high reliability healthcarewhack-a-mole (lack of prevention) pdca/pdsa is the only methodology a...

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1

High Reliability HealthcareAHA 85th Annual Meeting

Leadership Workshop

October 7 2015

Coleen Smith RN CPHQ

Director High Reliability Initiatives

LuAnn Vis RN CPHQ

Associate Director High Reliability Initiatives

Klaus Nether MMI CSSMBB

Director Solutions Development

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22

Objectives Discuss the importance of leaders as agents of

change on the journey toward high reliability

Describe why leadership commitment culture of safety and performance improvement are important elements in the high reliability journey

Identify the various components that contribute to establishing high reliability within a healthcare organization

Describe benefits of and barriers to beginning a high reliability journey within their own organization

Articulate specific actions they can take within their organizations to make progress toward high reliability

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What is the purpose cause or

belief that inspires you to do

what you do

3

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4

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sio

n

5

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sio

n

6

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7

How Safe is Healthcare

1

1

10 100 1000 10000 100K 1M 10M

Number of Encounters for Each Fatality

To

tal L

ive

s L

ost p

er

Ye

ar

10

100

1000

10000

100000

Dangerous

(gt11000

Health

Care

(1 of

~600)

Mountaineering

Bungee

Jumping

Driving in US

Chartered

Flights

Chemical

Manufacturing

Scheduled

Commercial

Airlines

European

Railroads

Nuclear

Power

Theme

Parks

Ultra Safe

(lt11M)

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88

State of Health Care

Health care used to be

ndashSimple

ndashCheap

ndashSafe

ndashIneffective

Today it is extremely complexexceedingly expensive often highly

effective and very dangerous

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99

Is Complexity Bad

Lots of things are complicated

ndash Building jet engines

ndash Putting animation in a slide

Complex processes are vulnerable to

error

ndash Getting a medication to a patient 30 steps

ndash If each step is done correctly 98 of the

time whatrsquos the likelihood of an error

How do others do better

45

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Perception of Quality

Added cost

OR

Essential to overall performance of the

organization

Companies that embrace quality as a way of running

day-to-day operations tend to be more successful in

process performance and delivering customer

satisfaction in comparison to those who merely seek

having a quality management system because they

ldquohave tordquo 10

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Current Approach to ldquoImprovementrdquo

Performance Improvement staff hired

without expertise

ldquoLearning on the jobrdquo is customary

Benchmarking for PI staffing levels does

not exist

No investment in improvement science

training

Facility in PI methodology and tools is

not an expectation for everyone

11

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You Get What You Pay For

Minimal investment Minimal

improvement

Project fatigue Lack of

sustainability

Reactive approach

to improvement

Whack-a-mole

(lack of prevention)

PDCAPDSA is the

only methodology

A basic algorithm for

learning

Adoption of best

practices

Wasteful adoption of

ill-fitted solutions

12

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Leadership

13

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14

How Have Others Done It

ldquoHigh reliability organizationsrdquo manage

very serious hazards extremely well

What do they all have in common

ndashHighly effective process improvement

ndashFully functional safety culture

Discover and fix unsafe conditions early

In health care we typically react only after

patients are harmed

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1515

How Safe are US Airlines

1990-2001

ndash 129 deaths per year

ndash 93 million flights per year

ndash Rate = 139 deaths per million flights

2002-2013




= 90

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1616

Safety Airlines vs Health Care

IOM ldquoTo Err is Humanrdquo estimate

ndash 44000-98000 deaths in hospitals

due to errors in care

ndash 344 million hospitalizations per year

ndash Rate = 1279-2849 deaths per million

hospitalizations

US Airlines 2002-2013


Hospital care is 894-1992 times less safe

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1717

Table Discussion

What does high reliability mean to

you and your organization

At your tables within your individual organization

or as a group discuss the following

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1919

What is ldquoHigh Reliabilityrdquo

in Health Care

Achieving and maintaining consistently

high levels of safety and quality

ndash Over time

ndash Across all health care services and settings

Exists for specific measures or in particular

services at individual health care facilities

Significant variation in performance within

hospitals and across the delivery system

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2020

Excellence in patient care for every patient every time

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2121

Five Principles of

High Reliability Organizations

Anticipation ndash ldquoStay Out of Troublerdquo

1 Preoccupation with failure

2 Reluctance to simplify

3 Sensitivity to operations

Containment ndash ldquoGet Out of Troublerdquo

4 Commitment to resilience

5 Deference to expertise

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2222

3rd Edition

now

available thoroughly

revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg

High Reliability Model

Chassin MR Loeb JM High-Reliability Health Care

Getting There from Here Milb Q 201391(3)459-90

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2424

Milbank Q 201391(3)459-90

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2525

High Reliability Maturity Model

Components

Leadership Commitment

bull Board

bull CEOManagement

bull Physicians

bull Quality Strategy

bull Quality Measures

bull Safe Adoption of IT

Adoption of Safety Culture

bull Trust

bull Accountability

bull Identifying Unsafe Conditions

bull Strengthening Systems

bull Assessment

Robust Process Improvementreg

bull Methods

bull Training

bull Spread

Stages of maturity

Beginning Developing Advancing Approaching

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Why

Improves organizational effectiveness

Improves organizational efficiency

Improves customer satisfaction

Improves compliance

Improves organizational culture

Improves documentation

26

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2727

Table Discussion

What is your vision of the future

around high reliability in 1 year

In 3 years



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2828

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29

LEADERSHIP

COMMITMENT TO ZERO PATIENT HARM

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3030

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3131

ldquoEnsuring patient safety is our core value

and itrsquos our only core valuerdquoDan Wolterman CEO Memorial Hermann Health System

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3232

Essentials for High Reliability

Aligned agreement of all senior leaders

sharing vision of eventual elimination of

harm to patientsndash Governing body senior physician and nursing leaders

The goal of zero

ndash Not satisfied with whatever the current level of safety

is - always looking for ways to improve it

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3333

ldquoThe beauty of the business case for quality is that it

starts and ends with the best interests of the patientrdquo

Financial benefit to employers patients

providers or insurers

Business Case(financial benefit for providers)

Overuse Care

Patient Centered CareDefective Care

Inefficient Care

Underuse Care

Quality Improvement Beneficiaries Build strategy on

1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices

Swensen etal The Business Case for Health-Care Quality Improvement

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34


to

ZERO

Patient

Harm

The High Reliability Journey Begins with

Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535

Board or Governing Body

The Board plays a prominent role in quality

and safety

Goes beyond the regulatory requirements and

listening to reports

Engages in the development of quality planning

and goals

Review adverse events and puts a storyface to

patient harm

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3636

Getting Boards on Board5 Million Lives Campaign 2008

1 Set specific aims to reduce harm

2 Get data and hear stories ndashput a ldquohuman facerdquo on harm data

3 Establish and monitor system-level measures ndashtransparent to organization and its customers

4 Change the environment policies and culture ndashestablish an environment that is respectful fair and just

5 Learning - Develop capability and learn about how the best-in-

the-world boards work with leadership to reduce harm

6 Establish executive accountability to reduce harm

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3737

CEO amp Senior Leadership

Stated commitment to zero patient harm

ndash Goes beyond regulatory requirements and

communicated relentlessly

The CEO leads the development and

implementation of a proactive quality agenda

ndash Aims for and achieves zero patient harm for vital

clinical processes

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3838

CEOManagement Tactics

Daily Safety Briefings

Look back ndash significant safety or quality

issues from the last 24 hours

Look ahead ndash anticipated safety or quality

issues in the next 24 hours

Follow up ndash status reports on issues

identified today or days before

Situational awareness amp heightened risk

awareness

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3939

Cincinnati Childrens Knowledge Sharing

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4040


Safety Culture Assessment

Safety Leadership Rounds

Teamwork Training and Skill building

Senior executive adopt-a-work unit

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42

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4343

Physicians

Physicians are engaged and

involved in quality and safety

ndash Broad involvement of several physicians

ndash Champion amp lead improvement projects

ndash Accept the leadership of other appropriate

clinicians

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4444

Physicians

Impact of physician

engagement

ndash Improved clinical outcomes

ndash Reduced malpractice risk

ndash Improved patient satisfaction

ndash Improved physician satisfaction

and decreased physician burnout

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4545

Quality Strategy

What priority is given to improving quality

and safety

ndash Quality is one of the top three or four

strategic priorities OR the highest-priority

strategic goal

ndash Improvement efforts directed at the most

important causes of harm in the

organizationrsquos patient population

ndash Stated goal ndash Zero harm

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47

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4848

Quality Measurement

What is the organizationrsquos approach to

measuring quality and safety

ndash Measurement goes beyond the regulatory

requirements

ndash Transparency of Information

ndash Who can access amp How often

ndash Align incentive systems based on results

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4949

ndash Level of support from IT for qualitysafety

improvement programs

ndash IT solutions are integral to sustained

improvement

ndash Commitment to safety

Safe Adoption of IT

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5050

Resources for ldquoSafe ITrdquo

Issue 42 Safely implementing health information and

Converging technologies

Issue 50 Medical device alarm safety in hospitals

Issue 54 Safe use of health information technology

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51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252

Table Discussion Leadership

What do you see as the biggest obstacle to

obtaining alignment around the goal of zero

harm

Do you see yourself as a Change Agent for

high reliability

ndash If YES Identify strategies that you can use

to obtain alignment around the goal of zero

harm

ndash If NO Why not

At your tables within your individual organization or as a

group discuss the following

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5353

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54

SAFETY CULTURE

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5555

Why Focus on Safety Culture

Improving safety culture is the

only way to fully empower staff

to find unknown risks

HROs depend critically on

safety culture

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56

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5757

Components of Safety Culture

Trust

ndash Coordinated and focused effort

to eradicate intimidating

behaviors and establish trusting

environment

ndash Is trust measured Are codes of

behavior self-policing

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5858

Accountability

ndash Balance between blameless errors

and blameworthy acts (eg honest

mistake versus poor choice)

ndash Equitable and transparent

disciplinary procedures


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5959

Accountability

Health care also fails to apply disciplinary

procedures equitably and uniformly

Lack of uniform accountability also erodes

trust stifles reporting of unsafe conditions

Belief in a completely ldquoblame-free culturerdquo

further impairs progress toward accountability

Striking the balance is critical

ndash Learning from blameless errors

ndash Accountability for adhering to safe practices

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60

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6161

Identifying Unsafe Conditions

ndash Are near missclose call events reported with

same frequency as actual harm events

ndash Are unsafe conditions recognized

Routinely Or is activity largely

retrospective


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6262

Tactics to Increase Reporting

Make sure staff know what you want to hear

about andhellip

Make sure you tell staff what you did with the

information they reported

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6363

Prerequisite for Reporting

What inhibits reporting even before

intimidating behavior comes into play

Failure to recognize unsafe conditions

ndash Distractions during medication prep

ndash Poor participation in timeouts

ndash Language barrier preventing full protection

of two-person check on blood products

Requires education on known hazards

Where are your unrecognized risks

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6464

Strengthening Systems

ndash What efforts are in place to recognize patterns

of causal factors across the organization

ndash Efforts to catalog and prioritize system

weaknesses--proactively

bull Responding to events that have already happened

Reactive

bull Active identification of unsafe conditions through analysis of processes

Proactivebull Ability to

accurately foresee potential problems based on system analysis

Predictive


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6565

Evolution of Safety Culture

Today we mostly react to adverse events

Close calls are ldquofree lessonsrdquo that can lead

to risk reduction

Unsafe conditions are further upstream from

harm than close calls

Ultimately proactive routine assessment of

safety systems to identify and repair

weaknesses gets closer to high reliability

--- if they are

recognized reported and acted on

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6666

Assessment

ndash Safety culture is measuredmdashhow

often Who is included

ndash Results used to plan efforts to

improve

ndash Metrics around improvement efforts

reported to senior leadership

systematic improvement initiatives

are in place


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6767

Tactics around MeasuringActing

If you already measure safety culture

develop a plan with built in

accountability to review the results and

work to improve

All unitsdepartments routinely report

on progress (which wonrsquot be immediate

or fast in many cases)

Discuss these results with the Board

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6868

Culture Change is Difficult

2007 (n= 382) 2012 (n=1128)

AHRQ Safety Culture Survey 2007 2012

1 Staff feel mistakes are heldagainst them (YES)

2 When event is reported it feelslike the person is being writtenup not the problem (YES)

3 Staff worry mistakes are kept intheir personnel files (YES)

50

57

65

50

54

65

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6969

What Behaviors are Intimidating

Wide range from hanging up the phone instead

of answering a question to verbal abuse

(cursing yelling) or physical abuse

Most common

ndash Refusal to answer questions or to return

phone calls or pages condescending tone or

language impatience with questions

ndash 2003 about frac14 of nurses and pharmacists

personally experienced these from MDs more

than 10 times in past year

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70

Start here

Deliberate harm test Incapacity test Foresight test Substitution test

Were the actions

intendedDoes there appear to be

evidence of ill health or

substance abuse

Did the individual depart from

agreed protocols or safe

procedures

Would another individual

coming from the same

professional group

possessing comparable

qualifications amp experience

behave in the same way in

similar circumstances

No NoNo

Were adverse consequences

intended

Yes Yes

Yes

Yes

Yes

Yes

Yes

Were the protocols and safe

procedures available

workable intelligible

correct and in routine use

Were there any deficiencies

in training experience or

supervision

No

Is there evidence that the

individual took an

unacceptable risk

Were there significant

mitigating circumstances

No

CONSIDER

bullDiscipline

bullReport to NPDB

bullPotential adjustment

to duties

bullReport to state quality

investigation office

bullRefer to Employee

Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline

bullPotential adjustment to

clinical duties

bullCorrective training

education

bull Improved supervision

bull Refer to Employee

Assistance Program

IDENTIFY

SYSTEM FAILURES

bullSummarily suspendterminate

CONSIDER

bullReport to NPDB

bullReferral to internal physician

impairment program

bullReferral to state physician

impairment program

bullReport to state quality ]


bullCorrective trainingeducation

IDENTIFY

SYSTEM FAILURES

bullSummarily suspend

terminate

CONSIDER

bullPolice



bullReport to National Prac-

titioner Databank (NPDB)

IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No

MDAssessing Errors Systematically

Yes

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7171

Summary

Fully functional safety culture is essential

to achieving high reliability in healthcare

Will take time and consistent effort on the

part of all leaders and the Board

ndash No guaranteed or foolproof methods

ndash Expect setbacks non-linear progress

Measure trust intimidating behavior culture

Set goals use RPI to drive improvement

No challenge is more important

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7272

Table Discussion Safety Culture

What are the barriers to recognizing

reporting and responding to unsafe

conditions

ndash Develop one or two strategies to try next

week

At your tables within your individual

organization or as a group discuss the

following

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7373

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74

ROBUST PROCESS IMPROVEMENTreg

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757575

Reliability is failure free operation over time from the viewpoint of the patient

-R Resar Institute for Healthcare Improvement

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7676

Current State of Improvement

We have made some progress

Improvement difficult to sustainspread

Getting to zero staying there is very rare

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n

7777

Semmelweisrsquo Original Data

Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878

Current State of Quality

Routine safety processes fail routinely

ndash Hand hygiene

ndash Medication administration

ndash Patient identification

ndash Communication in transitions of care

Preventable adverse events

ndash Surgery on wrong patient or body part

ndash Fires in ORs retained foreign objects

ndash Infant abductions inpatient suicides

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7979

RPIreg and High Reliability

How did HROs achieve zero harm

ndash How to get from low to high reliability

ndash How do we address safety processes that fail

40-60 of the time

ndash How to get major improvement quickly

Answer

RPIreg = Lean Six Sigma and

change management

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8080

RPI in Health Care Today

Only a small percentage of hospitals or

systems use RPI in any form or fashion

RPI is used differently by different hospitals

ndash Most use only some of the parts change

management is most often left out

ndash Most do not use it to transform

ndash Most do not have a plan for spread or for

linking RPI training to staff development

Compelling business case for RPI

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n

82

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8383

83

RPIreg is a blended set of

strategies tools

methods and training

programsmdashincluding

Lean Six Sigma and

Change Managementmdash

that is used to improve

business processes and

clinical outcomes

What is Robust Process Improvement

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8484

What is Lean

Philosophy continuous improvement of

processes through employee empowerment

Teaches us to view our processes from the

customerrsquos perspectivemdashin value streams

Tools to increase value and improve flow by

eliminating steps in processes that represent

pure waste

Waste increases cost produces no value

All unexamined processes have waste often as

much as 50 of time and effort is waste

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8585

Six Sigma Philosophy

Philosophy underlying six sigma helps us to think

about quality differently

Six sigma = accuracy and variation

Six sigma measures bad outcomes as ldquodefects

per million opportunitiesrdquo

1 rate of bad outcomes = 10000 defects per

million

It gives us tools and a way to think about getting

to zero harm the high reliability goal

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8686

Six Sigma

86

Define Measure Analyze Improve Control

Who are the

customers and

what are their

priorities

How is the process

performing and how is

it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements

A Methodology for Improving Processes

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8787

The Way We Do Improvement

Usual approach best practices toolkits

protocols checklists ldquobundlesrdquo

ndash Typical best practice is ldquoone-size-fits-allrdquo

ndash Can produce modest improvement

ndash Difficult to sustain

ndash Cannot get to zero this way

The ldquoone-size-fits-allrdquo approach works well

only for simple problems that do not vary

Toughest problems are not simple

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88

Causes Differ by Hospital

Each letter = one hospital

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89

Some Important Causes of Hand

Hygiene Failures

1 Faulty data on performance

2 Inconvenient location of sinks or hand

gel dispensers

3 Hands full

4 Ineffective education of caregivers

5 Lack of accountability

Each requires a very different

strategy to eliminate

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9090

The Technical Solution Is Not Enough

Lean Six Sigma provide technical solutions

Why does improvement fail so often

ndash Not for lack of a good technical solution

ndash Failures occur when organization fails to accept

and implement a good solution it had

RPI addresses this challenge directly

Change management = a systematic way to

implement and sustain good solutions

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9191

Facilitating Change

Key components of managing change

1 Plan engage all stakeholders identify

sponsor champion and process owner

2 Inspire paint a convincing picture of how

beneficial the change will be

3 Launch initiate the change intensify

communication to stakeholders

4 Support sustain the improvement

empower process owner

Change management is not linear

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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness

Studies show that between 50 and 75

of improvement efforts fail due to a lack

of focus on facilitating change

Adapted from General Electric Corsquos Change Acceleration Process copy 2008

Change Management GErsquos FormulaQuality x Acceptance x Accountability = Effectiveness

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94

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95

Why RPI The Business Case

Administrative processes in health care are

just as broken as clinical processes

ndashBilling supply chain throughput

ndashRPI can directly improve margins

Learning RPI allows organizations to solve

their own problems

Generate positive ROI now while learning

how to redesign care processes for future

Mayo program ROI = 51

J Patient Safety 20139(1)44-52

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96

Why RPI Major Improvements

Center Projects Results()

Hand hygiene 71

Hand-off communication failures 56

Wrong site surgery risks

ndashScheduling 46

ndashPre-op 63

ndashOperating Room 51

Colorectal SSIs 32

Falls with injury 62

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n

97

HAI Hospital Scorecard

Number of HAIs in one month

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n

98



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n

9999

Performance Improvement

for High Reliability

Methods ndash What methodstools are used for adoption of Robust

Process Improvementreg tools

ndash Commitment to adopting these tools throughout the

organization

Trainingndash Is training limited to the quality department

ndash Is there a plan to broaden training

Spreadndash Used in many areas Clinical as well as operational

ndash Proficiency in these tools tied to career advancement

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100100

Table Discussion RPIreg

What strategies have you used to

build your performance improvement

program

ndash Who were your key stakeholders

ndash What resistance did you find

ndash Were you successful in managing the

resistance



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101

RESOURCES

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102102

High reliability is catching on

Google search conducted September 29 2015

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Quick Access via the Websitewwwcenterfortransforminghealthcareorg

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104104

Patient Safety Systems Chapter

httpwwwjointcommissionorgaccreditation

hospitalsaspx

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n

105

IN SUMMARY

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n

106106

South Carolina Safe Care Commitment

What is Possible

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107107

Zero Harm Awards

Categories

ndash Hip replacement-hospital wide

ndash Knee replacement-hospital wide

ndash CLABSI-ICU only or special non-ICU

HematologyOncology or Renal Dialysis units

Twelve months or greater without incidence

2014 77 awards across 3 categories

statewide


statewide

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108108

In order to drastically improve safety

levels and advance towards high

reliability must have

Strong leadership support

Commitment to building a safety culture

Evidenced-based performance

improvement methodology

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109109

Transformation to High Reliability

We must have much more ambitious goals

for healthcare improvement zero harm

Current methods will not get us there

Lean six sigma and change management

(RPIreg) have far greater promise

Culture change is difficult takes time

Some hospitals and systems making real

progress showing that zero is achievable

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Launch

High reliability is achievable

Striving for high reliability is not a

project

ndash Leadership commitment to goal of zero

ndash Fully functioning culture of safety

ndash Highly effective improvement capacity

Enables better organizational

performance in many different areas

in addition to safety

110

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What can you do

next week

111

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112112

QUESTIONS OR COMMENTS

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22

Objectives Discuss the importance of leaders as agents of

change on the journey toward high reliability

Describe why leadership commitment culture of safety and performance improvement are important elements in the high reliability journey

Identify the various components that contribute to establishing high reliability within a healthcare organization

Describe benefits of and barriers to beginning a high reliability journey within their own organization

Articulate specific actions they can take within their organizations to make progress toward high reliability

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what you do

3

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n

4

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sio

n

5

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n

6

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7


1

1

10 100 1000 10000 100K 1M 10M


To

tal L

ive

s L

ost p

er

Ye

ar

10

100

1000

10000

100000

Dangerous

(gt11000

Health

Care

(1 of

~600)

Mountaineering

Bungee

Jumping

Driving in US

Chartered

Flights

Chemical

Manufacturing

Scheduled

Commercial

Airlines

European

Railroads

Nuclear

Power

Theme

Parks

Ultra Safe

(lt11M)

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88



ndashSimple

ndashCheap

ndashSafe

ndashIneffective



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n

99

Is Complexity Bad





error





45

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sio

n


Added cost

OR


organization







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n



without expertise



not exist


training



11

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n



improvement


sustainability

Reactive approach

to improvement

Whack-a-mole


PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

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Leadership

13

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14









patients are harmed

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n

1515


1990-2001




2002-2013




= 90

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n

1616







hospitalizations




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1717

Table Discussion





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1919


in Health Care



ndash Over time






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2020


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n

2121

Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




copy C

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n

2424

Milbank Q 201391(3)459-90

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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n

2727

Table Discussion



In 3 years



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n

2828

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n

29

LEADERSHIP


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n

3030

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n

3131



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n

3232





The goal of zero



copy C

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n

3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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ht

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n

3535



and safety




and goals


patient harm

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n

3636









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n

3737








clinical processes

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n

3838










awareness

copy C

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n

3939


copy C

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mis

sio

n

4040






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mis

sio

n

42

copy C

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n

4343

Physicians






clinicians

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n

4444

Physicians

Impact of physician

engagement






copy C

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n

4545

Quality Strategy


and safety



strategic goal





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n

47

copy C

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n

4848

Quality Measurement




requirements




copy C

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n

4949




improvement


Safe Adoption of IT

copy C

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oin

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mis

sio

n

5050






copy C

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n

51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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n

5252




harm


high reliability



harm

ndash If NO Why not



copy C

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n

5353

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n

54

SAFETY CULTURE

copy C

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n

5555






safety culture

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n

56

copy C

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5757


Trust




environment



copy C

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sio

n

5858

Accountability







copy C

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n

5959

Accountability










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n

60

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6161






retrospective


copy C

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sio

n

6262



about andhellip



copy C

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sio

n

6363











copy C

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sio

n

6464







Reactive




Predictive


copy C

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n

6565




to risk reduction






--- if they are


copy C

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sio

n

6666

Assessment




improve




are in place


copy C

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n

6767





work to improve





copy C

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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n

6969





Most common







copy C

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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n

7171

Summary










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n

7272




conditions


week



following

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sio

n

7373

copy C

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74


copy C

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sio

n

757575



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n

7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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7979





40-60 of the time


Answer


change management

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sio

n

8080











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sio

n

82

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n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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n

8484

What is Lean







pure waste




copy C

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n

8585








million



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n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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ht

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sio

n

8787











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sio

n

88



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89


Hygiene Failures



gel dispensers

3 Hands full





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ht

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sio

n

9090










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sio

n

9191

Facilitating Change











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n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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n

94

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n

95







their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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organization





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hospitalsaspx

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IN SUMMARY

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What is Possible

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what you do

3

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4

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1

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Care

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ndashSimple

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error





45

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Added cost

OR


organization







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without expertise



not exist


training



11

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improvement


sustainability

Reactive approach

to improvement

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PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

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Leadership

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patients are harmed

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= 90

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hospitalizations




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Table Discussion





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in Health Care



ndash Over time






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3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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2828

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29

LEADERSHIP


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3030

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3131



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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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3636









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3737








clinical processes

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3838










awareness

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3939


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4040






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42

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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5050






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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252




harm


high reliability



harm

ndash If NO Why not



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5353

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54

SAFETY CULTURE

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5555






safety culture

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56

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5757


Trust




environment



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5858

Accountability







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5959

Accountability










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60

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6161






retrospective


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6262



about andhellip



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6363











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6464







Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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6767





work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



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IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

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bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










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7272




conditions


week



following

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7373

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74


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757575



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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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8484

What is Lean







pure waste




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8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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8787











copy C

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88



copy C

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89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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9090










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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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94

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n

95







their own problems





copy C

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sio

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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97



copy C

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n

98



copy C

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9999






organization





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100100




program




resistance



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sio

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101

RESOURCES

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mis

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n

102102



copy C

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104104



hospitalsaspx

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105

IN SUMMARY

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sio

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106106


What is Possible

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sio

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107107

Zero Harm Awards

Categories







statewide


statewide

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mis

sio

n

108108








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109109










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Launch



project







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What can you do

next week

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112112


copy C

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4

copy C

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5

copy C

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6

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7


1

1

10 100 1000 10000 100K 1M 10M


To

tal L

ive

s L

ost p

er

Ye

ar

10

100

1000

10000

100000

Dangerous

(gt11000

Health

Care

(1 of

~600)

Mountaineering

Bungee

Jumping

Driving in US

Chartered

Flights

Chemical

Manufacturing

Scheduled

Commercial

Airlines

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Railroads

Nuclear

Power

Theme

Parks

Ultra Safe

(lt11M)

copy C

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ht

Th

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sio

n

88



ndashSimple

ndashCheap

ndashSafe

ndashIneffective



copy C

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n

99

Is Complexity Bad





error





45

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mis

sio

n


Added cost

OR


organization







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sio

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without expertise



not exist


training



11

copy C

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he J

oin

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om

mis

sio

n



improvement


sustainability

Reactive approach

to improvement

Whack-a-mole


PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

copy C

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ight T

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oin

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sio

n

Leadership

13

copy C

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14









patients are harmed

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1515


1990-2001




2002-2013




= 90

copy C

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1616







hospitalizations




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1717

Table Discussion





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1919


in Health Care



ndash Over time






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ht

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mis

sio

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2020


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sio

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2121

Five Principles of









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oin

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om

mis

sio

n

2222

3rd Edition

now


revised

broader range

of cases

copy C

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yrig

ht

Th

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oin

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mis

sio

n

2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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sio

n

2424

Milbank Q 201391(3)459-90

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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n

Why




Improves compliance



26

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n

2727

Table Discussion



In 3 years



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2828

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29

LEADERSHIP


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n

3030

copy C

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mis

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3131



copy C

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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

copy C

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n

3636









copy C

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3737








clinical processes

copy C

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3838










awareness

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3939


copy C

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4040






copy C

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42

copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

copy C

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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sio

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5050






copy C

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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252




harm


high reliability



harm

ndash If NO Why not



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5353

copy C

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54

SAFETY CULTURE

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safety culture

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56

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5757


Trust




environment



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5858

Accountability







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5959

Accountability










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60

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retrospective


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6262



about andhellip



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Reactive




Predictive


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to risk reduction






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Assessment




improve




are in place


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6767





work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










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7272




conditions


week



following

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7373

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copy C

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757575



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7676





copy C

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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8484

What is Lean







pure waste




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8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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8787











copy C

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88



copy C

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89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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9090










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9191

Facilitating Change











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92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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94

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95







their own problems





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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



copy C

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98



copy C

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9999






organization





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100100




program




resistance



copy C

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101

RESOURCES

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102102



copy C

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104104



hospitalsaspx

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105

IN SUMMARY

copy C

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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108108








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109109










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Launch



project







110

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What can you do

next week

111

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112112


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5

copy C

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6

copy C

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7


1

1

10 100 1000 10000 100K 1M 10M


To

tal L

ive

s L

ost p

er

Ye

ar

10

100

1000

10000

100000

Dangerous

(gt11000

Health

Care

(1 of

~600)

Mountaineering

Bungee

Jumping

Driving in US

Chartered

Flights

Chemical

Manufacturing

Scheduled

Commercial

Airlines

European

Railroads

Nuclear

Power

Theme

Parks

Ultra Safe

(lt11M)

copy C

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ndashSimple

ndashCheap

ndashSafe

ndashIneffective



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99

Is Complexity Bad





error





45

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Added cost

OR


organization







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without expertise



not exist


training



11

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improvement


sustainability

Reactive approach

to improvement

Whack-a-mole


PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

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Leadership

13

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14









patients are harmed

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1515


1990-2001




2002-2013




= 90

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1616







hospitalizations




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1717

Table Discussion





copy C

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1919


in Health Care



ndash Over time






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2020


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2121

Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

copy C

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ht

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oin

t C

om

mis

sio

n

2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

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ight T

he J

oin

t C

om

mis

sio

n

Why




Improves compliance



26

copy C

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ht

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t C

om

mis

sio

n

2727

Table Discussion



In 3 years



copy C

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yrig

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oin

t C

om

mis

sio

n

2828

copy C

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mis

sio

n

29

LEADERSHIP


copy C

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mis

sio

n

3030

copy C

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mis

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n

3131



copy C

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sio

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3232





The goal of zero



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sio

n

3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


copy C

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ht

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mis

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n

34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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sio

n

3535



and safety




and goals


patient harm

copy C

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sio

n

3636









copy C

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3737








clinical processes

copy C

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sio

n

3838










awareness

copy C

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sio

n

3939


copy C

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4040






copy C

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copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





copy C

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mis

sio

n

47

copy C

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4848

Quality Measurement




requirements




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n

4949




improvement


Safe Adoption of IT

copy C

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mis

sio

n

5050






copy C

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51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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ht

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sio

n

5252




harm


high reliability



harm

ndash If NO Why not



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sio

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5353

copy C

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sio

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54

SAFETY CULTURE

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5555






safety culture

copy C

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56

copy C

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5757


Trust




environment



copy C

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sio

n

5858

Accountability







copy C

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5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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sio

n

6262



about andhellip



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copy C

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6464







Reactive




Predictive


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6565




to risk reduction






--- if they are


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Assessment




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2007 (n= 382) 2012 (n=1128)





50

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

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clinical duties


education



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SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

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terminate

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SYSTEM FAILURES

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FAILURE

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Yes

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Summary










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7272




conditions


week



following

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7373

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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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7979





40-60 of the time


Answer


change management

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8080











copy C

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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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8787











copy C

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sio

n

88



copy C

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om

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sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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9090










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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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their own problems





copy C

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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sio

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97



copy C

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n

98



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9999






organization





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100100




program




resistance



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101

RESOURCES

copy C

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n

102102



copy C

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ight T

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n

104104



hospitalsaspx

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105

IN SUMMARY

copy C

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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108108








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109109










copy C

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Launch



project







110

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mis

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What can you do

next week

111

copy C

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112112


copy C

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mis

sio

n

6

copy C

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7


1

1

10 100 1000 10000 100K 1M 10M


To

tal L

ive

s L

ost p

er

Ye

ar

10

100

1000

10000

100000

Dangerous

(gt11000

Health

Care

(1 of

~600)

Mountaineering

Bungee

Jumping

Driving in US

Chartered

Flights

Chemical

Manufacturing

Scheduled

Commercial

Airlines

European

Railroads

Nuclear

Power

Theme

Parks

Ultra Safe

(lt11M)

copy C

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ndashSimple

ndashCheap

ndashSafe

ndashIneffective



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99

Is Complexity Bad





error





45

copy C

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Added cost

OR


organization







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without expertise



not exist


training



11

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ight T

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n



improvement


sustainability

Reactive approach

to improvement

Whack-a-mole


PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

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Leadership

13

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14









patients are harmed

copy C

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1515


1990-2001




2002-2013




= 90

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1616







hospitalizations




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1717

Table Discussion





copy C

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1919


in Health Care



ndash Over time






copy C

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2020


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2121

Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



copy C

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n

2828

copy C

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29

LEADERSHIP


copy C

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3030

copy C

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3131



copy C

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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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3535



and safety




and goals


patient harm

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n

3636









copy C

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3737








clinical processes

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3838










awareness

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3939


copy C

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4040






copy C

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42

copy C

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4343

Physicians






clinicians

copy C

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4444

Physicians

Impact of physician

engagement






copy C

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4545

Quality Strategy


and safety



strategic goal





copy C

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47

copy C

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4848

Quality Measurement




requirements




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n

4949




improvement


Safe Adoption of IT

copy C

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5050






copy C

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51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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5252




harm


high reliability



harm

ndash If NO Why not



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5353

copy C

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sio

n

54

SAFETY CULTURE

copy C

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sio

n

5555






safety culture

copy C

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n

56

copy C

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5757


Trust




environment



copy C

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sio

n

5858

Accountability







copy C

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5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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6262



about andhellip



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sio

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6363











copy C

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6464







Reactive




Predictive


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6565




to risk reduction






--- if they are


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6666

Assessment




improve




are in place


copy C

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sio

n

6767





work to improve





copy C

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Th

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oin

t C

om

mis

sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

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ht

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om

mis

sio

n

6969





Most common







copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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ht

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t C

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mis

sio

n

7171

Summary










copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7272




conditions


week



following

copy C

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yrig

ht

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t C

om

mis

sio

n

7373

copy C

op

yrig

ht

Th

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t C

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mis

sio

n

74


copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

757575



copy C

op

yrig

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Th

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t C

om

mis

sio

n

7676





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7979





40-60 of the time


Answer


change management

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8080











copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

82

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8484

What is Lean







pure waste




copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8787











copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

88



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

94

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

95







their own problems





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

97



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

98



copy C

op

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ht

Th

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oin

t C

om

mis

sio

n

9999






organization





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

100100




program




resistance



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

101

RESOURCES

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

102102



copy C

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ight T

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t C

om

mis

sio

n


copy C

op

yrig

ht

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t C

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mis

sio

n

104104



hospitalsaspx

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

105

IN SUMMARY

copy C

op

yrig

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hospitalizations




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Table Discussion





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in Health Care



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LeadershipSafety

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Components


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bull Accountability



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Table Discussion



In 3 years



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LEADERSHIP


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3030

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to

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clinicians

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Physicians

Impact of physician

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Quality Strategy


and safety



strategic goal





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Quality Measurement




requirements




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improvement


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harm


high reliability



harm

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SAFETY CULTURE

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safety culture

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Trust




environment



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Accountability







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Accountability










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retrospective


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about andhellip



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Reactive




Predictive


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to risk reduction






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work to improve





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2007 (n= 382) 2012 (n=1128)





50

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Most common







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Start here


Were the actions



substance abuse



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FAILURE

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Summary










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conditions


week



following

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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40-60 of the time


Answer


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83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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88



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Hygiene Failures



gel dispensers

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9090










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9191

Facilitating Change











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QQuality

AAcceptance

AAccountability

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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98



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organization





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program




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101

RESOURCES

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102102



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hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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Zero Harm Awards

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ndashSimple

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Is Complexity Bad





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without expertise



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improvement


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practices



12

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patients are harmed

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hospitalizations




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Table Discussion





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in Health Care



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3rd Edition

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2323

LeadershipSafety

Culture

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Process

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2424

Milbank Q 201391(3)459-90

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Components


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Stages of maturity


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Why




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2727

Table Discussion



In 3 years



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2828

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29

LEADERSHIP


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3030

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3131



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3232





The goal of zero



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3333






Overuse Care


Inefficient Care

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reputation

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4 Financial return

to maintain

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medical

practices


copy C

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34


to

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Patient

Harm


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Board

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Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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3636









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clinical processes

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3838










awareness

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3939


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4040






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42

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4343

Physicians






clinicians

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Physicians

Impact of physician

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4545

Quality Strategy


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Quality Measurement




requirements




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4949




improvement


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5050






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to

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Patient

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Quality Strategy

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harm

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SAFETY CULTURE

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safety culture

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56

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Trust




environment



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5858

Accountability







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Accountability










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retrospective


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about andhellip



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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

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supervision

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individual took an

unacceptable risk



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CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

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education



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impairment program


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SYSTEM

FAILURE

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7171

Summary










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conditions


week



following

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Monthly Death Rates

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Program

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40-60 of the time


Answer


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83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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Hygiene Failures



gel dispensers

3 Hands full





copy C

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9191

Facilitating Change











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QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



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98



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9999






organization





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100100




program




resistance



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RESOURCES

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102102



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104104



hospitalsaspx

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105

IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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Launch



project







110

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What can you do

next week

111

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112112


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99

Is Complexity Bad





error





45

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Added cost

OR


organization







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without expertise



not exist


training



11

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improvement


sustainability

Reactive approach

to improvement

Whack-a-mole


PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

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Leadership

13

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patients are harmed

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1990-2001




2002-2013




= 90

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hospitalizations




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Table Discussion





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in Health Care



ndash Over time






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2020


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Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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2828

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29

LEADERSHIP


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3030

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3131



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The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


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2 Organization

reputation

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to maintain

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medical

practices


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to

ZERO

Patient

Harm


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Safe Adoption of IT

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3535



and safety




and goals


patient harm

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clinical processes

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awareness

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3939


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4040






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4343

Physicians






clinicians

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Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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copy C

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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5050






copy C

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51


to

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Patient

Harm


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Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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harm


high reliability



harm

ndash If NO Why not



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SAFETY CULTURE

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safety culture

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5757


Trust




environment



copy C

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5858

Accountability







copy C

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5959

Accountability










copy C

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6161






retrospective


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6262



about andhellip



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Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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work to improve





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2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










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sio

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7272




conditions


week



following

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7373

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7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

7878



ndash Hand hygiene








copy C

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yrig

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mis

sio

n

7979





40-60 of the time


Answer


change management

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sio

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8080











copy C

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sio

n

82

copy C

op

yrig

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om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8484

What is Lean







pure waste




copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8787











copy C

op

yrig

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88



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Hygiene Failures



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Facilitating Change











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QQuality

AAcceptance

AAccountability

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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IN SUMMARY

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improvement


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hospitalizations




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Table Discussion





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in Health Care



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Five Principles of









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3rd Edition

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LeadershipSafety

Culture

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Process

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Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

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2727

Table Discussion



In 3 years



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2828

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LEADERSHIP


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3030

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3131



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The goal of zero



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Overuse Care


Inefficient Care

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2 Organization

reputation

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to maintain

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practices


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to

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Patient

Harm


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Quality Measures

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and safety




and goals


patient harm

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3636









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clinical processes

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awareness

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3939


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4040






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Physicians






clinicians

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Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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4848

Quality Measurement




requirements




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4949




improvement


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to

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Patient

Harm


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Quality Strategy

Quality Measures

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harm


high reliability



harm

ndash If NO Why not



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5353

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SAFETY CULTURE

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safety culture

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Trust




environment



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5858

Accountability







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5959

Accountability










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60

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retrospective


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6262



about andhellip



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6363











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Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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6767





work to improve





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2007 (n= 382) 2012 (n=1128)





50

57

65

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65

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Most common







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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

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Yes

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supervision

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individual took an

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bullDiscipline

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to duties




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No

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clinical duties


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impairment program




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terminate

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SYSTEM FAILURES

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FAILURE

No


Yes

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Summary










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conditions


week



following

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757575



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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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88



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89


Hygiene Failures



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9090










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mis

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n

9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

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n

94

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95







their own problems





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sio

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



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98



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9999






organization





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100100




program




resistance



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101

RESOURCES

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102102



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104104



hospitalsaspx

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105

IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

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statewide

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108108








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109109










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Launch



project







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What can you do

next week

111

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112112


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without expertise



not exist


training



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improvement


sustainability

Reactive approach

to improvement

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PDCAPDSA is the

only methodology


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Adoption of best

practices



12

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Leadership

13

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n

14









patients are harmed

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sio

n

1515


1990-2001




2002-2013




= 90

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1616







hospitalizations




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1717

Table Discussion





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1919


in Health Care



ndash Over time






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2020


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2121

Five Principles of









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3rd Edition

now


revised

broader range

of cases

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mis

sio

n

2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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mis

sio

n

2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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2828

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29

LEADERSHIP


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3030

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3131



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3232





The goal of zero



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3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


copy C

op

yrig

ht

Th

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mis

sio

n

34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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ht

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oin

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mis

sio

n

3535



and safety




and goals


patient harm

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clinical processes

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awareness

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3939


copy C

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Physicians






clinicians

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Quality Strategy


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4949




improvement


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5050






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harm

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Trust




environment



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Accountability







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Accountability










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2007 (n= 382) 2012 (n=1128)





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Start here


Were the actions



substance abuse



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professional group





No NoNo


intended

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supervision

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CONSIDER

bullDiscipline

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to duties




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FAILURE

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Summary










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conditions


week



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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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40-60 of the time


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83


strategies tools



Lean Six Sigma and




clinical outcomes


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million



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Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

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remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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Hygiene Failures



gel dispensers

3 Hands full





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Facilitating Change











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QQuality

AAcceptance

AAccountability

EEffectiveness






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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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98



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organization





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program




resistance



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101

RESOURCES

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102102



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hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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Zero Harm Awards

Categories







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statewide

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Launch



project







110

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What can you do

next week

111

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112112


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improvement


sustainability

Reactive approach

to improvement

Whack-a-mole


PDCAPDSA is the

only methodology


learning

Adoption of best

practices



12

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Leadership

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patients are harmed

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1990-2001




2002-2013




= 90

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hospitalizations




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Table Discussion





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in Health Care



ndash Over time






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Five Principles of









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3rd Edition

now


revised

broader range

of cases

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LeadershipSafety

Culture

Robust

Process

Improvementreg




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Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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Table Discussion



In 3 years



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LEADERSHIP


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3030

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The goal of zero



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Overuse Care


Inefficient Care

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reputation

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to maintain

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medical

practices


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to

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Patient

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and safety




and goals


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clinical processes

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3838










awareness

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3939


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Physicians






clinicians

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Physicians

Impact of physician

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Quality Strategy


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4848

Quality Measurement




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4949




improvement


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to

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harm


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safety culture

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Trust




environment



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Accountability







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Accountability










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retrospective


copy C

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about andhellip



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Reactive




Predictive


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to risk reduction






--- if they are


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work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










copy C

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sio

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7272




conditions


week



following

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7373

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7676





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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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7878



ndash Hand hygiene








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mis

sio

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7979





40-60 of the time


Answer


change management

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sio

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8080











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sio

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82

copy C

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sio

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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t C

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mis

sio

n

8484

What is Lean







pure waste




copy C

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yrig

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mis

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n

8585








million



copy C

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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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8787











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88



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89


Hygiene Failures



gel dispensers

3 Hands full





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9090










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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






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95







their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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98



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9999






organization





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100100




program




resistance



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101

RESOURCES

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102102



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104104



hospitalsaspx

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105

IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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109109










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Launch



project







110

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What can you do

next week

111

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112112


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Leadership

13

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14









patients are harmed

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1515


1990-2001




2002-2013




= 90

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1616







hospitalizations




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Table Discussion





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1919


in Health Care



ndash Over time






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2020


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2121

Five Principles of









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3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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2828

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29

LEADERSHIP


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3030

copy C

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3131



copy C

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3232





The goal of zero



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3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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3636









copy C

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3737








clinical processes

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3838










awareness

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n

3939


copy C

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4040






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42

copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

copy C

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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5050






copy C

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51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252




harm


high reliability



harm

ndash If NO Why not



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5353

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54

SAFETY CULTURE

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5555






safety culture

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56

copy C

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5757


Trust




environment



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5858

Accountability







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5959

Accountability










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60

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6161






retrospective


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6262



about andhellip



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6363











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6464







Reactive




Predictive


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6565




to risk reduction






--- if they are


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6666

Assessment




improve




are in place


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6767





work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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6969





Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










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7272




conditions


week



following

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7373

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74


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757575



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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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8484

What is Lean







pure waste




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n

8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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ht

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sio

n

8787











copy C

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t C

om

mis

sio

n

88



copy C

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om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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ht

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om

mis

sio

n

9090










copy C

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ht

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oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

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sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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t C

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mis

sio

n

94

copy C

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mis

sio

n

95







their own problems





copy C

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sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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97



copy C

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n

98



copy C

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9999






organization





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n

100100




program




resistance



copy C

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sio

n

101

RESOURCES

copy C

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mis

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n

102102



copy C

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sio

n


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n

104104



hospitalsaspx

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n

105

IN SUMMARY

copy C

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sio

n

106106


What is Possible

copy C

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sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

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n

108108








copy C

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sio

n

109109










copy C

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ight T

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sio

n

Launch



project







110

copy C

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ight T

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sio

n

What can you do

next week

111

copy C

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sio

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112112


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14









patients are harmed

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1515


1990-2001




2002-2013




= 90

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n

1616







hospitalizations




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sio

n

1717

Table Discussion





copy C

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sio

n

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1919


in Health Care



ndash Over time






copy C

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mis

sio

n

2020


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mis

sio

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2121

Five Principles of









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sio

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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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sio

n

2424

Milbank Q 201391(3)459-90

copy C

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om

mis

sio

n

2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

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ight T

he J

oin

t C

om

mis

sio

n

Why




Improves compliance



26

copy C

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ht

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om

mis

sio

n

2727

Table Discussion



In 3 years



copy C

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oin

t C

om

mis

sio

n

2828

copy C

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mis

sio

n

29

LEADERSHIP


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mis

sio

n

3030

copy C

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mis

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n

3131



copy C

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sio

n

3232





The goal of zero



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sio

n

3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


copy C

op

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ht

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mis

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n

34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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ht

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sio

n

3535



and safety




and goals


patient harm

copy C

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om

mis

sio

n

3636









copy C

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mis

sio

n

3737








clinical processes

copy C

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mis

sio

n

3838










awareness

copy C

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mis

sio

n

3939


copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

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4545

Quality Strategy


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4848

Quality Measurement




requirements




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4949




improvement


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5050






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Patient

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Quality Strategy

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Trust




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Accountability







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Accountability










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6161






retrospective


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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

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Yes

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supervision

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individual took an

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CONSIDER

bullDiscipline

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to duties




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SYSTEM

FAILURE

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Summary










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7272




conditions


week



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7676





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Monthly Death Rates

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Program

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7878



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40-60 of the time


Answer


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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

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remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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8787











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89


Hygiene Failures



gel dispensers

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9090










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9191

Facilitating Change











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QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



copy C

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98



copy C

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organization





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100100




program




resistance



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RESOURCES

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102102



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hospitalsaspx

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105

IN SUMMARY

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106106


What is Possible

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Zero Harm Awards

Categories







statewide


statewide

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Launch



project







110

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What can you do

next week

111

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112112


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1990-2001




2002-2013




= 90

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hospitalizations




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Table Discussion





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in Health Care



ndash Over time






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2020


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Five Principles of









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3rd Edition

now


revised

broader range

of cases

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LeadershipSafety

Culture

Robust

Process

Improvementreg




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Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Improves compliance



26

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Table Discussion



In 3 years



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2828

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LEADERSHIP


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3030

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The goal of zero



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Overuse Care


Inefficient Care

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reputation

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to maintain

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medical

practices


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to

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Patient

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and safety




and goals


patient harm

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clinical processes

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awareness

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Physicians






clinicians

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Physicians

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Quality Strategy


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Quality Measurement




requirements




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4949




improvement


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to

ZERO

Patient

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Quality Strategy

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Safe Adoption of IT

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harm


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safety culture

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5757


Trust




environment



copy C

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5858

Accountability







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5959

Accountability










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retrospective


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about andhellip



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Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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Summary










copy C

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7272




conditions


week



following

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7373

copy C

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copy C

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7676





copy C

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n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

7878



ndash Hand hygiene








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7979





40-60 of the time


Answer


change management

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8080











copy C

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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yrig

ht

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om

mis

sio

n

8484

What is Lean







pure waste




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mis

sio

n

8585








million



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mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

8787











copy C

op

yrig

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t C

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mis

sio

n

88



copy C

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yrig

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om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9090










copy C

op

yrig

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mis

sio

n

9191

Facilitating Change











copy C

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mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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IN SUMMARY

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What is Possible

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hospitalizations




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Table Discussion





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in Health Care



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LeadershipSafety

Culture

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Process

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Milbank Q 201391(3)459-90

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Components


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bull Accountability



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bull Methods

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Table Discussion



In 3 years



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LEADERSHIP


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Overuse Care


Inefficient Care

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reputation

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practices


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to

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Patient

Harm


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and safety




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awareness

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Physicians






clinicians

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Physicians

Impact of physician

engagement






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Quality Strategy


and safety



strategic goal





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Quality Measurement




requirements




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improvement


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to

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Patient

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harm


high reliability



harm

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SAFETY CULTURE

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safety culture

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Trust




environment



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5858

Accountability







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Accountability










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retrospective


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about andhellip



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Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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work to improve





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2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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Start here


Were the actions



substance abuse



procedures



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No NoNo


intended

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supervision

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individual took an

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CONSIDER

bullDiscipline

bullReport to NPDB


to duties




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impairment program




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SYSTEM FAILURES

Yes

No

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SYSTEM

FAILURE

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Yes

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Summary










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conditions


week



following

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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











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83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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88



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Hygiene Failures



gel dispensers

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9090










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9191

Facilitating Change











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92

QQuality

AAcceptance

AAccountability

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94

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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organization





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100100




program




resistance



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101

RESOURCES

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102102



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hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

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statewide

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109109










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Launch



project







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What can you do

next week

111

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112112


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1717

Table Discussion





copy C

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in Health Care



ndash Over time






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2020


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2121

Five Principles of









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3rd Edition

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broader range

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LeadershipSafety

Culture

Robust

Process

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Milbank Q 201391(3)459-90

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2525


Components


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bull CEOManagement

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bull Assessment


bull Methods

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Stages of maturity


copy C

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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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n

2828

copy C

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29

LEADERSHIP


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3030

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3131



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The goal of zero



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Overuse Care


Inefficient Care

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reputation

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to maintain

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medical

practices


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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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3636









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clinical processes

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3838










awareness

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3939


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4040






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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

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4545

Quality Strategy


and safety



strategic goal





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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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to

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Patient

Harm


Leadership

Board

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Quality Strategy

Quality Measures

Safe Adoption of IT

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harm


high reliability



harm

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SAFETY CULTURE

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safety culture

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56

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5757


Trust




environment



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5858

Accountability







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Accountability










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6161






retrospective


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6262



about andhellip



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6363











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Reactive




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are in place


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2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

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No

CONSIDER

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clinical duties


education



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CONSIDER

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impairment program


impairment program




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terminate

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SYSTEM FAILURES

Yes

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SYSTEM

FAILURE

No


Yes

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Summary










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7272




conditions


week



following

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7373

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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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40-60 of the time


Answer


change management

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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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88



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89


Hygiene Failures



gel dispensers

3 Hands full





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9090










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9191

Facilitating Change











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9292

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QQuality

AAcceptance

AAccountability

EEffectiveness






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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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98



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organization





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program




resistance



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RESOURCES

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102102



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104104



hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

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statewide


statewide

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Launch



project







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What can you do

next week

111

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112112


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in Health Care



ndash Over time






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2020


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2121

Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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Table Discussion



In 3 years



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2828

copy C

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LEADERSHIP


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3030

copy C

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3131



copy C

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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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clinical processes

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3838










awareness

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3939


copy C

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4040






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42

copy C

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Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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Quality Strategy


and safety



strategic goal





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4848

Quality Measurement




requirements




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improvement


Safe Adoption of IT

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5050






copy C

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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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harm


high reliability



harm

ndash If NO Why not



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5353

copy C

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54

SAFETY CULTURE

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safety culture

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n

56

copy C

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5757


Trust




environment



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5858

Accountability







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5959

Accountability










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60

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6161






retrospective


copy C

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6262



about andhellip



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6363











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6464







Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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work to improve





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sio

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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sio

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










copy C

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sio

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7272




conditions


week



following

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7373

copy C

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copy C

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copy C

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n

7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

7878



ndash Hand hygiene








copy C

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yrig

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mis

sio

n

7979





40-60 of the time


Answer


change management

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sio

n

8080











copy C

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mis

sio

n

82

copy C

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om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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yrig

ht

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oin

t C

om

mis

sio

n

8484

What is Lean







pure waste




copy C

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yrig

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mis

sio

n

8585








million



copy C

op

yrig

ht

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t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

8787











copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

88



copy C

op

yrig

ht

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t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

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t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

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om

mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

94

copy C

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yrig

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Th

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mis

sio

n

95







their own problems





copy C

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yrig

ht

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om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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mis

sio

n

97



copy C

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mis

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n

98



copy C

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9999






organization





copy C

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mis

sio

n

100100




program




resistance



copy C

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yrig

ht

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t C

om

mis

sio

n

101

RESOURCES

copy C

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oin

t C

om

mis

sio

n

102102



copy C

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ight T

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sio

n


copy C

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n

104104



hospitalsaspx

copy C

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sio

n

105

IN SUMMARY

copy C

op

yrig

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mis

sio

n

106106


What is Possible

copy C

op

yrig

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mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

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mis

sio

n

108108








copy C

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mis

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n

109109










copy C

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Launch



project







110

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in Health Care



ndash Over time






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2020


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Five Principles of









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3rd Edition

now


revised

broader range

of cases

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LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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2828

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LEADERSHIP


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3030

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3131



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The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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to

ZERO

Patient

Harm


Leadership

Board

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Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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and safety




and goals


patient harm

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clinical processes

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3838










awareness

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3939


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4040






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4343

Physicians






clinicians

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Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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4848

Quality Measurement




requirements




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4949




improvement


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5050






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to

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Patient

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Leadership

Board

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Physicians

Quality Strategy

Quality Measures

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harm


high reliability



harm

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SAFETY CULTURE

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safety culture

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56

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5757


Trust




environment



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5858

Accountability







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Accountability










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retrospective


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about andhellip



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Reactive




Predictive


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to risk reduction






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Assessment




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are in place


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work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



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SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




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SYSTEM FAILURES


terminate

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IDENTIFY

SYSTEM FAILURES

Yes

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No

SYSTEM

FAILURE

No


Yes

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Summary










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7272




conditions


week



following

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7373

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7676





copy C

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











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82

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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8484

What is Lean







pure waste




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8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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88



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Hygiene Failures



gel dispensers

3 Hands full





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9090










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9191

Facilitating Change











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92

QQuality

AAcceptance

AAccountability

EEffectiveness






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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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organization





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100100




program




resistance



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101

RESOURCES

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102102



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104104



hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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Zero Harm Awards

Categories







statewide


statewide

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Launch



project







110

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What can you do

next week

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112112


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2020


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2121

Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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n

2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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sio

n

2424

Milbank Q 201391(3)459-90

copy C

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mis

sio

n

2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

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ight T

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n

Why




Improves compliance



26

copy C

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sio

n

2727

Table Discussion



In 3 years



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2828

copy C

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29

LEADERSHIP


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3030

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3131



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3232





The goal of zero



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Overuse Care


Inefficient Care

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1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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3535



and safety




and goals


patient harm

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3636









copy C

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3737








clinical processes

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3838










awareness

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3939


copy C

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4040






copy C

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42

copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

copy C

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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5050






copy C

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51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252




harm


high reliability



harm

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5353

copy C

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54

SAFETY CULTURE

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sio

n

5555






safety culture

copy C

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mis

sio

n

56

copy C

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mis

sio

n

5757


Trust




environment



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om

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sio

n

5858

Accountability







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5959

Accountability










copy C

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6161






retrospective


copy C

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6262



about andhellip



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6464







Reactive




Predictive


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to risk reduction






--- if they are


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6666

Assessment




improve




are in place


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6767





work to improve





copy C

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sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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n

6969





Most common







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mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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ht

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mis

sio

n

7171

Summary










copy C

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sio

n

7272




conditions


week



following

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7373

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74


copy C

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757575



copy C

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7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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n

7878



ndash Hand hygiene








copy C

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n

7979





40-60 of the time


Answer


change management

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8080











copy C

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mis

sio

n

82

copy C

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sio

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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n

8484

What is Lean







pure waste




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n

8585








million



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n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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n

8787











copy C

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n

88



copy C

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sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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sio

n

9090










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n

9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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94

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95







their own problems





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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



copy C

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98



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9999






organization





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100100




program




resistance



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101

RESOURCES

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102102



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104104



hospitalsaspx

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105

IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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108108








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109109










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Launch



project







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What can you do

next week

111

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112112


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2121

Five Principles of









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2222

3rd Edition

now


revised

broader range

of cases

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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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n

Why




Improves compliance



26

copy C

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sio

n

2727

Table Discussion



In 3 years



copy C

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sio

n

2828

copy C

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n

29

LEADERSHIP


copy C

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n

3030

copy C

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3131



copy C

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3232





The goal of zero



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3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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n

3636









copy C

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3737








clinical processes

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3838










awareness

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n

3939


copy C

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n

4040






copy C

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n

42

copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

copy C

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

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n

5050






copy C

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n

51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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n

5252




harm


high reliability



harm

ndash If NO Why not



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5353

copy C

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n

54

SAFETY CULTURE

copy C

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n

5555






safety culture

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n

56

copy C

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5757


Trust




environment



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5858

Accountability







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n

5959

Accountability










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60

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6161






retrospective


copy C

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6262



about andhellip



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6363











copy C

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6464







Reactive




Predictive


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6565




to risk reduction






--- if they are


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6666

Assessment




improve




are in place


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6767





work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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6969





Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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sio

n

7171

Summary










copy C

op

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ht

Th

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oin

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om

mis

sio

n

7272




conditions


week



following

copy C

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mis

sio

n

7373

copy C

op

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oin

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sio

n

74


copy C

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oin

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mis

sio

n

757575



copy C

op

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sio

n

7676





copy C

op

yrig

ht

Th

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oin

t C

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sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7979





40-60 of the time


Answer


change management

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8080











copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

82

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8484

What is Lean







pure waste




copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8787











copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

88



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

94

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

95







their own problems





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

97



copy C

op

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ht

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om

mis

sio

n

98



copy C

op

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ht

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sio

n

9999






organization





copy C

op

yrig

ht

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om

mis

sio

n

100100




program




resistance



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

101

RESOURCES

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

102102



copy C

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ight T

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mis

sio

n


copy C

op

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mis

sio

n

104104



hospitalsaspx

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

105

IN SUMMARY

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

106106


What is Possible

copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

108108








copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

109109










copy C

opyr

ight T

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oin

t C

om

mis

sio

n

Launch



project







110

copy C

opyr

ight T

he J

oin

t C

om

mis

sio

n

What can you do

next week

111

copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

112112


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

2222

3rd Edition

now


revised

broader range

of cases

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

2424

Milbank Q 201391(3)459-90

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

opyr

ight T

he J

oin

t C

om

mis

sio

n

Why




Improves compliance



26

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

2727

Table Discussion



In 3 years



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

2828

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

29

LEADERSHIP


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

3030

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

3131



copy C

op

yrig

ht

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t C

om

mis

sio

n

3232





The goal of zero



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

3535



and safety




and goals


patient harm

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

3636









copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

3737








clinical processes

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

3838










awareness

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

3939


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

4040






copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

42

copy C

op

yrig

ht

Th

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oin

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

copy C

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4848

Quality Measurement




requirements




copy C

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n

4949




improvement


Safe Adoption of IT

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5050






copy C

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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252




harm


high reliability



harm

ndash If NO Why not



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5353

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54

SAFETY CULTURE

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5555






safety culture

copy C

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56

copy C

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5757


Trust




environment



copy C

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5858

Accountability







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5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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6262



about andhellip



copy C

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sio

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6363











copy C

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6464







Reactive




Predictive


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6565




to risk reduction






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Assessment




improve




are in place


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6767





work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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6969





Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

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terminate

CONSIDER

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SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










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7272




conditions


week



following

copy C

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7373

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copy C

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757575



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7676





copy C

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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7979





40-60 of the time


Answer


change management

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8080











copy C

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82

copy C

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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8484

What is Lean







pure waste




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n

8585








million



copy C

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sio

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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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n

8787











copy C

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n

88



copy C

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om

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n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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n

9090










copy C

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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



copy C

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98



copy C

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9999






organization





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100100




program




resistance



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101

RESOURCES

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102102



copy C

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copy C

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104104



hospitalsaspx

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105

IN SUMMARY

copy C

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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108108








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109109










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Launch



project







110

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What can you do

next week

111

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112112


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2323

LeadershipSafety

Culture

Robust

Process

Improvementreg




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2424

Milbank Q 201391(3)459-90

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Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



copy C

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2828

copy C

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29

LEADERSHIP


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3030

copy C

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3131



copy C

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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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3535



and safety




and goals


patient harm

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3636









copy C

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3737








clinical processes

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3838










awareness

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3939


copy C

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4040






copy C

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42

copy C

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n

4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






copy C

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mis

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n

4545

Quality Strategy


and safety



strategic goal





copy C

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n

47

copy C

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4848

Quality Measurement




requirements




copy C

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4949




improvement


Safe Adoption of IT

copy C

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n

5050






copy C

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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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harm


high reliability



harm

ndash If NO Why not



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5353

copy C

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54

SAFETY CULTURE

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safety culture

copy C

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n

56

copy C

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5757


Trust




environment



copy C

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mis

sio

n

5858

Accountability







copy C

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om

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n

5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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6262



about andhellip



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6363











copy C

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6464







Reactive




Predictive


copy C

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to risk reduction






--- if they are


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Assessment




improve




are in place


copy C

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sio

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6767





work to improve





copy C

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mis

sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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6969





Most common







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mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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mis

sio

n

7171

Summary










copy C

op

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om

mis

sio

n

7272




conditions


week



following

copy C

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om

mis

sio

n

7373

copy C

op

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sio

n

74


copy C

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757575



copy C

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sio

n

7676





copy C

op

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ht

Th

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sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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ht

Th

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oin

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mis

sio

n

7878



ndash Hand hygiene








copy C

op

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mis

sio

n

7979





40-60 of the time


Answer


change management

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sio

n

8080











copy C

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ht

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om

mis

sio

n

82

copy C

op

yrig

ht

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t C

om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8484

What is Lean







pure waste




copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

8787











copy C

op

yrig

ht

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t C

om

mis

sio

n

88



copy C

op

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t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

ht

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t C

om

mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

94

copy C

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sio

n

95







their own problems





copy C

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yrig

ht

Th

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oin

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om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

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ht

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t C

om

mis

sio

n

97



copy C

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n

98



copy C

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9999






organization





copy C

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n

100100




program




resistance



copy C

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sio

n

101

RESOURCES

copy C

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sio

n

102102



copy C

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n


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104104



hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

Categories







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statewide

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copy C

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109109










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Launch



project







110

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What can you do

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111

copy C

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112112


copy C

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2424

Milbank Q 201391(3)459-90

copy C

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mis

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2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

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n

Why




Improves compliance



26

copy C

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2727

Table Discussion



In 3 years



copy C

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mis

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2828

copy C

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29

LEADERSHIP


copy C

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3030

copy C

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3131



copy C

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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

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4 Financial return

to maintain

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medical

practices


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to

ZERO

Patient

Harm


Leadership

Board

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Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




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patient harm

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3636









copy C

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3737








clinical processes

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3838










awareness

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3939


copy C

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4040






copy C

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42

copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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47

copy C

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4848

Quality Measurement




requirements




copy C

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4949




improvement


Safe Adoption of IT

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5050






copy C

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51


to

ZERO

Patient

Harm


Leadership

Board

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Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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5252




harm


high reliability



harm

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5353

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54

SAFETY CULTURE

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safety culture

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56

copy C

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sio

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5757


Trust




environment



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5858

Accountability







copy C

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5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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6262



about andhellip



copy C

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6363











copy C

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6464







Reactive




Predictive


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6565




to risk reduction






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Assessment




improve




are in place


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6767





work to improve





copy C

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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6969





Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

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No

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clinical duties


education



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CONSIDER

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impairment program


impairment program




IDENTIFY

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terminate

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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7171

Summary










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7272




conditions


week



following

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7373

copy C

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74


copy C

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757575



copy C

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7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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40-60 of the time


Answer


change management

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8080











copy C

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82

copy C

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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8484

What is Lean







pure waste




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n

8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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8787











copy C

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88



copy C

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89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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9090










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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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95







their own problems





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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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97



copy C

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98



copy C

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9999






organization





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100100




program




resistance



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101

RESOURCES

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102102



copy C

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104104



hospitalsaspx

copy C

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105

IN SUMMARY

copy C

op

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om

mis

sio

n

106106


What is Possible

copy C

op

yrig

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mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

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mis

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n

108108








copy C

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n

109109










copy C

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Launch



project







110

copy C

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mis

sio

n

What can you do

next week

111

copy C

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mis

sio

n

112112


copy C

op

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mis

sio

n

2525


Components


bull Board

bull CEOManagement

bull Physicians





bull Trust

bull Accountability



bull Assessment


bull Methods

bull Training

bull Spread

Stages of maturity


copy C

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ight T

he J

oin

t C

om

mis

sio

n

Why




Improves compliance



26

copy C

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mis

sio

n

2727

Table Discussion



In 3 years



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

2828

copy C

op

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ht

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mis

sio

n

29

LEADERSHIP


copy C

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mis

sio

n

3030

copy C

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mis

sio

n

3131



copy C

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sio

n

3232





The goal of zero



copy C

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sio

n

3333






Overuse Care


Inefficient Care

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1 Patient needs

2 Organization

reputation

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to maintain

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medical

practices


copy C

op

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ht

Th

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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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3535



and safety




and goals


patient harm

copy C

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mis

sio

n

3636









copy C

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mis

sio

n

3737








clinical processes

copy C

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om

mis

sio

n

3838










awareness

copy C

op

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mis

sio

n

3939


copy C

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4040






copy C

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mis

sio

n

42

copy C

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n

4343

Physicians






clinicians

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mis

sio

n

4444

Physicians

Impact of physician

engagement






copy C

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mis

sio

n

4545

Quality Strategy


and safety



strategic goal





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mis

sio

n

47

copy C

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mis

sio

n

4848

Quality Measurement




requirements




copy C

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mis

sio

n

4949




improvement


Safe Adoption of IT

copy C

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om

mis

sio

n

5050






copy C

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Th

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mis

sio

n

51


to

ZERO

Patient

Harm


Leadership

Board

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Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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sio

n

5252




harm


high reliability



harm

ndash If NO Why not



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mis

sio

n

5353

copy C

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mis

sio

n

54

SAFETY CULTURE

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sio

n

5555






safety culture

copy C

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yrig

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oin

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mis

sio

n

56

copy C

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om

mis

sio

n

5757


Trust




environment



copy C

op

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om

mis

sio

n

5858

Accountability







copy C

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sio

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5959

Accountability










copy C

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sio

n

60

copy C

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mis

sio

n

6161






retrospective


copy C

op

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om

mis

sio

n

6262



about andhellip



copy C

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om

mis

sio

n

6363











copy C

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6464







Reactive




Predictive


copy C

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mis

sio

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6565




to risk reduction






--- if they are


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op

yrig

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sio

n

6666

Assessment




improve




are in place


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mis

sio

n

6767





work to improve





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

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ht

Th

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mis

sio

n

6969





Most common







copy C

op

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ht

Th

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oin

t C

om

mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7171

Summary










copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7272




conditions


week



following

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7373

copy C

op

yrig

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Th

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oin

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om

mis

sio

n

74


copy C

op

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Th

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om

mis

sio

n

757575



copy C

op

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mis

sio

n

7676





copy C

op

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Th

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om

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n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



ndash Hand hygiene








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7979





40-60 of the time


Answer


change management

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83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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copy C

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n

89


Hygiene Failures



gel dispensers

3 Hands full





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Facilitating Change











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QQuality

AAcceptance

AAccountability

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their own problems





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Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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organization





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program




resistance



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101

RESOURCES

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102102



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104104



hospitalsaspx

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IN SUMMARY

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106106


What is Possible

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107107

Zero Harm Awards

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statewide

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project







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Why




Improves compliance



26

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2727

Table Discussion



In 3 years



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2828

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LEADERSHIP


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3030

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3131



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3232





The goal of zero



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Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

2 Organization

reputation

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4 Financial return

to maintain

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medical

practices


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to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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3535



and safety




and goals


patient harm

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3636









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clinical processes

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awareness

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Physicians






clinicians

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Physicians

Impact of physician

engagement






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4545

Quality Strategy


and safety



strategic goal





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4848

Quality Measurement




requirements




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4949




improvement


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5050






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to

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Patient

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Physicians

Quality Strategy

Quality Measures

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harm


high reliability



harm

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SAFETY CULTURE

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safety culture

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56

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5757


Trust




environment



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5858

Accountability







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5959

Accountability










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60

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6161






retrospective


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about andhellip



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6363











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Reactive




Predictive


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to risk reduction






--- if they are


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Assessment




improve




are in place


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6767





work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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Summary










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7272




conditions


week



following

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7373

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copy C

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757575



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7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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yrig

ht

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oin

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om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

7979





40-60 of the time


Answer


change management

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yrig

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t C

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mis

sio

n

8080











copy C

op

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mis

sio

n

82

copy C

op

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mis

sio

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

yrig

ht

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mis

sio

n

8484

What is Lean







pure waste




copy C

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mis

sio

n

8585








million



copy C

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yrig

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t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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yrig

ht

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mis

sio

n

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copy C

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n

88



copy C

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sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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ht

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t C

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mis

sio

n

9090










copy C

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mis

sio

n

9191

Facilitating Change











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sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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sio

n

94

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n

95







their own problems





copy C

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yrig

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sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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97



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organization





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program




resistance



copy C

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101

RESOURCES

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102102



copy C

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104104



hospitalsaspx

copy C

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sio

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105

IN SUMMARY

copy C

op

yrig

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mis

sio

n

106106


What is Possible

copy C

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mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

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op

yrig

ht

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mis

sio

n

108108








copy C

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mis

sio

n

109109










copy C

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mis

sio

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Launch



project







110

copy C

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ight T

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sio

n

What can you do

next week

111

copy C

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sio

n

112112


copy C

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mis

sio

n

2727

Table Discussion



In 3 years



copy C

op

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mis

sio

n

2828

copy C

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sio

n

29

LEADERSHIP


copy C

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sio

n

3030

copy C

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yrig

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mis

sio

n

3131



copy C

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sio

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3232





The goal of zero



copy C

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sio

n

3333






Overuse Care


Inefficient Care

Underuse Care


1 Patient needs

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reputation

3 Esprit de corps

4 Financial return

to maintain

state-of-the-art

medical

practices


copy C

op

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ht

Th

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34


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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3535



and safety




and goals


patient harm

copy C

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sio

n

3636









copy C

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sio

n

3737








clinical processes

copy C

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sio

n

3838










awareness

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n

3939


copy C

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4040






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42

copy C

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4343

Physicians






clinicians

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4444

Physicians

Impact of physician

engagement






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mis

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n

4545

Quality Strategy


and safety



strategic goal





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sio

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47

copy C

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4848

Quality Measurement




requirements




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4949




improvement


Safe Adoption of IT

copy C

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mis

sio

n

5050






copy C

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51


to

ZERO

Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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sio

n

5252




harm


high reliability



harm

ndash If NO Why not



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mis

sio

n

5353

copy C

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mis

sio

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54

SAFETY CULTURE

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5555






safety culture

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sio

n

56

copy C

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mis

sio

n

5757


Trust




environment



copy C

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mis

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n

5858

Accountability







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5959

Accountability










copy C

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60

copy C

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retrospective


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2007 (n= 382) 2012 (n=1128)





50

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Start here


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Summary










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7272




conditions


week



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7373

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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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strategies tools



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million



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8686

Six Sigma

86


Who are the

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what are their

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How is the process


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Hygiene Failures



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QQuality

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their own problems





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Hand hygiene 71



ndashScheduling 46

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Colorectal SSIs 32


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program




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RESOURCES

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hospitalsaspx

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IN SUMMARY

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What is Possible

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Zero Harm Awards

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statewide

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What can you do

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2828

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LEADERSHIP


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The goal of zero



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to

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Patient

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clinical processes

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awareness

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3939


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4040






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Physicians






clinicians

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Impact of physician

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Quality Strategy


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4848

Quality Measurement




requirements




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4949




improvement


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harm


high reliability



harm

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Trust




environment



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Accountability







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Predictive


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to risk reduction






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work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

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CONSIDER

bullReport to NPDB


impairment program


impairment program




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terminate

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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Summary










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conditions


week



following

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7676





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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


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strategies tools



Lean Six Sigma and




clinical outcomes


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pure waste




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million



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Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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How do we

remove the

causes of the

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How can we

maintain the

improvements


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89


Hygiene Failures



gel dispensers

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9090










copy C

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Facilitating Change











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QQuality

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their own problems





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Colorectal SSIs 32


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IN SUMMARY

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What is Possible

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Zero Harm Awards

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statewide


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LEADERSHIP


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3131



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The goal of zero



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Overuse Care


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practices


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to

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Patient

Harm


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Quality Measures

Safe Adoption of IT

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and safety




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clinical processes

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4343

Physicians






clinicians

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Physicians

Impact of physician

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Quality Strategy


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copy C

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4848

Quality Measurement




requirements




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4949




improvement


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5050






copy C

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to

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Patient

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Physicians

Quality Strategy

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harm


high reliability



harm

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5353

copy C

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SAFETY CULTURE

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safety culture

copy C

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56

copy C

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5757


Trust




environment



copy C

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5858

Accountability







copy C

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5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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6262



about andhellip



copy C

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6363











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Reactive




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copy C

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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Most common







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Start here


Were the actions



substance abuse



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No NoNo


intended

Yes Yes

Yes

Yes

Yes

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Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

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No

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clinical duties


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FAILURE

No


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7171

Summary










copy C

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7272




conditions


week



following

copy C

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7373

copy C

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copy C

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757575



copy C

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7676





copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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7878



ndash Hand hygiene








copy C

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40-60 of the time


Answer


change management

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8080











copy C

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82

copy C

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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What is Lean







pure waste




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8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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improvements


copy C

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copy C

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88



copy C

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89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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9090










copy C

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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

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copy C

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their own problems





copy C

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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97



copy C

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organization





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program




resistance



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RESOURCES

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102102



copy C

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104104



hospitalsaspx

copy C

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105

IN SUMMARY

copy C

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106106


What is Possible

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107107

Zero Harm Awards

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statewide

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copy C

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What can you do

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112112


copy C

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3030

copy C

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3131



copy C

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3232





The goal of zero



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Overuse Care


Inefficient Care

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to

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Patient

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Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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3535



and safety




and goals


patient harm

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3636









copy C

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clinical processes

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3838










awareness

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3939


copy C

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4040






copy C

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copy C

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4343

Physicians






clinicians

copy C

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4444

Physicians

Impact of physician

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copy C

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4545

Quality Strategy


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copy C

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copy C

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4848

Quality Measurement




requirements




copy C

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4949




improvement


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5050






copy C

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to

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Patient

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Quality Strategy

Quality Measures

Safe Adoption of IT

copy C

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harm


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5353

copy C

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SAFETY CULTURE

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Trust




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Accountability







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Accountability










copy C

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retrospective


copy C

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to risk reduction






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6767





work to improve





copy C

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sio

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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mis

sio

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7171

Summary










copy C

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sio

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7272




conditions


week



following

copy C

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7373

copy C

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copy C

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copy C

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copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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7878



ndash Hand hygiene








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40-60 of the time


Answer


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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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sio

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8484

What is Lean







pure waste




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n

8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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88



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n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

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oin

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mis

sio

n

9090










copy C

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mis

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9191

Facilitating Change











copy C

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9292

92

QQuality

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copy C

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copy C

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their own problems





copy C

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96



Hand hygiene 71



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Colorectal SSIs 32


copy C

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104104



hospitalsaspx

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IN SUMMARY

copy C

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sio

n

106106


What is Possible

copy C

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mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

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copy C

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The goal of zero



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Patient

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clinical processes

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awareness

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3939


copy C

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4040






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copy C

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Physicians






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Impact of physician

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Quality Strategy


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4848

Quality Measurement




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4949




improvement


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5050






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Patient

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SAFETY CULTURE

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safety culture

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56

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5757


Trust




environment



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5858

Accountability







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5959

Accountability










copy C

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60

copy C

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6161






retrospective


copy C

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6262



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6363











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6464







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2007 (n= 382) 2012 (n=1128)





50

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65

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No NoNo


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Yes Yes

Yes

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supervision

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No

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to duties




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No

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No

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7171

Summary










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7272




conditions


week



following

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7676





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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



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40-60 of the time


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8383

83


strategies tools



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pure waste




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million



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Six Sigma

86


Who are the

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How is the process


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What are the

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89


Hygiene Failures



gel dispensers

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9090










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QQuality

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copy C

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their own problems





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Hand hygiene 71



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Colorectal SSIs 32


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organization





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program




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RESOURCES

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102102



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hospitalsaspx

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105

IN SUMMARY

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106106


What is Possible

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107107

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The goal of zero



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Overuse Care


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copy C

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to

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Patient

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and safety




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clinical processes

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3838










awareness

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copy C

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Physicians






clinicians

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Quality Strategy


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4848

Quality Measurement




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improvement


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2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

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Start here


Were the actions



substance abuse



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

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clinical duties


education



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impairment program


impairment program




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terminate

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Yes

No

No

SYSTEM

FAILURE

No


Yes

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Summary










copy C

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conditions


week



following

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

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7878



ndash Hand hygiene








copy C

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mis

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40-60 of the time


Answer


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83


strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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n

8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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defects

How do we

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causes of the

defects

How can we

maintain the

improvements


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Hygiene Failures



gel dispensers

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9090










copy C

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Facilitating Change











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QQuality

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AAccountability

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copy C

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copy C

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their own problems





copy C

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Hand hygiene 71



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Colorectal SSIs 32


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Accountability










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retrospective


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2007 (n= 382) 2012 (n=1128)





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Summary










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Monthly Death Rates

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Six Sigma

86


Who are the

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their own problems





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Colorectal SSIs 32


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IN SUMMARY

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What is Possible

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Patient

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awareness

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2007 (n= 382) 2012 (n=1128)





50

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Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

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bullDiscipline

bullReport to NPDB


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No

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clinical duties


education



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No

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FAILURE

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Summary










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conditions


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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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8383

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strategies tools



Lean Six Sigma and




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n

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million



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mis

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8686

Six Sigma

86


Who are the

customers and

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priorities

How is the process


it measured

What are the

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defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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Hygiene Failures



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QQuality

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their own problems





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awareness

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retrospective


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their own problems





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Colorectal SSIs 32


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IN SUMMARY

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What is Possible

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Physicians






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Quality Measurement




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2007 (n= 382) 2012 (n=1128)





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No NoNo


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supervision

No


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No

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No

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No

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FAILURE

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Yes

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Summary










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conditions


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7777


Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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40-60 of the time


Answer


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strategies tools



Lean Six Sigma and




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What is Lean







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million



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mis

sio

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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

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defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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Hygiene Failures



gel dispensers

3 Hands full





copy C

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mis

sio

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9090










copy C

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mis

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Facilitating Change











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QQuality

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AAccountability

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awareness

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Monthly Death Rates

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their own problems





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Colorectal SSIs 32


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IN SUMMARY

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What is Possible

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2007 (n= 382) 2012 (n=1128)





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No


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No

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FAILURE

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conditions


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Monthly Death Rates

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40-60 of the time


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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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causes of the

defects

How do we

remove the

causes of the

defects

How can we

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improvements


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Facilitating Change











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QQuality

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their own problems





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Colorectal SSIs 32


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Who are the

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How is the process


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How can we

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their own problems





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Zero Harm Awards

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statewide

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4545

Quality Strategy


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Quality Measurement




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improvement


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SAFETY CULTURE

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safety culture

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Trust




environment



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Accountability







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Accountability










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retrospective


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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



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professional group





No NoNo


intended

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No

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Summary










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week



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Monthly Death Rates

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strategies tools



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clinical outcomes


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Six Sigma

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How is the process


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What are the

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improvements


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their own problems





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IN SUMMARY

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What is Possible

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Zero Harm Awards

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statewide


statewide

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4343

Physicians






clinicians

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Physicians

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Quality Measurement




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4949




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2007 (n= 382) 2012 (n=1128)





50

57

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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



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IDENTIFY

SYSTEM FAILURES


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terminate

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SYSTEM FAILURES

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No

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FAILURE

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Summary










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conditions


week



following

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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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7878



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40-60 of the time


Answer


change management

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8383

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strategies tools



Lean Six Sigma and




clinical outcomes


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sio

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8484

What is Lean







pure waste




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million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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yrig

ht

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mis

sio

n

9090










copy C

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sio

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9191

Facilitating Change











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QQuality

AAcceptance

AAccountability

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their own problems





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Hand hygiene 71



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Colorectal SSIs 32


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organization





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hospitalsaspx

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IN SUMMARY

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sio

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106106


What is Possible

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107107

Zero Harm Awards

Categories







statewide


statewide

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sio

n

108108








copy C

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4444

Physicians

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Quality Strategy


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Accountability







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Accountability










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2007 (n= 382) 2012 (n=1128)





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Start here


Were the actions



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Monthly Death Rates

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Six Sigma

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Who are the

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their own problems





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Colorectal SSIs 32


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hospitalsaspx

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IN SUMMARY

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What is Possible

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Quality Strategy


and safety



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copy C

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4848

Quality Measurement




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improvement


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to

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Trust




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Accountability







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2007 (n= 382) 2012 (n=1128)





50

57

65

50

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copy C

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70

Start here


Were the actions



substance abuse



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

SYSTEM FAILURES


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bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

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SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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Summary










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conditions


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following

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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

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ndash Hand hygiene








copy C

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mis

sio

n

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40-60 of the time


Answer


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copy C

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sio

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8383

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strategies tools



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clinical outcomes


copy C

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What is Lean







pure waste




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mis

sio

n

8585








million



copy C

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mis

sio

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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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Hygiene Failures



gel dispensers

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copy C

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mis

sio

n

9090










copy C

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copy C

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9292

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QQuality

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AAccountability

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sio

n

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copy C

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their own problems





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Hand hygiene 71



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Colorectal SSIs 32


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copy C

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organization





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RESOURCES

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IN SUMMARY

copy C

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106106


What is Possible

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Zero Harm Awards

Categories







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statewide

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sio

n

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requirements




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5050






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Patient

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Quality Strategy

Quality Measures

Safe Adoption of IT

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5757


Trust




environment



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Accountability







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6161






retrospective


copy C

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work to improve





copy C

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sio

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6868


2007 (n= 382) 2012 (n=1128)





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Were the actions



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No NoNo


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supervision

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No

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to duties




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No

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Summary










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Monthly Death Rates

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strategies tools



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Six Sigma

86


Who are the

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QQuality

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their own problems





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Colorectal SSIs 32


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program




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hospitalsaspx

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IN SUMMARY

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What is Possible

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Zero Harm Awards

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requirements




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improvement


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Trust




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Accountability







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6868


2007 (n= 382) 2012 (n=1128)





50

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50

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70

Start here


Were the actions



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

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bullReport to NPDB


impairment program


impairment program




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terminate

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No

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FAILURE

No


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Summary










copy C

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conditions


week



following

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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ndash Hand hygiene








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40-60 of the time


Answer


change management

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


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8484

What is Lean







pure waste




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n

8585








million



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sio

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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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mis

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copy C

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n

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Hygiene Failures



gel dispensers

3 Hands full





copy C

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sio

n

9090










copy C

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9191

Facilitating Change











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9292

92

QQuality

AAcceptance

AAccountability

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n

94

copy C

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95







their own problems





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sio

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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organization





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program




resistance



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101

RESOURCES

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hospitalsaspx

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IN SUMMARY

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sio

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106106


What is Possible

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mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

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mis

sio

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108108








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109109










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Launch



project







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What can you do

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improvement


Safe Adoption of IT

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to

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Patient

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Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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harm


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Trust




environment



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Accountability







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Accountability










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work to improve





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sio

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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sio

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mis

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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impairment program


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No

No

SYSTEM

FAILURE

No


Yes

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mis

sio

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Summary










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sio

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conditions


week



following

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7373

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sio

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

7878



ndash Hand hygiene








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yrig

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mis

sio

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7979





40-60 of the time


Answer


change management

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mis

sio

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8080











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sio

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8383

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strategies tools



Lean Six Sigma and




clinical outcomes


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ht

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om

mis

sio

n

8484

What is Lean







pure waste




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mis

sio

n

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million



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n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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sio

n

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n

88



copy C

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mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





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9090










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9191

Facilitating Change











copy C

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9292

92

QQuality

AAcceptance

AAccountability

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copy C

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copy C

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95







their own problems





copy C

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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organization





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IN SUMMARY

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What is Possible

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Zero Harm Awards

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to

ZERO

Patient

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Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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SAFETY CULTURE

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safety culture

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56

copy C

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Trust




environment



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5858

Accountability







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5959

Accountability










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6161






retrospective


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work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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Most common







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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

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bullReport to NPDB


impairment program


impairment program




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No

SYSTEM

FAILURE

No


Yes

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Summary










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conditions


week



following

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Monthly Death Rates

Handwashing

Program

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ndash Hand hygiene








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40-60 of the time


Answer


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strategies tools



Lean Six Sigma and




clinical outcomes


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What is Lean







pure waste




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million



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mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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ht

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mis

sio

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mis

sio

n

88



copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9090










copy C

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om

mis

sio

n

9191

Facilitating Change











copy C

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mis

sio

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9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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sio

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copy C

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sio

n

95







their own problems





copy C

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sio

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


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sio

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97



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sio

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organization





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program




resistance



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RESOURCES

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102102



copy C

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104104



hospitalsaspx

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sio

n

105

IN SUMMARY

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mis

sio

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106106


What is Possible

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sio

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107107

Zero Harm Awards

Categories







statewide


statewide

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What can you do

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112112


copy C

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sio

n

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to

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Patient

Harm


Leadership

Board

CEOManagement

Physicians

Quality Strategy

Quality Measures

Safe Adoption of IT

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harm


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5353

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SAFETY CULTURE

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safety culture

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mis

sio

n

5757


Trust




environment



copy C

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mis

sio

n

5858

Accountability







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Accountability










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retrospective


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sio

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6262



about andhellip



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Reactive




Predictive


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to risk reduction






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work to improve





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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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Most common







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mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

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SYSTEM FAILURES

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No

No

SYSTEM

FAILURE

No


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mis

sio

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Summary










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sio

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conditions


week



following

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7373

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n

7676





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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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om

mis

sio

n

7878



ndash Hand hygiene








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mis

sio

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40-60 of the time


Answer


change management

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sio

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sio

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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yrig

ht

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om

mis

sio

n

8484

What is Lean







pure waste




copy C

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ht

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om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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yrig

ht

Th

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mis

sio

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mis

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n

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op

yrig

ht

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oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

ht

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t C

om

mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

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oin

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om

mis

sio

n

94

copy C

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yrig

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sio

n

95







their own problems





copy C

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yrig

ht

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oin

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om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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ht

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oin

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om

mis

sio

n

97



copy C

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organization





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program




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RESOURCES

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102102



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104104



hospitalsaspx

copy C

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yrig

ht

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oin

t C

om

mis

sio

n

105

IN SUMMARY

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

106106


What is Possible

copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

108108








copy C

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mis

sio

n

Launch



project







110

copy C

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What can you do

next week

111

copy C

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ht

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mis

sio

n

112112


copy C

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Th

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5252




harm


high reliability



harm

ndash If NO Why not



copy C

op

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Th

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oin

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mis

sio

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5353

copy C

op

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Th

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om

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sio

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54

SAFETY CULTURE

copy C

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safety culture

copy C

op

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Th

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oin

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mis

sio

n

56

copy C

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mis

sio

n

5757


Trust




environment



copy C

op

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ht

Th

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oin

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om

mis

sio

n

5858

Accountability







copy C

op

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Th

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om

mis

sio

n

5959

Accountability










copy C

op

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Th

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oin

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om

mis

sio

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60

copy C

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Th

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oin

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om

mis

sio

n

6161






retrospective


copy C

op

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ht

Th

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oin

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om

mis

sio

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6262



about andhellip



copy C

op

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ht

Th

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oin

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om

mis

sio

n

6363











copy C

op

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Predictive


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work to improve





copy C

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mis

sio

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

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ht

Th

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mis

sio

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6969





Most common







copy C

op

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Th

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oin

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om

mis

sio

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

op

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ht

Th

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oin

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om

mis

sio

n

7171

Summary










copy C

op

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ht

Th

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oin

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om

mis

sio

n

7272




conditions


week



following

copy C

op

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ht

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oin

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mis

sio

n

7373

copy C

op

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Th

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oin

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mis

sio

n

74


copy C

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mis

sio

n

757575



copy C

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mis

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7676





copy C

op

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Th

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oin

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mis

sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

op

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ht

Th

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oin

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om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

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oin

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om

mis

sio

n

7979





40-60 of the time


Answer


change management

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

8080











copy C

op

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ht

Th

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oin

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om

mis

sio

n

82

copy C

op

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Th

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oin

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om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

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Th

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oin

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om

mis

sio

n

8484

What is Lean







pure waste




copy C

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oin

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mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

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ht

Th

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oin

t C

om

mis

sio

n

8787











copy C

op

yrig

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Th

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oin

t C

om

mis

sio

n

88



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

9090










copy C

op

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Th

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om

mis

sio

n

9191

Facilitating Change











copy C

op

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mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

94

copy C

op

yrig

ht

Th

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mis

sio

n

95







their own problems





copy C

op

yrig

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Th

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oin

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om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

97



copy C

op

yrig

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Th

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oin

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om

mis

sio

n

98



copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

9999






organization





copy C

op

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om

mis

sio

n

100100




program




resistance



copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

101

RESOURCES

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

102102



copy C

opyr

ight T

he J

oin

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om

mis

sio

n


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

104104



hospitalsaspx

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

105

IN SUMMARY

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

106106


What is Possible

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

108108








copy C

op

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ht

Th

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oin

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om

mis

sio

n

109109










copy C

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ight T

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om

mis

sio

n

Launch



project







110

copy C

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ight T

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oin

t C

om

mis

sio

n

What can you do

next week

111

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

112112


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

5353

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

54

SAFETY CULTURE

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

5555






safety culture

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

56

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

5757


Trust




environment



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

5858

Accountability







copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

5959

Accountability










copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

60

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6161






retrospective


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6262



about andhellip



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6363











copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6464







Reactive




Predictive


copy C

op

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Th

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oin

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om

mis

sio

n

6565




to risk reduction






--- if they are


copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

6666

Assessment




improve




are in place


copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

6767





work to improve





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

6969





Most common







copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7171

Summary










copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7272




conditions


week



following

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7373

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

74


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

757575



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7676





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7979





40-60 of the time


Answer


change management

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8080











copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

82

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8484

What is Lean







pure waste




copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8787











copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

88



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9292

92

QQuality

AAcceptance

AAccountability

EEffectiveness






copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

94

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

95







their own problems





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

97



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

98



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9999






organization





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

100100




program




resistance



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

101

RESOURCES

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

102102



copy C

opyr

ight T

he J

oin

t C

om

mis

sio

n


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

104104



hospitalsaspx

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

105

IN SUMMARY

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

106106


What is Possible

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

108108








copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

109109










copy C

opyr

ight T

he J

oin

t C

om

mis

sio

n

Launch



project







110

copy C

opyr

ight T

he J

oin

t C

om

mis

sio

n

What can you do

next week

111

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

112112


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

54

SAFETY CULTURE

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

5555






safety culture

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

56

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

5757


Trust




environment



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

5858

Accountability







copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

5959

Accountability










copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

60

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6161






retrospective


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6262



about andhellip



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6363











copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6464







Reactive




Predictive


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

6565




to risk reduction






--- if they are


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

6666

Assessment




improve




are in place


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

6767





work to improve





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

6969





Most common







copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

7171

Summary










copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7272




conditions


week



following

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7373

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

74


copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

757575



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7676





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

7979





40-60 of the time


Answer


change management

copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

8080











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Who are the

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Colorectal SSIs 32


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2007 (n= 382) 2012 (n=1128)





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No NoNo


intended

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No


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No

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No

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FAILURE

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Monthly Death Rates

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Six Sigma

86


Who are the

customers and

what are their

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How is the process


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How can we

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their own problems





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Colorectal SSIs 32


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IN SUMMARY

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What is Possible

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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



substance abuse



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

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clinical duties


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No

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conditions


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Monthly Death Rates

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1841 1842 1843 1844 1845 1846 1847 1848

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strategies tools



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Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


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their own problems





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hospitalsaspx

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IN SUMMARY

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What is Possible

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Zero Harm Awards

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What can you do

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Accountability







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copy C

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

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copy C

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Most common







copy C

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70

Start here


Were the actions



substance abuse



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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mis

sio

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7171

Summary










copy C

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mis

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7272




conditions


week



following

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7373

copy C

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copy C

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copy C

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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7878



ndash Hand hygiene








copy C

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40-60 of the time


Answer


change management

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copy C

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82

copy C

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mis

sio

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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mis

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pure waste




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8585








million



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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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defects

How can we

maintain the

improvements


copy C

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copy C

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88



copy C

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om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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copy C

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Facilitating Change











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9292

92

QQuality

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AAccountability

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copy C

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copy C

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their own problems





copy C

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sio

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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mis

sio

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97



copy C

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n

98



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9999






organization





copy C

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program




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copy C

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Th

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101

RESOURCES

copy C

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Th

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102102



copy C

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copy C

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mis

sio

n

104104



hospitalsaspx

copy C

op

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mis

sio

n

105

IN SUMMARY

copy C

op

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Th

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mis

sio

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106106


What is Possible

copy C

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sio

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107107

Zero Harm Awards

Categories







statewide


statewide

copy C

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copy C

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109109










copy C

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copy C

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What can you do

next week

111

copy C

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112112


copy C

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mis

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5858

Accountability







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op

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mis

sio

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5959

Accountability










copy C

op

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n

60

copy C

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mis

sio

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6161






retrospective


copy C

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6262



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6363











copy C

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Assessment




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work to improve





copy C

op

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Th

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mis

sio

n

6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

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Th

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mis

sio

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6969





Most common







copy C

op

yrig

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Th

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oin

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om

mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

op

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Th

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oin

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om

mis

sio

n

7171

Summary










copy C

op

yrig

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om

mis

sio

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7272




conditions


week



following

copy C

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om

mis

sio

n

7373

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

74


copy C

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mis

sio

n

757575



copy C

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mis

sio

n

7676





copy C

op

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Th

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oin

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mis

sio

n

7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

7878



ndash Hand hygiene








copy C

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yrig

ht

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oin

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om

mis

sio

n

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40-60 of the time


Answer


change management

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op

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mis

sio

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copy C

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Th

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sio

n

82

copy C

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Th

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oin

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om

mis

sio

n

8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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Th

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om

mis

sio

n

8484

What is Lean







pure waste




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Th

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mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

8787











copy C

op

yrig

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Th

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oin

t C

om

mis

sio

n

88



copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

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t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

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mis

sio

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9292

92

QQuality

AAcceptance

AAccountability

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copy C

op

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Th

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oin

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om

mis

sio

n

94

copy C

op

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om

mis

sio

n

95







their own problems





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

97



copy C

op

yrig

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Th

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oin

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om

mis

sio

n

98



copy C

op

yrig

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Th

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oin

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mis

sio

n

9999






organization





copy C

op

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mis

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n

100100




program




resistance



copy C

op

yrig

ht

Th

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mis

sio

n

101

RESOURCES

copy C

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n

102102



copy C

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ight T

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sio

n


copy C

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mis

sio

n

104104



hospitalsaspx

copy C

op

yrig

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Th

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oin

t C

om

mis

sio

n

105

IN SUMMARY

copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

106106


What is Possible

copy C

op

yrig

ht

Th

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oin

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om

mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

copy C

op

yrig

ht

Th

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oin

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mis

sio

n

108108








copy C

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om

mis

sio

n

109109










copy C

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ight T

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om

mis

sio

n

Launch



project







110

copy C

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ight T

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oin

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om

mis

sio

n

What can you do

next week

111

copy C

op

yrig

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mis

sio

n

112112


copy C

op

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om

mis

sio

n

5959

Accountability










copy C

op

yrig

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Th

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om

mis

sio

n

60

copy C

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om

mis

sio

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6161






retrospective


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mis

sio

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6262



about andhellip



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copy C

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Reactive




Predictive


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Assessment




improve




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sio

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6767





work to improve





copy C

op

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Th

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mis

sio

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

op

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Th

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mis

sio

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Most common







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yrig

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Th

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oin

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om

mis

sio

n

70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



Assistance Program

IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

bullPolice





IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

copy C

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Th

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oin

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om

mis

sio

n

7171

Summary










copy C

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yrig

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om

mis

sio

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7272




conditions


week



following

copy C

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om

mis

sio

n

7373

copy C

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om

mis

sio

n

74


copy C

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om

mis

sio

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757575



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mis

sio

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7676





copy C

op

yrig

ht

Th

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oin

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om

mis

sio

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

op

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ht

Th

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oin

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om

mis

sio

n

7878



ndash Hand hygiene








copy C

op

yrig

ht

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oin

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om

mis

sio

n

7979





40-60 of the time


Answer


change management

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op

yrig

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om

mis

sio

n

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copy C

op

yrig

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Th

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mis

sio

n

82

copy C

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Th

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oin

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om

mis

sio

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8383

83


strategies tools



Lean Six Sigma and




clinical outcomes


copy C

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ht

Th

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om

mis

sio

n

8484

What is Lean







pure waste




copy C

op

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ht

Th

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oin

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om

mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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ht

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om

mis

sio

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n

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copy C

op

yrig

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e J

oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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yrig

ht

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oin

t C

om

mis

sio

n

9090










copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

9191

Facilitating Change











copy C

op

yrig

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om

mis

sio

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9292

92

QQuality

AAcceptance

AAccountability

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copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

94

copy C

op

yrig

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Th

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om

mis

sio

n

95







their own problems





copy C

op

yrig

ht

Th

e J

oin

t C

om

mis

sio

n

96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

op

yrig

ht

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oin

t C

om

mis

sio

n

97



copy C

op

yrig

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oin

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om

mis

sio

n

98



copy C

op

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mis

sio

n

9999






organization





copy C

op

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ht

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100100




program




resistance



copy C

op

yrig

ht

Th

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mis

sio

n

101

RESOURCES

copy C

op

yrig

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Th

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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

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supervision

No


individual took an

unacceptable risk



No

CONSIDER

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to duties




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No

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clinical duties


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FAILURE

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Yes

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Summary










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conditions


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following

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copy C

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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40-60 of the time


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strategies tools



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Six Sigma

86


Who are the

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gel dispensers

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QQuality

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their own problems





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ndashPre-op 63


Colorectal SSIs 32


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copy C

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hospitalsaspx

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IN SUMMARY

copy C

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What is Possible

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Zero Harm Awards

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What can you do

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copy C

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retrospective


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2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

CONSIDER

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IDENTIFY

SYSTEM FAILURES

Yes

No

No

SYSTEM

FAILURE

No


Yes

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mis

sio

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7171

Summary










copy C

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7272




conditions


week



following

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7373

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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sio

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7878



ndash Hand hygiene








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mis

sio

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40-60 of the time


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8383

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strategies tools



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pure waste




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million



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mis

sio

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8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

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defects

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remove the

causes of the

defects

How can we

maintain the

improvements


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mis

sio

n

89


Hygiene Failures



gel dispensers

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copy C

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om

mis

sio

n

9090










copy C

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9292

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QQuality

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copy C

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copy C

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their own problems





copy C

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sio

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ndashScheduling 46

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Colorectal SSIs 32


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copy C

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program




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RESOURCES

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hospitalsaspx

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IN SUMMARY

copy C

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n

106106


What is Possible

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mis

sio

n

107107

Zero Harm Awards

Categories







statewide


statewide

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n

108108








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sio

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What can you do

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2007 (n= 382) 2012 (n=1128)





50

57

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Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



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IDENTIFY

SYSTEM FAILURES


CONSIDER

bullReport to NPDB


impairment program


impairment program




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SYSTEM FAILURES


terminate

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IDENTIFY

SYSTEM FAILURES

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No

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SYSTEM

FAILURE

No


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mis

sio

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Summary










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conditions


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following

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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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sio

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mis

sio

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40-60 of the time


Answer


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sio

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sio

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8383

83


strategies tools



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clinical outcomes


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sio

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What is Lean







pure waste




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million



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Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

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How do we

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causes of the

defects

How can we

maintain the

improvements


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copy C

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oin

t C

om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

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yrig

ht

Th

e J

oin

t C

om

mis

sio

n

9090










copy C

op

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ht

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om

mis

sio

n

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copy C

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QQuality

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their own problems





copy C

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Hand hygiene 71



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Colorectal SSIs 32


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copy C

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copy C

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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

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No

CONSIDER

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clinical duties


education



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SYSTEM FAILURES


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impairment program


impairment program




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terminate

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SYSTEM FAILURES

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No

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FAILURE

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Yes

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Summary










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conditions


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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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strategies tools



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pure waste




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million



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Six Sigma

86


Who are the

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copy C

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Hygiene Failures



gel dispensers

3 Hands full





copy C

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QQuality

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their own problems





copy C

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ndashPre-op 63


Colorectal SSIs 32


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copy C

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organization





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hospitalsaspx

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IN SUMMARY

copy C

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What is Possible

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Zero Harm Awards

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What can you do

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

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copy C

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Most common







copy C

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70

Start here


Were the actions



substance abuse



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


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IDENTIFY

SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




IDENTIFY

SYSTEM FAILURES


terminate

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SYSTEM FAILURES

Yes

No

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FAILURE

No


Yes

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mis

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7171

Summary










copy C

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conditions


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following

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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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40-60 of the time


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8383

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strategies tools



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pure waste




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million



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8686

Six Sigma

86


Who are the

customers and

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priorities

How is the process


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What are the

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improvements


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Hygiene Failures



gel dispensers

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mis

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QQuality

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copy C

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sio

n

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copy C

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their own problems





copy C

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t C

om

mis

sio

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96



Hand hygiene 71



ndashScheduling 46

ndashPre-op 63


Colorectal SSIs 32


copy C

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mis

sio

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97



copy C

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organization





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program




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hospitalsaspx

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sio

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IN SUMMARY

copy C

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mis

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106106


What is Possible

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Zero Harm Awards

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What can you do

next week

111

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mis

sio

n

112112


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to risk reduction






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sio

n

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Assessment




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are in place


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sio

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6767





work to improve





copy C

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mis

sio

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6868


2007 (n= 382) 2012 (n=1128)





50

57

65

50

54

65

copy C

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Most common







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mis

sio

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

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clinical duties


education



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IDENTIFY

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CONSIDER

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impairment program


impairment program




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SYSTEM FAILURES


terminate

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SYSTEM FAILURES

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No

No

SYSTEM

FAILURE

No


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mis

sio

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7171

Summary










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mis

sio

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7272




conditions


week



following

copy C

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mis

sio

n

7373

copy C

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yrig

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mis

sio

n

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sio

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sio

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7777


Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

copy C

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mis

sio

n

7878



ndash Hand hygiene








copy C

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oin

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mis

sio

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40-60 of the time


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mis

sio

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copy C

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copy C

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mis

sio

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8383

83


strategies tools



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clinical outcomes


copy C

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mis

sio

n

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What is Lean







pure waste




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mis

sio

n

8585








million



copy C

op

yrig

ht

Th

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om

mis

sio

n

8686

Six Sigma

86


Who are the

customers and

what are their

priorities

How is the process


it measured

What are the

most important

causes of the

defects

How do we

remove the

causes of the

defects

How can we

maintain the

improvements


copy C

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mis

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op

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n

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copy C

op

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oin

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om

mis

sio

n

89


Hygiene Failures



gel dispensers

3 Hands full





copy C

op

yrig

ht

Th

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oin

t C

om

mis

sio

n

9090










copy C

op

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mis

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Facilitating Change











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mis

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92

QQuality

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AAccountability

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mis

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94

copy C

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their own problems





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Hand hygiene 71



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Colorectal SSIs 32


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2007 (n= 382) 2012 (n=1128)





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Were the actions



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No NoNo


intended

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Yes

Yes

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supervision

No


individual took an

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No

CONSIDER

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to duties




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No

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FAILURE

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Summary










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Monthly Death Rates

Handwashing

Program

1841 1842 1843 1844 1845 1846 1847 1848

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Six Sigma

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their own problems





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Hand hygiene 71



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Colorectal SSIs 32


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IN SUMMARY

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work to improve





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2007 (n= 382) 2012 (n=1128)





50

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Start here


Were the actions



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professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

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clinical duties


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IDENTIFY

SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




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SYSTEM FAILURES


terminate

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SYSTEM FAILURES

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No

No

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FAILURE

No


Yes

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Summary










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conditions


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following

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Monthly Death Rates

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1841 1842 1843 1844 1845 1846 1847 1848

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86


Who are the

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their own problems





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What is Possible

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2007 (n= 382) 2012 (n=1128)





50

57

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50

54

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mis

sio

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70

Start here


Were the actions



substance abuse



procedures



professional group





No NoNo


intended

Yes Yes

Yes

Yes

Yes

Yes

Yes







supervision

No


individual took an

unacceptable risk



No

CONSIDER

bullDiscipline

bullReport to NPDB


to duties




Assistance Program

IDENTIFY

SYSTEM FAILURES

No

CONSIDER

bullDiscipline


clinical duties


education



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IDENTIFY

SYSTEM FAILURES


CONSIDER

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impairment program


impairment program




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SYSTEM FAILURES


terminate

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No

No

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FAILURE

No


Yes

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conditions


week



following

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Monthly Death Rates

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Program

1841 1842 1843 1844 1845 1846 1847 1848

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40-60 of the time


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strategies tools



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sio

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Six Sigma

86


Who are the

customers and

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How is the process


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What are the

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How do we

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How can we

maintain the

improvements


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n

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mis

sio

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copy C

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their own problems





copy C

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sio

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Hand hygiene 71



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ndashPre-op 63


Colorectal SSIs 32


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hospitalsaspx

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105

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No

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Were the actions



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No


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No

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No

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Six Sigma

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Monthly Death Rates

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Monthly Death Rates

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Six Sigma

86


Who are the

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How is the process


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Facilitating Change











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QQuality

AAcceptance

AAccountability

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Hand hygiene 71



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Colorectal SSIs 32


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organization





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Hand hygiene 71



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Colorectal SSIs 32


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Zero Harm Awards

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Hand hygiene 71



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Zero Harm Awards

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Hand hygiene 71



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ndashPre-op 63


Colorectal SSIs 32


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QQuality

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ndashPre-op 63


Colorectal SSIs 32


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Zero Harm Awards

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Zero Harm Awards

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Colorectal SSIs 32


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Zero Harm Awards

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high reliability healthcarewhack-a-mole (lack of prevention) pdca/pdsa is the only methodology a...

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