1 © 2010 tmit nqf-endorsed ® safe practices for better healthcare safe practice 4 risks and...
TRANSCRIPT
1© 2010 TMIT
NQF-Endorsed®
Safe Practices for Better Healthcare
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
© 2006 HCC, Inc. CD000000-0000XX 2© 2010 TMIT
Slide Deck Overview
Slide Set Includes:
Section 1: NQF-Endorsed® Safe Practices for Better Healthcare Overview
Section 2: Harmonization Partners Section 3: The Problem Section 4: Practice Specifications Section 5: Example Implementation Approaches Section 6: Front-line Resources
3© 2010 TMIT
NQF-Endorsed®
Safe Practices for Better HealthcareOverview
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
4© 2010 TMIT
2010 NQF Safe Practices for Better Healthcare: A Consensus Report
34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness
5© 2010 TMIT
Culture SP 1
2010 NQF Report
CHAPTER 7: Healthcare-Associated Infections• Hand Hygiene• Influenza Prevention• Central Line-Associated Blood Stream Infection
Prevention • Surgical-Site Infection Prevention• Daily Care of the Ventilated Patient• MDRO Prevention• Catheter-Associated UTI Prevention
Information Management and Continuity of Care
Medication Management
Healthcare-Associated Infections
Condition- and Site-Specific Practices
Consent & Disclosure
Wrong-siteSx Prevention
Press. Ulcer Prevention
VTE Prevention
Anticoag. Therapy
VAP Prevention
Central Line-Assoc.BSI Prevention
Sx-Site Inf.Prevention
Contrast Media Use
Hand HygieneInfluenza
Prevention
Pharmacist Leadership Structures and Systems
Med. Recon.
Culture
CPOE
Read-Back & Abbrev.
Discharge Systems
PatientCare Info.
LabelingDiag. Studies
Culture Meas.,FB., and Interv.
Structuresand Systems
Risk and HazardsTeam Trainingand Skill Bldg.
Nursing Workforce
ICU CareDirect
Caregivers
Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care
CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]
Culture of Safety Leadership Structures and Systems Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Risks and Hazards
CHAPTER 5: Information Management and Continuity of Care
Patient Care Information Order Read-Back and Abbreviations Labeling Diagnostic Studies Discharge Systems Safe Adoption of Computerized Prescriber Order Entry
CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Leadership Structures and Systems
CHAPTER 8: Condition- and Site-Specific Practices• Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention • Pressure Ulcer Prevention• VTE Prevention• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention• Organ Donation• Glycemic Control• Falls Prevention• Pediatric Imaging
Informed Consent
Life-Sustaining Treatment
Disclosure
CHAPTER 3: Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver
Consent and Disclosure
Care of Caregiver
MDROPrevention
UTIPrevention
FallsPrevention
OrganDonation
GlycemicControl
PediatricImaging
7© 2010 TMIT
Harmonization Partners
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
8© 2010 TMIT
Harmonization – The Quality Choir
9© 2010 TMIT
The Patient – Our Conductor
© 2006 HCC, Inc. CD000000-0000XX 10© 2010 TMIT
The Objective
Risks and Hazards
Ensure that patient safety risks and hazards are continuously identified and communicated to all levels of the organization, that mitigation activities are aggressively undertaken to minimize harm to patients, and that patient safety information is communicated to the appropriate external organizations.
[Institute for Healthcare Improvement, How to Improve: Medication Systems, N.D.; Pizzi, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, 2001]
11© 2010 TMIT
The Problem
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
© 2006 HCC, Inc. CD000000-0000XX 12© 2010 TMIT
The Problem
13© 2010 TMIT
[http://online.wsj.com/article/SB123491688329704423.html]
14© 2010 TMIT
[http://www.timesonline.co.uk/tol/news/uk/article468980.ece]
15© 2010 TMIT
[http://www.myfoxny.com/dpp/health/091226_near_miss_registry]
16© 2010 TMIT
[http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Jul/Why-Not-the-Best--Results-from-the-National-Scorecard-on-U-S--Health-System-Performance--2008.aspx]
© 2006 HCC, Inc. CD000000-0000XX 17© 2010 TMIT
The Problem
Frequency
Medical errors have been associated with subsequent personal distress, decreased empathy, and increased probability of making another medical error
Risk mitigation is typically not integrated across an organization
Clinicians significantly underreport medical errors A culture of name, blame, and shame behaviors and
the fear of malpractice liability have been major barriers to performance improvement
Zero must be the goal for adverse events[West, JAMA 2006 Sep 6;296(9):1071-8; Kaldjian, J Gen Intern Med 2007 Jul;22(7):988-96; Kaldjian, Arch Intern Med 2008 Jan 14;168(1):40-6; The Joint Commission, 2009 Accreditation Requirements Chapter, 2009]
© 2006 HCC, Inc. CD000000-0000XX 18© 2010 TMIT
The Problem
Severity
The severity of harm due to the absence of coordinated patient safety programs cannot be accurately estimated
However, recent studies have shown that as many as 15% of Medicare beneficiaries experience serious harm in hospitals
Readmission and mortality rates of seniors after acute care hospital admissions may be much higher than previously presumed
[Boutwell, Reducing Re-hospitalizations in a State or Region: Minicourse M1, 2008; Levinson, Office of Inspector General. Adverse events in hospitals: overview of key issues, 2008; Denham, J Patient Saf 2009 Mar;5(1):42-52]
© 2006 HCC, Inc. CD000000-0000XX 19© 2010 TMIT
The Problem
Preventability
Healthcare organizations can identify and mitigate patient safety risks and hazards by using a number of internal methods
Patient safety organizations that provide federal protection of information should increase the sharing of adverse event information and lessons learned
Supply adequate resources to cover the cost of strategies regularly evaluated for effectiveness
[Helmreich, BMJ 2000 Mar 18;320(7237):781-5; Carthey, Qual Health Care 2001 Mar;10(1):29-32; Marx, Qual Saf Health Care 2003 Dec;12 Suppl 2:ii33-8; Wreathall, Qual Saf Health Care 2004 Jun;13(3):206-12; Milch, J Gen Intern Med 2006 Feb;21(2):165-70; Centers for Medicare & Medicaid Services, Hospital Conditions of Participation: Patients’ Rights, 2008]
20© 2010 TMIT
Practice Specifications
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
© 2006 HCC, Inc. CD000000-0000XX 21© 2010 TMIT
Additional Specifications
© 2006 HCC, Inc. CD000000-0000XX 22© 2010 TMIT
Safe Practice Statement
Identification and Mitigation of Risks and Hazards
Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm.
© 2006 HCC, Inc. CD000000-0000XX 23© 2010 TMIT
Additional Specifications
Risk and Hazard Identification Activities
Risks and hazards should be identified on an ongoing basis from multiple sources
The risk and hazard analysis should integrate the information gained from multiple sources to provide organization-wide context
The organizational culture should be framed by a focus on system (not individual) errors and blame-free reporting, and should use data from risk assessment to create a just culture
[Institute of Medicine, Patient Safety: Achieving a New Standard for Care, 2004; Agency for Healthcare Research and Quality, National Healthcare Disparities Report 2008, 2009; Nuckols, Jt Comm J Qual Patient Saf 2009 Mar;35(3):139-45; Pronovost, Clin Chest Med 2009 Mar;30(1):169-79]
© 2006 HCC, Inc. CD000000-0000XX 24© 2010 TMIT
Additional Specifications
Retrospective Identification
Use a number of retrospective measures and indicators to identify risk from historical data
Specific steps should be taken to ensure that the lessons learned are communicated across the organization and applied in other care settings
Some retrospective identification and analysis activities are triggered by adverse events
Retrospective identification of risks and hazards should occur regularly, and progress reports should be generated as frequently as needed
[Nuckols, Jt Comm J Qual Patient Saf 2009 Mar;35(3):139-45]
© 2006 HCC, Inc. CD000000-0000XX 25© 2010 TMIT
Additional Specifications
Real-Time and Near Real-time Identification
Evaluate real-time or near real-time tools for their value in risk identification for the areas of high risk
Consider using trigger, observational, and technology tools
A structured, proactive risk assessment should be undertaken to identify risks and hazards in order to prevent harm and error
Evaluate the prospective or proactive tools and methods in order to identify risks
[Institute of Medicine, Patient Safety: Achieving a New Standard for Care, 2004; Alemi, Qual Manag Health Care 2007 Oct-Dec;16(4):300-10; Hovor, Qual Manag Health Care 2007 Oct-Dec;16(4):349-53; Adler, J Patient Saf 2008 Dec;4(4):245-9; Emily, Risk Anal 2009 Apr;29(4):565-75; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010]
© 2006 HCC, Inc. CD000000-0000XX 26© 2010 TMIT
Additional Specifications
Integrated Organization-Wide Risk Assessment
The systematic integration of information about risks and hazards across the organization should be undertaken to optimally prevent systems failures At least annually, create frequent progress and summary of reports annually for risk management, complaints/customer service, disclosure support, culture measurement, and other informationInformation should be provided to the governance board and senior administrative leadership continually
[Centers for Disease Control and Prevention, Emergency Preparedness and Response, N.D.; Centers for Disease Control and Prevention, Pandemic Influenza Resources; N.D.; APIC, Pandemics, 2008; Boothman, Journal of Health & Life Sciences Law 2009 Jan;2(2):125-59; Chiozza, Clin Chim Acta 2009 Jun;404(1):75-8; McDonald, Full Disclosure and Residency Education, 2008]
© 2006 HCC, Inc. CD000000-0000XX 27© 2010 TMIT
Additional Specifications
Risk Mitigation Activities
Every organization has a unique risk profile and should carefully design performance improvement projects that target prioritized risk areas
Performance Improvement Programs
Organizations should provide documentation of performance improvement programs
[Denham, J Patient Saf 2005 Mar;1(1):41-55; Pronovost, Health Aff (Millwood) 2009 May-Jun;28(3):w479-89; Damiani, Med Sci Monit 2009 Jul;15(7):RA157-66; Denham, J Patient Saf 2009 Sep;5(3):188-96; Wayre, Healthc Financ Manage 2009 Jan;63(1):86-91; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010]
© 2006 HCC, Inc. CD000000-0000XX 28© 2010 TMIT
Additional Specifications
Specific Risk-Assessment and Mitigation Activities
Organizations should document evidence of high performance or actions taken to close common patient safety gaps for the patient safety risk areas, such as:
Falls Malnutrition Pneumatic Tourniquets Aspiration Workforce Fatigue
[Weingart, Jt Comm J Qual Patient Saf 2009 Apr;35(4):206-15; Yeo, JAMA 2009 Sep 23;302(12):1301-8; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook 2010]
29© 2010 TMIT
Example Implementation Approaches
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
© 2006 HCC, Inc. CD000000-0000XX 30© 2010 TMIT
Example Implementation Approaches
© 2006 HCC, Inc. CD000000-0000XX 31© 2010 TMIT
Example Implementation Approaches
Have the organization’s leaders partner with front-line caregivers to design a path for the adoption of this safe practice’s activities
Periodically assess tools used for prospective, near real-time, and retrospective risk identification and mitigation
New risk identification opportunities are presented through the use of evolving trigger tools, such as the Global Trigger Tool
Evaluate the risk areas identified by purchasers to be high priority to them
[Centers for Disease Control and Prevention, Legionellosis Resource Site (Legionnaires' Disease and Pontiac Fever), N.D.; Centers for Medicare & Medicaid Services, CMS Proposes to Expand Quality Program for Hospital Inpatient Services in FY 2009, 2008; Centers for Medicare & Medicaid Services, Hospital-Acquired Conditions Overview, 2008; Mills, Qual Saf Health Care 2008 Feb;17(1):37-46; Percarpio, Jt Comm J Qual Patient Saf 2008 Jul;34(7):391-8; Wu, JAMA 2008 Feb 13;299(6):685-7; Griffin, IHI Global Trigger Tool for Measuring Adverse Events (Second Edition), 2009]
© 2006 HCC, Inc. CD000000-0000XX 32© 2010 TMIT
Example Implementation Approaches
Strategies of Progressive Organizations
Some organizations have declared that governance board members must spend equal time in meetings and activities on financial issues and quality/safety issues
Organizations have embraced patient safety and risk reduction as their primary competitive initiatives
High-performing organizations provide feedback to staff on improvements that resulted from adverse event reporting
[McDonald, Full Disclosure and Residency Education; 2008; Gallagher, JAMA 2009;302(6):669-77; McDonald, Responding to Patient Safety Incidents: The Seven Pillars; 2009]
33© 2010 TMIT
Front-line Resources
Safe Practice 4Risks and Hazards
Chapter 2: Improving Patient Safety by
Creating and Sustaining a Culture of Safety
34© 2010 TMIT
35© 2010 TMIT
The 3 Ts of Leadership Engagement:Truth, Trust, and Teamwork
Charles Denham
36© 2010 TMIT
Poster available in Spanish[http://www.jointcommission.org/PatientSafety/SpeakUp/]
© 2006 HCC, Inc. CD000000-0000XX 37© 2010 TMIT
NQF & TMIT National Webinar Series
Leadership and Leadership Principles forSafety (Safe Practices 1-4)
Charles R. Denham, MD – Leadership and Culture Practices: New Roles for Leaders
Peter B. Angood, MD – Important National Highlights Regarding Leadership and Culture
James Conway, MS – Bringing Boards On-board: Critical Issues in 2009
Dan Ford, MBA – Patient Perspective on Medication Management Safe Practices
Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4942 (July 16, 2009)