Building a Safe Healthcare System
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1 Building a Safe Healthcare System
2 Objectives 2 Discuss the process of improving healthcare systems. Introduce widely-used methodologies in QI/PS.
3 What is Quality Improvement? 3 Process of continually evaluating clinical practices using patient outcomes as the basis. Patient safety is a subset of QI. Minimizing risks of errors and injury. Increase chances of catching errors before they occur through system performance. Donald Berwick, A User s Manual for the IOM s Quality Chasm Report, Health Affairs 21:3 (2002):
4 Quality Is a Team-Oriented Process 4 Quality Management departments Regulatory requirements Goal: Patientcentered care Risk Management departments Surveys of patient satisfaction Adverse event reviews
5 Effecting System Change: Process 5 Planning Benchmarking: Compare ourselves with others or from an historical internal perspective. Defining the process Root Cause Analysis Fishbone (Ishikawa) Diagrams Flow Charts Brainstorming Effecting Change Recognize and accept need for change Identify participants, resources, and the value of change. Implement interventions. Monitor outcomes.
6 Effecting System Change: Culture 6 Organizational culture: patterned way that an organization responds to challenges. Organizational learning: process of increasing the capacity for effective organizational action through knowledge and understanding. Culture of safety: safety is everyone s responsibility; avoids shame-and-blame; errors are learning opportunities. Westrum R, Qual Saf Health Care, :22-27; Carroll JS and Edmondson AC, Qual Saf Health Care, :51-56; Mohr JJ and Batalden PB, Qual Saf Health Care, :45-50; and Sachdeva AK and Blair PG, Surg Clin N Am, :
7 Effecting System Change: Culture Pathological Bureaucratic Generative Westrum R, Qual Saf Health Care, :22-27
8 Highly Reliable Systems 8 Necessary resources are allocated to safety. Openness exists regarding errors and problems. Communication is frequent and candid and organizational learning is promoted. Singer SJ et al, Qual Saf Health Care, : ; Schulman PR, Qual Saf Health Care, (Suppl II):ii39-ii44
9 Highly Reliable Systems: Teams 9 Highly reliable teams: Adapt to changes in task environment. Maintain open and flexible communication. Anticipate the needs of each team member. Entin EE and Serfaty D, Hum Factors :
10 Highly Reliable Systems: Microsystem 10 Each local group of clinicians, staff working together with shared clinical purpose to provide care for their patients. Mohr JJ, Batalden P, Barach P, Qual Saf Health Care, 2004;13(Suppl II):ii34-ii38.
11 Nolan TW, BMJ, : Highly Reliable Systems: Reducing Error 11 Decrease complexity. Optimize information processing. Automate intelligently. Employ constraints. Physical Procedural Cultural Avoid the unwanted side effects of change.
12 Analyzing Data to Improve 12 PDCA Six Sigma Human Factors Engineering RCA LEAN FMEA/ HFMEA
13 Common Methodology: RCA 13 Root Cause Analysis: identify the basic causal factors underlying a variation or adverse event. The error is like a weed only a symptom of more widespread underlying problems. RCA analyzes underlying causes of adverse events problems that are below the surface and not obvious. Root Cause Analysis Basics,
14 Common Methodology: PDCA 14 Hospital and private practice systems use the Plan, Do, Check (Study), Act cycle methodology. Used by the Joint Commission (JC), the Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies.
15 Plan-Do-Check-Act (PDCA) Cycle, Common Methodology: PDCA 15 Act: Develop plan to implement change. If successful, periodically reevaluate to maintain levels of success. If not successful, modify action plan and repeat cycle. Plan: Explore a challenge, perform a literature search, and develop an action plan that is measureable, achievable, and relevant. Check (Study): Evaluate progress to plan change. Do: Implement your action plan with quantifiable data measurement.
16 Common Methodology: Lean 16 Cultural commitment to know and provide what customer wants. Revise process to: Eliminate waste. Add value. Sample tool: Fishbone diagram Map out all the variables.
17 Common Methodology: Lean 17 Push Push: Reactively dealing with delays. Pull: Anticipate problems and optimize the system. Pull Eliminate Pushes and adopt Pulls. Thomas Pyzdek, The Six Sigma Handbook. McGraw Hill, 2003.
18 Common Methodology: Human Factors 18 Study human behavior, abilities, limitations and interaction with system components. Human Error Theory: inherent risks for organization-wide and personal error therefore, layers of defense. Gawron VJ et al, Am J Med Qual, :57-67; Reason J, Qual Saf Health Care, :56-61
19 Common Methodology: Human Factors 19 Swiss cheese model: Human error is inevitable. An error-free system cannot be created. Systems require layers of defense. Reason J, BMJ, :
20 Firth-Cozens J, Qual Saf Health Care, (Suppl II):ii26-ii31. Common Methodology: Human Factors 20 Risks Defenses
21 Common Methodology: Human Factors 21 Some mechanisms already adopted based on human factors. Preoperative verification process Time Outs Operative site marking All Joint Commission mandates since July 2004
22 Analyzing Data to Improve 22 PDCA LEAN Human Factors Engineering Six Sigma FMEA/ HFMEA RCA There are many other QI methodologies and tools. Additional resources are available on the EQuIP website.
23 Analyzing Data to Improve 23 If corrective action is validated by improved outcomes, plan to roll out with good communication and training for staff. Plan to monitor frequently. Quality improvement is an ongoing process!
24 Summary 24 System change and improvement is long-term and continual process. Both cultural and process issues are important. There are many methodologies and tools, but the keys to success are the same. Analysis of current performance. Communication. Measurable outcomes and monitoring. Every system has inherent risks for error.
25 EQuIP Staff 25 EQuIP Director Murtuza (Zee) Ali, MD, FACC, FSCAI EQuIP Coordinator Victoria Harkin, MA (504)
26 Acknowledgements 26 Murtuza Ali, MD Peter DeBlieux, MD John Paige, MD Fred Rodriguez, MD Rebecca Frey, PhD Stacey Holman, MD Richard Tejedor, MD Quality, Safety and Risk Department, Interim LSU Hospital.
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National Health Regulatory Authority Kingdom of Bahrain THE NHRA GUIDANCE ON SERIOUS ADVERSE EVENT MANAGEMENT AND REPORTING THE PURPOSE OF THIS DOCUMENT IS TO OUTLINE SERIOUS ADVERSE EVENTS THAT SHOULD