Making a Patient Safety Program Work

1. Making a Patient Safety Program Work Karen Frush, MD Chief Patient Safety Officer Duke University Health System August 21, 2005

2. Making a Patient Safety Program Work: A Practical Approach • Transformation of current culture: safety is at the center of all efforts • Fundamental responsibility of healthcare providers: understand risk, accept responsibility for harm, lead efforts to prevent harm • Commitment and participation of all employees and staff is necessary to continuously improve and excel in safety performance

3. Duke University Health SystemPatient Safety Program A National Imperative • 1999 IOM Report prompted an increased national focus on patient safety • Response externally driven by media, regulators and consumers • Not specific to the institution • Strong sense of denial and invulnerability remained intact

4. Our Defining Event: The Transplant Mismatch How could this happen at Duke?

6. Duke University Health System Patient Safety Program Institutional Imperative • February 2003 transplant mismatch provided a true organizational imperative for change • Patient Safety Program: to act as a catalyst for the development of a culture of safety at all levels of patient care, from frontline providers to executive leadership (IOM, November, 1999)

7. What is Patient Safety? In its simplest form, patient safety is “prevention of harm to patients.”

8. What is Quality? • Degree to which health care services increase the likelihood of a desired outcome • Appropriateness of care • Expected health benefits exceed expected health risks • Reasonable chance of nontrivial benefit • Improper not to provide the care • Adherence to professional standards • Measured in terms of performance indicators

9. Effectiveness Effectiveness Timeliness Timeliness Efficiency Efficiency Safety Safety Equity Equity Background Relationship Between Quality and Patient Safety Patient safety is a component under the umbrella of clinical quality. CLINICAL QUALITY Patient Patient Centeredness Centeredness Institute of Medicine I (1999) Institute of Medicine II (2001)

10. Duke University Health SystemPatient Safety Program “Most errors are made by good but fallible people, working in a challenged and imperfect system.”

11. Isn’t it easier just to get a CT?

13. Making a Patient Safety Program Work:Understand the Urgency • “It wasn’t one doctor, one nurse or one decimal point…it was a huge systems breakdown.” Sorrel King • “American healthcare operates with levels of unreliability, injury, waste…and poor service that long ago became unacceptable in many other industries.” Donald Berwick, MD • “There is a massive gap between where we are and where we could be.” Brent James, MD R. Langreth: “Fixing Hospitals”. Forbes, June 20, 2005. pg 68-76.

14. Making a Patient Safety Program Work:Establish a Culture of Safety • Acknowledge the ubiquity of risk, and take responsibility for reducing risk • View the recognition of errors as opportunities for reducing risk • Create a non-punitive environment for reporting errors; actively encourage reporting of adverse events and near-misses • Develop a method to share stories and lessons learned

15. Making a Patient Safety Program Work:Build an infrastructure • Identify safety leaders throughout all levels of the organization • Establish multi-disciplinary local safety teams to identify risk and develop solutions • Perform safety walkrounds with executives to close the gap between front line and leadership: What is the next thing that is going to hurt a patient in this area?

16. The Johns Hopkins Comprehensive Unit-based Safety Program • Evaluate culture of safety • Educate staff on science of safety • Identify defects • Assign executive to adopt unit • Learn from one defect per month • Evaluate culture www.safetyresearch.jhu.edu

17. Safety WalkRoundsAllan Frankel, M.D. • A carefully choreographed discussion between Frontline Staff and hospital leaders, patient safety specialist, a scribe, and other (Managers, Pharmacists, Students). • Lasting about one hour and regularly repeated • As frequently as weekly, but at a minimum monthly • Located wherever frontline staff do their work • Fully supported by back office quality analysis • Fully integrated into Operations committees • Requiring rigorous application to detail in every step

18. Safety WalkRoundsAsking the right questions • “How will the next patient be harmed in your area?” • “How does the environment fail you?” • “The last patient who was hurt as a result of how we delivered care – what happened?” ...goal is openess and transparency…

19. Making a Patient Safety Program Work:Design improvements into the system • Avoid reliance on memory • Simplify and standardize whenever possible • Use constraints and forcing functions • Promote effective team functioning, communication • Include patients and patient advocates in safety efforts and initiatives • Measure results, monitor progress

20. Making a Patient Safety Program Work:Improve communication and team work • Promote formal teamwork training • Standardize Communication (SBAR) • Crew Resource Management • Assertion, psychological safety • Develop checklists • Hand-offs, procedures • Initiate teamwork training in professional schools, residency programs

21. Making a Patient Safety Program Work:Include patients and families • Establish patient advocacy groups to advise leaders • Include patients and families on safety teams, in safety walk rounds • Empower patients and families to actively participate in care

22. Making a Patient Safety Program Work:Measure results and monitor progress • CMS Quality Metrics • AHRQ Patient Safety Indicators • JCAHO National Patient Safety Goals • IHI 100,000 Lives Campaign

23. The Centers for Medicare and Medicaid Services www.hospitalcompare.hhs.gov Quality measures: Heart Attack (AMI) Care Heart Failure Care Pneumonia Care

24. JCAHO National Patient Safety Goals • Improve the safety of using medications • Computerized physician order entry • Clinical pharmacists • Medication reconciliation (IHI) • Reduce the risk of health care-associated infections • Central line-associated bloodstream infections (IHI) • Ventilator-associated pneumonia (IHI) • Surgical site infections (IHI)

25. Making a Patient Safety Program Work:Focus on a few performance measures • External metrics • CMS, AHRQ, JCAHO, IHI • Internal metrics • BSC based on strategic agenda • Meaningful indicators for local teams • “Actionable”

26. Making a Patient Safety Program Work:Implement change via local safety teams • Review risk data • Local and aggregate • Implement improvement strategies • Best practice • Customized strategies for local culture • Include patients and patient advocates in safety efforts and initiatives

27. Making a Patient Safety Program Work:Outcomes-based Measures • Reduce Mortality • Rapid Response Teams • Reduce ADEs (Severity Index) • Objective data (automated surveillance, chart review) • Eliminate Nosocomial Infections • VAP bundle in ICUs • BSI in ICUs • Eliminate Perioperative Injuries • Wrong site surgery (Time out) • Surgical Site Infections

28. Making a Patient Safety Program Work …All hospitals and healthcare agencies should establish a Patient Safety Program, to act as a catalyst for the development of a culture of safety at all levels of patient care, from frontline providers to executive leadership (IOM, November, 1999)

29. Making a Patient Safety Program Work • Transformation of current culture: safety is at the center of all efforts • Fundamental responsibility of healthcare providers: understand risk, accept responsibility for harm, lead efforts to prevent harm • Commitment and participation of all employees and staff is necessary to continuously improve and excel in safety performance