Practical Tools in Patient Safety Tools Carol Haraden Amelia Brooks Jennifer Lenoci-Edwards

Transcription

1 Session Code These presenters have nothing to disclose Practical Tools in Patient Safety Tools Carol Haraden Amelia Brooks Jennifer Lenoci-Edwards December 5 th 8:30 4:00 #IHIFORUM

2 Introduction 2 Morning Session (8:30 AM 12:00 PM) 8:30 8:45 Welcome and orientation to the workshop 8:45 9:00 Starting the Safety Tools Journey and overview of the tools 9:00 9:15 Introduction to the workshop case study 9:15 10:00 Using a Mortality Diagnostic Tool 10:00 10:15 Refreshment Break 10:15 12:00 Using Root Cause Analysis to understand cause and effect Afternoon Session (1:00 PM 4:00 PM) 1:00 2:15 Using Trigger Tools to identify systems issues 2:15 2:30 Refreshment Break 2:30 3:30 Using FMEA a more proactive approach 3:30 4:00 Linking diagnostics to improvement- bringing it all together 4:00 Close

3 Objectives 3 Be familiar with the range of tools necessary to support development of a learning system Describe the current diagnostic approach of your organization. Discuss the use of the data gained from diagnostic tools to prevent, detect and mitigate harm to patients Critically appraise the usefulness of the presented diagnostic tools to improve the safety and quality of your organization over time Be clear on the practicalities of connecting root cause analysis to improvement Have developed a practical skill set for use on return to work

4 Table Discussion P4 What s your experience of using safety tools? How could we use safety tools to better effect?

5 Framework for Safe, Reliable and Effective Care Psychological Safety Accountability Culture Leadership Teamwork & Communication Transparency Engagement of Patients & Family Negotiation Learning System Reliability Improvement & Measurement Continuous Learning IHI and Allan Frankel

6 Framework for Safe, Reliable and Effective Care Creating an environment where people feel comfortable and have opportunities to raise concerns or ask questions. Being held to act in a safe and respectful manner given the training and support to do so. Facilitating and mentoring teamwork, improvement, respect and psychological safety. Leadership Psychological Safety Accountability Teamwork & Communication Developing a shared understanding, anticipation of needs and problems, agreed methods to manage these as well as conflict situations Openly sharing data and other information concerning safe, respectful and reliable care with staff and partners and families. Transparency Engagement of Patients & Family Negotiation Gaining genuine agreement on matters of importance to team members, patients and families. Reliability Improvement Continuous Learning Applying best evidence and minimizing non-patient specific variation with the goal of failure free operation over time. & Measurement Regularly collecting and learning from defects and successes. Improving work processes and patient outcomes using standard improvement tools including measurements over time. IHI and Allan Frankel

7 Teamwork and Communication Negotiation Learning System Accountability Leadership Psychological Safety Framework for Safe, Reliable and Effective Care How it works in real life Culture Continuous Learning Improvement and Measurement Reliability Transparency IHI and Allan Frankel

8 Focus on Improvement, Measurement and Continuous Learning 8

9 Tools for Today s Minicourse 9 Most used Least used RCA Mortality GTT FMEA But how well used?

10 10 Build our Continuous Learning System

11 Case Study P11 5 mins to read the case study in full 5 mins to share your reactions with your neighbor 5 mins to share our reactions as a group

12 Session Code These presenters have nothing to disclose Mortality Diagnostic December 5 th 8:30 4:00 #IHIFORUM

13 Diagnostic Journey People die and are harmed unnecessarily every day in our hospitals. In order for us to understand this, we need a diagnostic journey that moves out of a model for judgment and into a model for learning.

14 The Mortality Diagnostic 2x2 Matrix Review most recent 50 consecutive deaths Place them into a two by two matrix based on: - Was the patient admitted for palliative care? - Was the patient admitted to the ICU? Focus your work initially on boxes that have at least 20% of your mortality

15 Diagnostic The 2 x 2 Matrix Admitted to the ICU? Yes No Admitted for Palliative Care Only? Yes No Box #1 Box #2 Box #3 Box #4

16 Box 3+4 Findings: Failure to Rescue, Plan, Communicate Failure to Plan identified most frequently across organizations issues related to defining comfort care earlier in the hospitalization 9 organizations identified need for focus on comfort care/palliative care lack of clear leader/ captain of the ship identified one organization noted: all failure to plan became failure to rescue Failure to Communicate failure to communicate clinical changes to physician Failure to Rescue 4 organizations specifically identified the need for a RRT

17 Recognize, Communicate, Plan Failure to Recognize: Any situation in which a patient has died and there was evidence that an intervention could have been made anytime prior to the patient s death Example: the staff was worried, change in heart rate, change in respiratory rate, change in blood pressure, change in O2 saturation or change in consciousness or neurological status that was not responded to. Failure to Plan, such as: diagnosis, treatment, or calling a rescue team Failure to Communicate: Patient to staff, clinician to clinician, inadequate documentation, inadequate supervisor, leadership (no quarterback for the team), etc.

18 The Impact of Care Evaluate ALL deaths in box 3 and box 4 to assess the estimated impact of our care on mortality: *As you review the deaths in box 3 & 4, ask yourself the questions honestly (focusing on learning, not judgment): Was perfect care rendered? If perfect care wasn t rendered, could the outcome of death have been prevented if the care had been better? What number of deaths could have been prevented?

19 US 2X2 Table Aggregate 64 Hospitals ICU Admission Comfort Care 86/3175 3% (0-14%) Non Comfort Care 1161/ % (10-72%) No ICU Admission 402/ % (0-40%) 1526/ % (18-76%)

20 2x2 Matrix Findings 25 of 29 participating organizations completed a 2x2 matrix Majority of deaths occurred in box % deaths in box 2 4 organizations - 20% deaths in box 3 23 organizations - 20% deaths in box 4 24 organizations

21 Case Study hrs 84 year old was admitted with diarrhoea and vomiting hypoglycaemic. treated with IV fluids and oral glucose. Arterial blood gases were checked and showed a partially compensated metabolic acidosis with base excess -11. No explanation was documented Blood results showed acute kidney injury grade 2. The blood gas results handwritten in the notes and a serum lactate 9.0 but no comment was made as to the significance. The drug chart confirms that no antibiotics were prescribed hours after arrival at hospital the patient suffered a fatal cardiac arrest. A discussion with the family was documented which states they were happy for a death certificate to be issued and she was not referred for a Post Mortem. The cause of death on the death certificate was pulmonary thromboembolism.

22 Case Study 1: Key points This case represents a failure to recognise severe metabolic acidosis due to lactate representing hypoperfusion most likely due to septic shock. Early aggressive fluid resuscitation and IV antibiotics are essential treatments

23 Case Study 2 An 84 year old man with previous pulmonary thromboembolism was admitted by his GP with acute breathlessness and chest pain, suspected further PTE. On arrival his observations were stable, SEWS = 0. The working diagnosis was?acs,?pte. His first ECG was performed after 2.5 hours and there were no diagnostic changes. 4 hours after arrival he was given Aspirin, Clopidogrel and Fondaparinux. At that time he was noted to appear unwell and routine observations were repeated for first time since admission SEWS now = 7. Medical staff reviewed now noted to be severely hypoxic, given stat dose Dalteparin and commenced CPAP although patient rapdily deteriorated with ventricular arrhythmias and fatal cardiac arrest.

24 Case Study 2: Key points When the GP letter suggests pulmonary embolism the diagnosis should be given strong consideration and if in doubt treated. A 4 hour delay between initial observations is too long in an emergency admission, even if the initial observations are normal. In addition a 2.5 hour delay in performing an ECG in suspected ACS is unacceptable.

25 Summing Up - Mortality P25

26 Session Code These presenters have nothing to disclose Root Cause Analysis December 5 th 8:30 4:00 #IHIFORUM

27 What s been your experience? How many RCAs have you been part of? How many RCAs does your organisation do each year? How many of those are for the same kinds of event? How many of those result in sustainable improvement? How useful is RCA for improvement?

28 What s the aim of RCA? P28

29 What s the aim of RCA? P29 To learn To improve

30 What s the process of RCA? P30

31 What s the process of RCA? P31 Gather information, create timeline Contributing factors, root causes Actions, recommendations Assurance, closing the loop

32 What s the process of RCA? P32 Gather information, create timeline Learning Contributing factors, root causes Actions, recommendations Improvement Assurance, closing the loop

33 Worst Case Scenario P33 Lots of RCA Lots of reports Lots of resources Little or no improvement

34 Best Case Scenario P34 Selective RCAs Triangulation of knowledge Efficient use of resources Evidence of improvement

35 Our Focus P35 Understanding true cause and effect Differentiating between system and person dependent issues Identifying common causes of harm Linking RCA to clear improvement

36 Exercise #1 P36 Back to Audrey In groups of 2/3 people, review your assigned portion of the case study Identify all the potential problems, issues, concerns, questions (What went wrong? When? For whom?) Categorize using fishbone 20 mins

37 Fishbone P37

38 Exercise #2 P38 Decide what information is missing Prioritize missing information what is it most important for you to learn about? Prepare questions for the faculty to help you determine cause 10 mins

39 What else do you need to know? P39

40 Exercise #3 P40 Using the new information, for each of your priority issues, discuss and document cause theories If you still don t have enough information, make a note of that Group the causes into system or individual Prioritize your system causes based on frequency (in this case) and significance

41 What are the big system issues P41 and what s causing the big system issues?

42 How common are these causes? P42 How do you find out if your theory about system causes of harm is correct?

43 Turning Into Improvement P43

44 Session Code These presenters have nothing to disclose Trigger Tools December 5 th 8:30 4:00 #IHIFORUM

45 Why Use Trigger Tools? 45 Traditional reporting of errors, incidents, or events does not reliably occur in the best of health care cultures Voluntary methods markedly underestimate adverse events Events can be reliably detected without resorting to as yet unproven electronic surveillance methods Can be integrated into a good sampling methodology to follow event rates over time

46 Background of IHI Trigger Tools 46 Computerized triggers for ADE identification and concurrent intervention - Classen (1990, 1994) Adverse Drug Event Trigger Tool - Resar, Federico, Griffin, Haraden (1999) ICU Adverse Event Trigger Tool - Resar, Simmonds, Haraden (2002) Surgical Trigger Tool - Griffin, Classen (2004) Global Trigger Tool (GTT) testing and spread to US and international hospitals - Resar, Federico, Griffin, Haraden ( )

47 How Much Harm 47 Global Trigger Tool Shows That Events in Hospitals May Be Ten Times Greater Than Previously Measured Classen DC, Resar R, Griffin F, et al. Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs Apr;30(4):

48 Old (Errors) vs. New (Harm) 48 Errors are the focus of discussion and solutions Tends to focus only on those results felt to be related to error, ignores other events Requires judgment Human found responsible for most of the errors Concentrates less on people more on systems Looks at all unintended results Makes measurement easier Concentrates on preventable versus unpreventable harm and those errors that cause harm

49 Definition of Harm 49 In the IHI Global Trigger Tool, the definition used for harm is as follows: Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.

50 Global Trigger Tool 50

51 The Process 51 When examining a record, the reviewer looks to answer the following questions: 1. Have you identified a trigger? If yes, the reviewer examines the relevant section of the record in more look if patient experienced any harm. If NO, move onto the next record 2. Did harm occur? If yes, move onto the next question in the tool If none is detected, move onto the next record. After 20 minutes if unable to decide if harm occurred you ignore the record and move on. 3. What was the severity of harm detected? The reviewer should grade the severity of every incidence of detected harm. 4. Was the detected harm incident preventable? The reviewer should determine whether the detected harm was preventable - based on a combination of evidence found and professional judgement.

52 How it is Actually Done 1 - Set your timer for 20 minutes 2 - Review coding summary (look for e-codes/obvious events) 3 - Review the discharge summary 4 - Review the labs 5 - Review the x-ray reports 6 - Review the procedure notes 7 - Any time left over, review nurse notes

53 Triggers and Events 53 When a trigger is found, review appropriate portion(s) of record to determine if adverse event occurred. Some triggers will not lead to an event. Adverse events can be found without detecting a trigger first. An event maybe detected by multiple triggers.

54 Global Trigger Tool Examples Readmit within 30 days with recurrence of abscess right hip. Readmit next day w/ileus s/p exp lap for tumor. Stopped lasix-acute renal failure. Readmitted in 30 days for wound revision due to incisional seroma. Readmit related with wound infection. Volume Depletion with altered mental status caused by Lasix - resulted in hospital admission. ARF due to nephrotoxicity due to combination of ACE and NSAIDS taken at home. Ischemic colitis had rt hemicolectomy. New onset CP=MI. Unresponsive, coded. Decreased loc & sats on Morphine PCA. Rec'd Narcan.

55 Severity Index for Adverse Events (modified NCC MERP INDEX) Level E Caused temporary harm that required intervention 55 Level F Level G Level H Level I Resulted in prolonged stay Contributed to or resulted in permanent harm. Required intervention to sustain life (1hr rule of thumb) Contributed to or resulted in death.

56 Examples of E 56 Stage 1 or 2 pressure ulcer Post-op superficial wound infection Hypoglycemia with symptoms Symptomatic constipation due to opioids Bleed due to medications Catheter Associated Urinary Tract Infection Fall with minor injury Mild confusion due to medication

57 Example Case: Positive Trigger 57 A patient on chronic anticoagulation has an INR of 8.2. Does that represent an adverse event? A) Yes B) No

58 Analysis of a Trigger (INR 8.2) 58 Elevated INR is not an adverse event only a trigger. Review of appropriate portion of the record revealed that a large retroperitoneal bleed was noted. The event clearly caused a prolongation of the hospitalization and should be classified as a category? The event caused hypovolemic shock and patient was sent to the ICU due to severity and should be classified as a category?

59 Severity Index for Adverse Events (modified NCC MERP INDEX) Level E Level F Level G Level H Caused temporary harm that required intervention Resulted in prolonged stay and/or re-hospitalization Contributed to or resulted in permanent Resident harm. Required intervention to sustain life (1hr rule of thumb) 59 Level I Contributed to or resulted in death.

60 Global Trigger Tool 60

61 Assessing Harm Scenario 61 Day 1 Patient is post-op left knee arthroplasty for osteoarthritis. 84 years old with multiple chronic conditions (CHF, a. fib, mitral regurgitation, hypertension) set to be discharged on day 6. Day 5 Superficial infection develops around surgical site Day 7 Started on levofloxacin with an onset of diffuse pruritic rash over back and chest. Rash progressed to face, neck and arms. Levofloxacin discontinued and begun on cephalexin, prednisone, and antihistamines.

62 Your turn Triggers? 2. Harms to the patient? 3. Score the Harm 4. Preventable or Non-Preventable

63 Assessing Harm Answers Triggers HAI, Antihistamine Use 2. Two unrelated adverse events a) SSI b) Allergic reaction to a medication 3. Both events caused F level harm 4. First event was preventable; Second event was not preventable, unless there was a known allergy

64 Key Points 64 Follow recommended sequence for review Look for triggers only don t read the entire record Remember that a positive trigger is not necessarily an adverse event Determine and assign harm based on perspective of patient: Did I suffer harm? Post-operative complications are always adverse events, even if expected (they are still unintended) An adverse event found without a trigger should be included in your data

65 Discussion areas Cascade Events 65 Examples of multiple, related events counted as single events: Excess anti-coagulant led to hematemesis, hypotension and acute kidney injury resulting in hospitalization. Disorientation and hallucinations due to multiple medications (acetaminophen and hydrocodone, cyclobenzaprine, and lorazepam) led to a fall, skin tear and rib fracture, which led to pneumonia requiring a hospitalization.

66 Characteristics of Your GTT Team 66 You want team members who are committed to: Finding all harm regardless of preventability Who are going to approach the effort with objectivity and candor versus explaining the events away Understand how the tool can used to leverage and improve safety across the organization Creating the learning system by using all the information that is gleaned from all of the data

67 Many Trigger Tools Global Trigger Tool Modules Cares (General) Critical Care Medication Surgery L&D ED Ambulatory Trigger Tool Skilled Nursing Facility/Long Term Care Trigger Tool

68 Your turn 68 CASE: Pt. was admitted to the hospital possible sepsis. Hypotension was believed to be secondary to atrial fib with rapid ventricular response. Pt. had a pacemaker placed and was transferred to long term care facility. One week later the patient was readmitted to the hospital with shortness of breath and was found to have myocardial infarction, a temperature, elevated WBC and vegetation visualized on TEE. Blood cultures drawn were positive for MRSA. Pacemaker removed though patient continued to deteriorate and died of MRSA Sepsis and infected pacemaker.

69 Your turn Triggers? 2. Harms to the patient? 3. Score the Harm 4. Preventable or Non-Preventable

70 Your turn Triggers? Readmission, Code, + Blood Cultures 2. Harms to the patient? Yes, death 3. Score the Harm I contributed to death 4. Preventable or Non-Preventable - Preventable

71 Value of Using the Trigger Tool 71 Understand our true rate of adverse events in our organization Help us articulate preventable harms occurring to our patients and help us identify areas of potential improvement When you find harm reoccurring and you want to understand it more deeply, pull an enriched sample of patients: from the population of patients who may have a condition predisposing them to a particular harm: diabetics - hyperglycemia; patients with atrial fibrillation - anticoagulation What can you learn about the enriched sample: the real occurrence rate of adverse events? the clinical care processes underlying the harm particular characteristics of the patients that suffer that harm?

72 72 How to Use Failure Modes and Effects Analysis (FMEA)

73 A Brief History of FMEA Used for aerospace development in 1940s 1960s Military Procedure MIL-P-1629 Procedures for Performing a Failure Mode, Effects and Criticality Analysis published 1949 Helpful in avoiding errors in costly rocket technology Ford Motor Company reintroduced FMEA in late 1970s Safety and regulatory consideration after Pinto affair Ford also used FMEAs effectively for production improvement as well as design improvement DaimlerChrysler, Ford, General Motors partnership FMEA recommended for their suppliers SAE J1739 (3 rd edition, August 2002) QS-9000 (1994, based on ISO 9000) qs9000.asq.org

74 Failure Modes and Effects Analysis Systematic, proactive method of evaluating a process Identify where and how it might fail Assess the relative impact of different failures Identify the parts of the process most in need of change FMEA includes analysis of: Steps in the process Failure modes (What could go wrong?) Failure causes (Why would the failure happen?) Failure effects (What would be the consequences of each failure?)

75 Applicability of FMEA to Health Care Unlimited! Examples of processes in health care include: Medication safety Ordering processes Dispensing processes Administration processes Falls prevention Patient identification Computerized physician order entry Patient registration and scheduling Equipment evaluation and usage IV pumps MRI scanners Surgical equipment

76 Creating your own FMEA Select a process to evaluate with FMEA Recruit a multidisciplinary team Meet together to list all the steps in the process List failure modes and causes For each failure mode, assign a numeric value for Likelihood of occurrence (1 10) Likelihood of detection (1 10) Severity (1 10) Evaluate the results Multiply numbers to get a Risk Priority Number (RPN) Total RPN is the sum of all step and failure mode RPNs

77 Sample FMEA Spreadsheet Steps in the Process Failure Mode Failure Causes Failure Effects Likelihood of Occurrence (1 10) Likelihood of Detection (1 10) Severity (1 10) Risk Priority Number (RPN) Actions to Reduce Occurrence of Failure 1 2 Total RPN (sum of all RPNs): Failure Mode: Failure Causes: Failure Effects: Likelihood of Occurrence: Likelihood of Detection: Severity: Risk Profile Number (RPN): What could go wrong? Why would the failure happen? What would be the consequences of failure? 1 10, 10 = very likely to occur 1 10, 10 = very unlikely to detect 1 10, 10 = most severe effect Likelihood of Occurrence Likelihood of Detection Severity

78 Targeting Areas for Improvement Prioritize improvement efforts based on RPN Focus on failure modes with high RPNs Failure modes with low RPNs have little effect Consider individual RPN components as well: Reduce severity first most important component Pay special attention to 9 and 10, regardless of total RPN Take preventive/corrective actions to avoid failure mode Then occurrence has greatest overall benefit Then detection be sure to test effectiveness Create multiple scenarios showing different changes Target half-life (50% reduction) for each pass

79 Plan Actions to Reduce Harm from Failure Modes If the failure mode is likely to occur: Can any cause be eliminated? Can a forcing function be added (e.g., medical gas outlets that accept only matching gauges)? Modify other processes that contribute to causes. If the failure is unlikely to be detected: Can previous events serve as flags to indicate likely occurrence? Add an intervention step earlier in the process (e.g., add pharmacy rounds to remove discontinued medications within 1 hour) Consider device alerts when values are approaching unsafe limits If the failure is likely to cause severe harm: Identify early warning signs that a failure mode has occurred, and train staff to recognize them for early intervention Provide information and resources (e.g., reversal agents) at points of care for events that may require immediate action

80 Tracking Progress Your process probably changes; so should your FMEA! Periodically (twice a year) revisit your process Update your FMEA based on changes you have made Track your RPN over time to see progress Be sure to make changes Focus on continuous improvement

81 Health Care Case Study Medication System Chemotherapy What clues? Trigger tool data Pharmacy interventions Traditional reporting systems Leadership WalkRounds Conduct FMEA on chemotherapy process

82 Case Study: FMEA Chemotherapy Steps in the Process Failure Mode Failure Causes Failure Effects Likelihood of Occurrence (1 10) Likelihood of Detection (1 10) Severity (1 10) Risk Priority Number (RPN) Actions to Reduce Occurrence of Failure MD Order Incorrect drug is ordered Mental slip; handwriting issue, mis-reading protocol; lack of knowledge; protocol printed incorrectly Pot. fatal outcome Database of protocols; chemo checking checklist Incorrect dose is ordered Calculation error; mis-reading protocol, incorrect patient data (weight, height, WBC, creatinine), BSA caclulated incorrectly, handwriting issue; patient data not available; mental slip; protocol printed incorrectly. Pot. Fatal outcome Database of protocols; chemo checking checklist

83 Case Study: FMEA Chemotherapy Steps in the Process Failure Mode Failure Causes Failure Effects Likelihood of Occurrenc e (1 10) Likelihood of Detection (1 10) Severity (1 10) Risk Priority Number (RPN) Actions to Reduce Occurrence of Failure Wrong route is ordered Mis-reading protocol, handwriting issue; mental slip; protocol printed incorrectly; dangerous abbreviation; dangerous convention. Pot. fatal outcome especially if it is an intrathecal route Pre-typed order form template; database of protocols Dose exceeds lifetime limits Knowledge; patient information unavailable; history of prior dosing unavailable Pot. Fatal outcome Patient dosing cards Total RPN 420 (2092)

84 Case Study: Chemotherapy Develop Action Plan Intended Impact Action Step Responsible Party Status/Discussion Completion Date Recalculate RPN

85 Case Study: FMEA Chemotherapy Revised Steps in the Process Failure Mode Failure Causes Failure Effects Likelihood of Occurrence (1 10) Likelihood of Detection (1 10) Severity (1 10) Risk Priority Number (RPN) Comments MD Order Incorrect drug is ordered Mental slip; handwriting issue, mis-reading protocol; lack of knowledge; protocol printed incorrectly DATABASE FOR PRTOCOLS Pot. fatal outcome 1 8 (3) (80) Will require long-term commitment to maintain database and careful attention to complying with policies. Incorrect dose is ordered Calculation error; mis-reading protocol, incorrect patient data (weight, height, WBC, creatinine), BSA caclulated incorrectly, handwriting issue; patient data not available; mental slip; protocol printed incorrectly. Pot. Fatal outcome 2 (4) 1 (3) (120) Having database available to MDs may assist with this element. Will require careful attention to complying with policies

86 Case Study: FMEA Chemotherapy REVISED Steps in the Process Failure Mode Failure Causes Failure Effects Likelihood of Occurrence (1 10) Likelihood of Detection (1 10) Severity (1 10) Risk Priority Number (RPN) Comments Wrong route is ordered Mis-reading protocol, handwriting issue; mental slip; protocol printed incorrectly; dangerous abbreviation; dangerous convention. PRETYPED TEMPLATE Pot. fatal outcome especially if it is an intrathecal route. 1 (2) 1 (2) (40) Having database available to MDs may assist with this element. Will require careful attention to complying with policies Dose exceeds lifetime limits Knowledge; patient information unavailable; history of prior dosing unavailable PATIENT DOSING CARDS Pot. Fatal outcome 2 3 (9) Total RPN 120 (1438) (180) Not possible to be perfect with the information as it relies on the patient to complete and it cannot be initiated until the patient is within the system

87 Example: Chemotherapy FMEA RPN Chemotherapy FMEA RPN Baseline RPN May-03 Goal

88 Session Code These presenters have nothing to disclose Bringing it all Together for Improvement December 5 th 8:30 4:00 #IHIFORUM

89 I have all this data.. 89 Patient Safety Team: Incident reporting & reviews RCAs of significant events Complaints Team: Complaints reviews and investigations Patient Experience Team: Patient satisfaction surveys Legal Team: Coroner Cases Clinical Governance: Mortality Reviews Improvement Team: FMEAs, improvement projects Improvement Committee: GTT reviews

90 I have all these priorities.. 90 Patient Safety Team: Falls Pressure Ulcers Complaints Team: Communication Patient Experience Team: Communication Legal Team: Continuity of Care Clinical Governance: Handover Improvement Team: Cost savings Improvement Committee: Hospital Acquired Pneumonia

91 A Systems View P91 RCA Mortality GTT FMEA Are there common underlying trends in all this data that can improve all these areas? Communication, respect, psychological safety, culture? Is there a common service line that requires some additional resources to improve quality and safety? Do you see improvement efforts underway that are stuck in siloed service lines and can be leveraged to address your priority areas? Do you see a bright spot in our organization that is addressing your priority area successfully?