Medical Office Survey on Patient Safety Culture Initiatives

Transcription

1 Medical Office Survey on Patient Safety Culture Initiatives MARIAH RAMIREZ MENTOR: KATHY DONOHUE BSN,MBA,CHCQM,CPPS DIRECTOR AMBULATORY QUALITY CEQI

2 Agenda I. The Reality of Medical Errors II. Definition: Patient Safety Culture III. Overview of AHRQ 2016 Medical Office Survey on Patient Safety Culture IV: Description of Summer Project Methods Initiatives Evaluation Tool V: My Role/Learning Experience

3 The Reality of Medical Errors in Healthcare Setting 1 jet/day 44,000-98,000/year Source: To Err is Human: Building a Safer Health System, 1999

4 What is Patient Safety Culture? the product of individual and group values, attitudes, perceptions and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization s health and safety management.

5 AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers includes: nurses, physicians, front-desk staff, medical assistants, nurse practitioners, etc. Purpose of AHRQ Survey: Can assess the baseline status of the patient safety culture in a medical office Can act as an intervention to raise staff awareness about patient safety issues Can be a mechanism to evaluate the impact of patient safety improvement initiatives Is a way to track changes in patient safety culture over time

6 10 Domains Measured Patient Care Tracking and Follow-Up Staff Training Overall Perceptions of Patient Safety and Quality Office Process and Standardization Teamwork Communication about Error Leadership Support for Patient Safety Communication Openness Organizational Learning Work Pressure and Pace

7 Characteristics of Survey Respondents Comparative AHRQ Database 25,127 medical office respondents Clinical Staff Administrative Staff Registered Nurses Areas of Strength Teamwork Patient Care Tracking/Follow-Up Areas of Opportunity Work Pressure and Pace Communication about Error Clinical Practices of the University of Pennsylvania (CPUP) 1,952 medical office respondents Physicians Administrative or Clerical Staff Advanced practice nurse Areas of Strength Teamwork Patient Care Tracking/Follow-Up Overall Perceptions of Patient Safety Areas of Opportunity Work Pressure and Pace Communication about Error Office Processes and Standardization

8 Aim of Summer Project Goal: Improve Patient Safety Culture across the Clinical Practices of University of Pennsylvania Objectives: Raise awareness about current state of safety culture across CPUP Design and implement interventions to narrow gaps in safety culture Maintain improvements achieved in patient safety culture Perceived Culture of Safety Patient Safety

9 Initiatives Implemented to Achieve the Aim 1 Signage 2 - Language of Safety 3 Department-Level Data Presentations 4 - Penn-Specific Patient Safety Culture Toolkit

10 Raising Staff Awareness: Data Presentation Meetings

11 Raising Staff Awareness: Culture of Safety Toolkit Construction Patient Care Tracking and Follow-Up Staff Training Overall Perceptions of Patient Safety and Quality Office Process and Standardization Teamwork Communication about Error Leadership Support for Patient Safety Communication Openness Organizational Learning Work Pressure and Pace 2 Areas of Focus - Office Process and Standardization Work Pressure and Pace - Communication Communication Openness Communication about Error

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13 Safety Initiatives by Department

14 Evaluation Tool: Penn Medicine Safety Net - Flexible, web-based event reporting tool - Tracks medical errors through reporting of incidents by all Penn Medicine employees - Submission Examples: - Labeling errors on tests - Patient fall - Near-miss events - Equipment unavailable or broken

15 Evaluating the Impact Difficulty in measuring culture: - Current Measure: - Safety Net Submissions as a proxy variable - Future Measure: - Results of 2018 Medical Office Patient Safety Culture Survey

16 My Role Evaluate the impact of patient safety initiatives by department Data Presentation Meetings Attendee Collected safety initiatives of all 19 departments of CPUP Created and disseminated Culture of Patient Safety Toolkit throughout CPUP Presented work periodically to Quality Vice Chairs Meeting and Data Presentation Meetings for feedback

17 My Learning Experience Presentation Skills Interaction with medical staff The importance of taking initiative Being receptive to constructive criticism and feedback Patient Safety Culture knowledge Understanding of essential components within a health system that are crucial for success

18 Acknowledgements Kathy Donohue My mentor David Horowitz, MD CPUP Chief Medical Officer Barbara Prior MSN CPUP Associate Executive Director Laquisha Reed CEQI Administrative Coordinator CEQI Office SUMR 2017 Cohort Joanne Levy Safa Browne Leonard Davis Institute for Health Economics

19 Questions?