Download
1 / 34
340 likes | 498 Views
John G. Reiling President/CEO. Enhancing Patient Safety and Quality: Evidence-based design meets patient safety September 2009. Background – IOM Report. The risk of dying as a result of medical error far surpasses the risk of dying in an airline accident.
E N D
John G. Reiling President/CEO Enhancing Patient Safety and Quality: Evidence-based design meets patient safetySeptember 2009
Background – IOM Report The risk of dying as a result of medical error far surpasses the risk of dying in an airline accident. Death on domestic flights: 1 in 8,000,000 flights.
Background – IOM Report (continued) Death in hospitals from medical errors: 1 in 343 admits to 1 in 764 admits. Adverse Events in Hospitals 1 in 27 admits to 1 in 34 admits.
The National Learning Lab The participants: AHA MGMA AMA NPSF AphA PSI ASQ WHA Center for Patient UW-Milwaukee Safety at VA University of MN IHI VHA ISMP JCAHO
National Advisory Committee (invitees) Jim Adams, Exec. Director & Fellow, IBM Center of Healthcare Management Frank T. Brogan, President, Florida Atlantic University Carolyn Clancy, MD, MPH, Director of Agency for Healthcare Research & Quality William F. Coyne, PhD., Former Senior VP for R&D for 3M, Healthcare for 3M, and 3M Canada Tim Flaherty, M.D., Past Chairman, NPSF & Past Chair of American Medical Association Lillee Smith Gelinas, RN, BSN, MSN, FAAN, Vice President & Chief Nursing Officer of VHA, Inc. Pascal Goldschmidt, MD, Senior Vice President & Dean, University of Miami Miller School of Medicine Donald Holmquest, M.D., Ph.D., J.D., President & CEO of California Regional Health Information Org Beverly Johnson, President & CEO, Institute for Family Centered Healthcare Lucian L. Leape, MD, Adjunct Professor, Harvard Univ. School of Public Health Kathy Malloch, PhD., MBA, RN, FAAN, Pres of Malloch & Assoc & Director of the MHI Program at ASU David Marx, J.D., President of Outcome Engineering, LLC David Nash, M.D., M.B.A., FACP, Chairman, Jefferson Medical College, Thomas Jefferson University Richard Norling, Chief Executive Officer and Director of Premier, Inc. Dennis O’Leary, President Emeritus of Joint Commission Paul O’Neill, Former Secretary of the U.S. Treasury Mary A. Pittman, Ph.D., American Hospital Association & Current President of the Public Health Institute & Past President of the Health Research and Educational Trust William Rupp, MD, Past President of Luther Midelfort & Immanuel St. Joseph’s-Mayo Health Systems & Institute for Healthcare Improvement Donna E. Shalala, Ph.D, President, University of Miami Gail Warden, President Emeritus, Henry Ford Health Systems Bennet Waters, D.H.A., Chief of Staff for the US Dept. of Homeland Security, Office of Chief Medi Officer
Human Factors/Safety in Healthcare The environment (facilities, equipment, technology) affects performance. The processes affect performance. The culture affects performance.
Human Factors/Safety in Healthcare You can design environments, culture, and processes.
Human Factors/Safety in Healthcare Focus environments, processes, and culture on safety and quality by: Minimizing risk of failure Evidence-based medicine.
What Practices Will Most Improve Safety? Evidence-based medicine meets patient safety.
Design Recommendations Latent Conditions: Noise Reduction Scalability, Adaptability, Flexibility Visibility of Patients to Staff Patients Involved with Their Care Standardization Automate Where Possible Minimize Fatigue Immediate Accessibility of Information, Close to the Point of Service Minimize Handoffs Minimize Patient Movement Communication
Lean Principles Continuous Flow Pull vs. Push Standardize Work Visual Control Proven Technology Culture of Stopping to Fix Problems Get Quality Right the First Time
Design Recommendations Active Failures Operative/Post-Op Complications/Infections Events Relating to Medication Errors Deaths of Patients in Restraints Inpatient Suicides Transfusion Related Events Correct Tube-Correct Connector-Correct Hole Patient Falls Deaths Related to Surgery at Wrong Site MRI Hazards
Process Recommendations Matrix Development (Post Learning Lab) FMEA at Each Stage of Design Patients/Families Involved in Design Process Equipment Planning Day 1 Mock-ups Day 1 Design for the Vulnerable Patient Articulate a Set of Principles for Measurement Establish a Checklist for Current/Future Design
Creating a Culture of Safety Shared Values/Beliefs about Safety within the Organization Always Anticipating Precarious Events Informed Employees and Medical Staff Culture of Reporting Learning Culture “Just” Culture Blame-Free Environment Recognizing Human Fallibility Physician Team Work Culture of Continuous Improvement Empowering Families to Participate in Care of Patients Informed & Activated Patient
Results of the AHRQ Grant #UCI HS15384 All latent conditions studied improved with the exception of fatigue: Noise Reduction Scalability, Adaptability, Flexibility Visibility of Patients to Staff Patients Involved with Their Care Standardization Automate Where Possible Minimize Fatigue Immediate Accessibility of Information, Close to the Point of Service Minimize Handoffs Minimize Patient Movement
Results of the AHRQ Grant #UCI HS15384 Infections: The only consistent data recorded for infections during the 5 years of this study were for ventilator pneumonia and surgical site infections.
Results of the AHRQ Grant #UCI HS15384 Infections: The only consistent data recorded for infections during the 5 years of this study were for ventilator pneumonia and surgical site infections.
Results of the AHRQ Grant #UCI HS15384 Lean/Six Sigma Process Redesign Continuous Flow Pull vs. Push Standardize Work Visual Control Proven Technology Culture of stopping to fix problems Get quality right the first time
Results of the AHRQ Grant #UCI HS15384 Safety Culture Shared Values/Beliefs about Safety within the Organization Always Anticipating Precarious Events Informed Employees and Medical Staff Culture of Reporting Learning Culture “Just” Culture Blame-Free Environment Recognizing Human Infallibility Physician Team Work Culture of Continuous Improvement Empowering Families to Participate in Care of Patients Informed & Activated Patient
