ORIENTATION FOR STUDENTS

1. ORIENTATION FOR STUDENTS PATIENT SAFETY PERFORMANCE IMPROVEMENT Quality & Risk

2. RISK MANAGEMENT, PERFORMANCE IMPROVEMENT, & PATIENT SAFETY • An organizational QUALITY PERFORMANCE program exists to: • Evaluate and improve processes that enhance patient safety and result in quality service • Educate and involve staff in processes • Identify events and other opportunities that allow for process review and improvement

3. WHAT IS PERFORMANCE IMPROVEMENT? • Performance Improvement is EVERY staff person’s concern • It is the assessing of how things are done or turn out and how to make them better • No matter what your job, you play an important role in helping OMH provide safe quality patient care. • Performance Improvement is vital to our organization and your department’s goals! • IT IS HOW WE ARE JUDGED!!!

4. What is the Current Climate? • Public trust at an all time low • Institute of Medicine Reports (12/99 & 3/01) • Headlines about fraud / medical mistakes • Increased co pays and denials / decreased access • Legislation • Staffing shortages heavily reported • Patient / family expectations increasing as to clinical and non clinical services

5. PATIENT SAFETY & QUALITY - EXAMPLE ACTIVITIES & SOURCES • Application / Credentialing • Orientation • Job Descriptions • Evaluations • Continuing Education • Policies / Procedures • Regulatory Compliance • (Environmental) Safety

6. Documentation • External Alerts / Guidelines -reviewed • Third party reports • Complaints • Infection Control • Internal Surveys • Occurrence Reporting • Monitors / Screens / Profiles • Peer Review

7. JCAHO Patient Safety Goals • Focus on previously reported Sentinel Events • Are surveyed as an “all or none” • Can change every year • Evidenced - based and require “culture change” • Seven goals / 13 aspects

8. 2003-04 Patient Safety Goals • Patient identification • Use of 2 unique identifiers • Use of “time out” prior to invasive procedure • Effective communication • “Read back” on verbal / phone orders • Standardize abbreviations / list those not to be used

9. Safe use of high-alert medications • Remove concentrated electrolytes • Standardize / limit drug concentrations • Eliminate wrong site, patient, procedure surgery • Pre-op verification process • Site marking

10. Safe use of infusion pumps • Free-flow protection • Effectiveness of clinical alarm systems • PM and testing of systems • Settings - parameters, audible for distance/competing noise • Nosocomial Infections reduced and Monitored • CDC Guidelines adopted and implemented • Tracking of serious injury / death related to nosocomial infection

11. DO THE RIGHT THINGAt 99% : • 2 airplanes will crash during landing at O’Hare airport per day • 1 new hire a year will have falsified their application • One Xray study each day will be done wrong or misread • 17 Lab studies would be reported incorrectly each day

12. Measuring Performance Improvement & Safe Care • It is important to objectively know we are doing a good job • Measuring where we are and that we have done to improve must be done using data • Data comes from lots of sources.. Sometimes even you ! • Data then is analyzed (interpreted) • And then changes are sometimes made and re measured

13. STRIVE FOR 100% QUALITY Because at 99%: • The wrong procedure would be performed in surgery once a week • Every two months a baby would be dropped to the floor at delivery • 8 bills a day will be for too much and contain errors • One EMS call each week would fail to meet EMTALA regulations

14. Plan, Do, Study & Act Oconee Memorial Hospital utilizes the PDSA methodology to continuously measure, assess, and improve processes and outcomes. #1 Plan the improvement and the data Do the improvement and the data collection #2 Act to hold the gain and continue improvement Study the results of the implementation #4 #3

15. OMH SPECIFIC ACTIVITIES ADDRESSING PI / PATIENT SAFETY • Organization-wide initiative - MISSION • Routine monitoring of outcomes / events • Timely reporting and evaluation of events / complaints with process the focus • Use of external information as a source for process change • Departmental initiatives to enhance processes

16. COMMON PATIENT SAFETY ISSUES • Medication orders-prescribing, dispensing, administering, verbal/phone orders • Recognition / knowledge of patient condition & failure to respond to information on patient status • Communication breakdown with patient or staff • Procedure error- skill, appropriate application

17. Other “Issues” • Confidentiality & Other Patient’s Rights Issues • Documentation • Regulatory Compliance • Workplace Safety • Equipment / Product Usage • Appropriate Communication

18. COMMON BARRIERS to GOOD PI / PATIENT SAFETY • Lack of consistency • Lack of knowledge / understanding • Lack of commitment • Not involving staff in the process evaluation • Lack of willingness to change • Failure to admit to mistakes • Lack of communication

19. Examples of OMH Patient Safety Initiatives • Medication Safety • Fall Prevention • External Information as resource • Patient Confidentiality (HIPAA) • Policy Revisions • Universal Protocol for correct surgery • Patient Identification • Disclosure

20. NOTHING WILL CHANGE UNLESS YOU CHANGE IT SAFETY IS AN INDIVIDUAL & COLLECTIVE RESPONSIBILITY