PharmD, FISMP Medication Safety Analyst,
More informationFRIENDS OF EVIDENCE CASE STUDY
Asthma Improvement Collaborative FRIENDS OF EVIDENCE CASE STUDY This is one of a series of illustrative case studies, under the auspices of the Friends of Evidence, describing powerful approaches to evidence
More informationE-Referral (Ministry of Health (MoH) - Oman) Mr. Abdullah Al Raqadi, DG of Information Technology
E-Referral (Ministry of Health (MoH) - Oman) Mr. Abdullah Al Raqadi, DG of Information Technology I. Background information The problem of manual Medical Records is quite complex. Each patient has multiple
More informationCIO Legislative Brief
CIO Legislative Brief Comparison of Health IT Provisions in the Committee Print of the 21 st Century Cures Act (dated November 25, 2016), H.R. 6 (21 st Century Cures Act) and S. 2511 (Improving Health
More informationPractice Spotlight. Children's Hospital Central California Madera, California
Practice Spotlight Children's Hospital Central California Madera, California http://www.childrenscentralcal.org Richard I. Sakai, Pharm.D., FASHP, FCSHP Director of Pharmacy Services IN YOUR VIEW, HOW
More information12.01 Safety Management Plan UWHC Administrative Policies
Page 1 of 7 12.01 Safety Management Plan Category: UWHC Administrative Policy Policy Number: 12.01 Effective Date: October 8, 2013 Version: Revision Section: Environmental Safety (Hospital Administrative)
More informationAdministrative Update: How to Implement Discharge Pharmacy Services (DPS) Objectives
Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Morgan Pendleton, PharmD, BCOP Hematology/Oncology Clinical Pharmacist Wake Forest Baptist Health Objectives Evaluate the need
More informationCOACHING GUIDE for the Lantern Award Application
The Lantern Award application asks you to tell your story. Always think about what you are proud of and what you do well. That is the story we want to hear. This coaching document has been developed to
More informationRoot Cause Analysis Practicum Human Factors Engineering Short Course
Learning Objectives Root Cause Analysis Practicum Human Factors Engineering Short Course 1. Identify human factors and other work system issues associated with an adverse event. 2. Develop a Cause-Effect
More informationTHE ROLE OF BIOMEDICAL ENGINEERING IN HEALTH TECHNOLOGY MANAGEMENT
THE ROLE OF BIOMEDICAL ENGINEERING IN HEALTH TECHNOLOGY MANAGEMENT THE OPPORTUNITIES AND CHALLENGES IN A LOCAL HEALTH CARE SETTING 2017 CADTH SYMPOSIUM HAL HILFI, CORPORATE MANAGER THE OTTAWA HOSPITAL
More informationDepartment of Veterans Affairs VA HANDBOOK 5005/106 [STAFFING
Department of Veterans Affairs VA HANDBOOK 5005/106 Washington, DC 20420 Transmittal Sheet April 3, 2018 [STAFFING 1. REASON FOR ISSUE: To revise the Department of Veterans Affairs (VA) qualification standard
More informationADMINISTRATIVE SUMMARY OF INVESTIGATION BY THE VA OFFICE OF INSPECTOR GENERAL IN RESPONSE TO ALLEGATIONS REGARDING PATIENT WAIT TIMES
ADMINISTRATIVE SUMMARY OF INVESTIGATION BY THE VA OFFICE OF INSPECTOR GENERAL IN RESPONSE TO ALLEGATIONS REGARDING PATIENT WAIT TIMES VA Medical Center in Wilmington, Delaware March 1, 2016 1. Summary
More informationOn the CUSP: Stop BSI
On the CUSP: Stop BSI Learning From Defects December 6, 2011 Comprehensive Unit-based Safety Program (CUSP) 1. Educate staff on science of safety (www.safercare.net) 2. Identify defects 3. Assign executive
More informationDesigning for Safety
2014 FGI Guidelines Update Series FGI Guidelines Update #1 July 11, 2013 Designing for Safety Ellen Taylor, AIA, MBA, EDAC In 2010 one of the topics introduced to the Guidelines for Design and Construction
More informationQAPI Making An Improvement
Preparing for the Future QAPI Making An Improvement Charlene Ross, MSN, MBA, RN Objectives Describe how to use lessons learned from implementing the comfortable dying measure to improve your care Use the
More information4. Hospital and community pharmacies
4. Hospital and community pharmacies As FIP is the international professional organisation of pharmacists, this paper emphasises the role of the pharmacist in ensuring and increasing patient safety. The
More informationA17/B17: Addressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care
A17/B17: Addressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care Gordy Schiff, MD, Associate Director of Brigham and Women s Center for Patient Safety Research
More informationThe Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow
The Impact of CPOE and CDS on the Medication Use Process and Pharmacist Workflow Conflict of Interest Disclosure The speaker has no real or apparent conflicts of interest to report. Anne M. Bobb, R.Ph.,
More informationDepartment of Veterans Affairs VA HANDBOOK 5005/42. September 28, 2010 STAFFING
Department of Veterans Affairs VA HANDBOOK 5005/42 Washington, DC 20420 Transmittal Sheet September 28, 2010 STAFFING 1. REASON FOR ISSUE: To establish a Department of Veterans Affairs (VA) qualification
More informationRoot Cause Analysis. Why things happen
Root Cause Analysis Why things happen Secret There is really no such thing as a root cause There are contributing factors and there is no end to them Purpose of a Root Cause Analysis The purpose is to
More informationSNOMED CT AND 3M HDD: THE SUCCESSFUL IMPLEMENTATION STRATEGY
SNOMED CT AND 3M HDD: THE SUCCESSFUL IMPLEMENTATION STRATEGY Federal Health Care Agencies Take the Lead The United States government has taken a leading role in the use of health information technologies
More informationORs in facilities that adopted team training had a lower rate of deaths for
Patient safety VA study shows fewer patient deaths after OR team training ORs in facilities that adopted team training had a lower rate of deaths for surgical patients than facilities that had not yet
More informationAutomation and Information Technology
4 Automation and Information Technology Positions Automation and Information Technology Ensuring Patient Safety and Data Integrity During Cyber-attacks (1701) To advocate that healthcare organizations
More information1. When will physicians who are not "meaningful" EHR users start to see a reduction in payments?
CPPM Chapter 7 Review Questions 1. When will physicians who are not "meaningful" EHR users start to see a reduction in payments? a. January 1, 2013 b. January 1, 2015 c. January 1, 2016 d. January 1, 2017
More informationNational Patient Safety Agency Root Cause Analysis (RCA) Investigation
National Patient Safety Agency Root Cause Analysis (RCA) Investigation Margaret O Donovan Assistant Director for Acute Services Types of failure Active failures - slips, lapses, fumbles, mistakes, procedural
More informationRCA in Healthcare 3/23/2017. Why Root Cause Analysis is Performed. Root Cause Analysis in Healthcare Part - 1. Contd. Contd.
Why Root Cause Analysis is Performed Root Cause Analysis in Healthcare Part - 1 Prof (Col) Dr R N Basu Executive Director Academy of Hospital Administration Kolkata Chapter The goal of the root cause analysis
More informationContains Nonbinding Recommendations. Draft Not for Implementation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Public Notification of Emerging Postmarket Medical Device Signals ( Emerging Signals ) Draft Guidance for Industry
More informationILLUSTRATION BY STEPHANE MANEL
+A ILLUSTRATION BY STEPHANE MANEL AN INTERVIEW WITH BERNARD J. TYSON, CHAIRMAN AND CEO OF KAISER PERMANENTE SERVING PATIENTS AS CONSUMERS BERNARD J. T YSON is chairman and CEO of Kaiser Permanente, a health
More informationVeterans of Foreign Wars of the United States Views on Commission on Care Recommendations
Veterans of Foreign Wars of the United States Views on Commission on Care Recommendations The VHA Care System Recommendation #1: Across the United States, with local input and knowledge, VHA should establish
More informationPractice Spotlight. Baystate Health - Baystate Medical Center Springfield, Massachusetts
Practice Spotlight Baystate Health - Baystate Medical Center Springfield, Massachusetts www.baystatehealth.org Erin Taylor, PharmD Clinical Pharmacy Supervisor Gary Kerr, PharmD, MBA Director, Pharmacy
More informationLessons from Chicago
Lessons from Chicago Lela Holden, PhD, RN Patient Safety Officer Edward P. Lawrence Center for Quality & Safety Massachusetts General Hospital October 5, 2010 Let s hear from Catherine Zeta-Jones 2002
More informationRoot Cause Analysis: The NSW Health Incident Management System
Root Cause Analysis: The NSW Health Incident Management System SARAH MICHAEL, RN, GradDipQHCM PAUL DOUGLAS, MB, BS, DRACOG, MHA, FRACMA With a background in intensive care, Sarah is a Principal Analyst
More informationNATIONAL HEALTH IT. For the Underserved. The National Health IT Collaborative for the Underserved 1
The National Health IT Collaborative for the Underserved 1 NATIONAL HEALTH IT For the Underserved "A Pu blicpriva te Partnership for a Healthier America7' Introducing the National Health IT Collaborative
More informationYvette R. Roberts DNP, MSN, MS, MHA, CPHIT
Yvette R. Roberts DNP, MSN, MS, MHA, CPHIT yroberts@govst.edu Education 2013 Governors State University, University Park, IL Doctor in Nursing Practice 2013 Governors State University, University Park,
More informationProviding the Highest Quality of Care for the Nation s Veterans
Providing the Highest Quality of Care for the Nation s Veterans Barbara Fleming, MD, PhD Chief Quality and Performance Officer, Veterans Health Administration Outline Historical Perspective Key Drivers
More informationJCI 6 th ed. Hospital Standards Review: Patient-Centered Standards
JCI 6 th ed. Hospital Standards Review: Patient-Centered Standards Standards Overview This presentation provides a general sense of what types of issues and themes are covered in our Patient- Centered
More informationReducing Medical Errors at the Bedside
Transcript Details This is a transcript of an educational program accessible on the ReachMD network. Details about the program and additional media formats for the program are accessible by visiting: https://reachmd.com/programs/clinicians-roundtable/reducing-medical-errors-at-the-bedside/3974/
More informationOrganizational Overview
0 Organizational Overview First All Digital Hospital in U.S. Fully integrated EMR across 2 Hospitals & 60 Clinics National Valve Center Five Star Hotel for; Patients, Physicians, Nurses & and all team
More informationIncident Reporting and Investigations. Mary Bolbrock, RN MSN Ann Marie McDonald, RN EdD
Incident Reporting and Investigations Mary Bolbrock, RN MSN Ann Marie McDonald, RN EdD Objectives To serve as a training tool for identification of incidents and conduction of incident investigations To
More informationUNDERSTANDING THE CONTENT OUTLINE/CLASSIFICATION SYSTEM
BOARD OF PHARMACY SPECIALTIES CRITICAL CARE PHARMACY SPECIALIST CERTIFICATION CONTENT OUTLINE/CLASSIFICATION SYSTEM FINALIZED SEPTEMBER 2017/FOR USE ON FALL 2018 EXAMINATION AND FORWARD UNDERSTANDING THE
More informationQuality Management Building Blocks
Quality Management Building Blocks Quality Management A way of doing business that ensures continuous improvement of products and services to achieve better performance. (General Definition) Quality Management
More informationABMS Organizational QI Forum Links QI, Research and Policy Highlights of Keynote Speakers Presentations
ABMS Organizational QI Forum Links QI, Research and Policy Highlights of Keynote Speakers Presentations When quality improvement (QI) is done well, it can improve patient outcomes and inform public policy.
More informationIncreasing Benefits Access for People with Medicare: Lessons Learned from the Second Generation of Benefits Enrollment Centers (BECs)
Increasing Benefits Access for People with Medicare: Lessons Learned from the Second Generation of Benefits Enrollment Centers (BECs) A report from the Center for Benefits Access at the National Council
More informationSustaining the practice
Linda O. Nichols, PhD Jennifer Martindale-Adams, EdD Caregiver Center VA Medical Center Memphis American Society on Aging Annual Meeting Rosalynn Carter Institute Workshop Going to Scale in Provision of
More informationLetitia Cameron, MD Aniel Rao, MD Michael Hill, MD
Presented by: Suchita Pancholi, MD Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD I. Introductions II. III. IV. Marshmallow Challenge Why Teach Patient Safety? Barriers to Teaching Patient Safety V.
More informationTitle: Lifelong Learning: Developing Professional and Personal Leadership
Title: Lifelong Learning: Developing Professional and Personal Leadership Jennifer L. Saylor, PhD, MSN, BSN, RN, APRN-BC School of Nursing, University of Delaware, Newark, DE, USA Session Title: Leadership
More informationThe Four Pillars of Ambulatory Care Management - Transforming the Ambulatory Operational Framework
The Four Pillars of Ambulatory Care Management - Transforming the Ambulatory Operational Framework Institution: The Emory Clinic, Inc. Author/Co-author(s): Donald I. Brunn, Chief Operating Officer, The
More informationExecutive Summary: Davies Ambulatory Award Community Health Organization (CHO)
Davies Ambulatory Award Community Health Organization (CHO) Name of Applicant Organization: Community Health Centers, Inc. Organization s Address: 110 S. Woodland St. Winter Garden, Florida 34787 Submitter
More informationCASE STUDY: PENINSULA REGIONAL MEDICAL CENTER
CASE STUDY: PENINSULA REGIONAL MEDICAL CENTER Incorporating IV room efficiencies while striving toward improving patient care 111852 2K 01/13 Page 1 of 5 OVERVIEW Peninsula Regional Medical Center (PRMC),
More informationMedication Reconciliation for Older Adults Transitioning from. Long-Term Care to Home. Allison (Leverett) Kackman
Medication Reconciliation for Older Adults Transitioning from Long-Term Care to Home By Allison (Leverett) Kackman Washington State University Spokane. Riverpoint campus Ubrary P.O. Box 1495 Spokane, WA
More informationAchieving safety in medication management through barcoding technology
Achieving safety in medication management through barcoding technology Kara Marx, RN, FACHE, FHIMSS Vice President of Information Services Sharp Healthcare. SESSION OBJECTIVES Describe the primary activities
More informationADVANCES IN Telehealth: The best ways to engage with patients using different mediums
ADVANCES IN Telehealth: The best ways to engage with patients using different mediums Use Internet & Mobile Technology to Gain Productivity The aging population and an increased focus on health are two
More informationA GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University
More informationHealth Management Information Systems: Computerized Provider Order Entry
Health Management Information Systems: Computerized Provider Order Entry Lecture 2 Audio Transcript Slide 1 Welcome to Health Management Information Systems: Computerized Provider Order Entry. The component,
More informationClinical Pharmacist Renal
POSITION DESCRIPTION Date : January 2011 Job Title : Clinical Pharmacist Department : Pharmacy Service Location : North Shore or Waitakere Hospitals Reporting To : Clinical Pharmacist Coordinator Direct
More informationTL5b: Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through planned change.
Transformational Leadership: Advocacy and Influence TL5: Nurse Leaders lead effectively through change. TL5b: Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully
More informationElectronic Prescribing (erx): The Pros and Cons. Richard Kalish, MD, MPH Medical Director Boston HealthNet August 13, 2009
Electronic Prescribing (erx): The Pros and Cons Richard Kalish, MD, MPH Medical Director Boston HealthNet August 13, 2009 Established in 1995 Boston HealthNet Partnership between Boston Medical Center,
More informationMedication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety
Medication Safety Action Bundle Adverse Drug Events (ADE) All High-Risk Medication Safety Background The Institute of medicine (IOM) estimates that 1.5 million preventable Adverse Drug Events (ADE) occur
More informationDOCUMENT E FOR COMMENT
DOCUMENT E FOR COMMENT TABLE 4. Alignment of Competencies, s and Curricular Recommendations Definitions Patient Represents patient, family, health care surrogate, community, and population. Direct Care
More informationGAO. Testimony Before the Subcommittee on Health, Committee on Veterans Affairs, House of Representatives
GAO For Release on Delivery Expected at 10:00 a.m. EDT Thursday, September 23, 2010 United States Government Accountability Office Testimony Before the Subcommittee on Health, Committee on Veterans Affairs,
More informationA Step-by-Step Guide to Tackling your Challenges
Institute for Innovation and Improvement A Step-by-Step to Tackling your Challenges Click to continue Introduction This book is your step-by-step to tackling your challenges using the appropriate service
More information