Texas Center for Quality and Patient Safety

1. Texas Center for Quality and Patient Safety Patient Safety and Quality Improvement: The Essentials Dennis Cook, MSN, RN, CPPS Senior Director, Texas Center for Quality and & Patient Safety Texas Hospital Association

2. Objective The participant will be able to describe the essential components of an effective healthcare quality and patient safety evaluation and improvement system.

3. Why is Patient Safety So Important? Patient Safety

4. Patient Safety Movement Institute for Healthcare Improvement 100K lives Campaign TeamSTEPPS “To Err is Human”IOM Report National Implementation of TeamSTEPPS JCAHO National Patient Safety Goals DoDMedTeams® ED Study Patient Safety and Quality Improvement Act of 2005 Executive Memo from President Adoption by Military Health System from 2007-2011 1995 1999 2001 2003 2004 2005 2011 2006 2008

5. IOM Report – 2001 What should be the foundation of health care quality and patient safety? STEEEP

6. Standardization of Hospital Quality Measures NPSGs Patient ID, Communication, Medication Safety, Infection Prevention, Suicide Prevention, Correct Surgery HACs ADEs, CAUTI, CLABSI, Falls, OB injury, Pressure Ulcers, SSI, VTE, VAP Core Measures AMI, Pneumonia, HF, SCIP

7. Process Improvement Strategies PDCA RCA FMEA Six Sigma

8. Impact Accreditation Joint Commission Det Norske Veritas (DNV) Consumer Awareness Leapfrog Hospital Compare Media Financial Incentive

9. Error Theory - Swiss Cheese Model Mixed Messages Inadequate Communication Distractions Inadequate Technology Hazards Event Occurs

10. Contributing Factors to Error • Behavioral assessment process • Physical assessment process • Patient identification process • Patient observation procedures • Care planning process • Continuum of care • Staffing levels • Orientation & training of staff • Competency assessment/credentialing • Supervision of staff • Communication with patient/family • Communication among staff members • Availabilityof information • Adequacy of technological support • Equipment maintenance and management • Physical environment • Security systems and processes • Medication management • Human Factors • Disruptive behavior • Policy & procedure • Process variation • Documentation • Leadership

11. Communication Error?? “Please send me a patient safety check by noon”

12. Communication Error??

13. Communication

14. Root Cause Analysis (RCA) • A structured retrospective process for identifying the causal or contributing factors underlying adverse events. • RCA follows defined process for identifying specific contributing factors rather than attributing the incident to the first error one finds or to preconceived notions a person might have about the event. • The goal is to create an action plan for improvement which will prevent the error or incident from occurring in the future.

15. Failure Mode Effect Analysis (FMEA) • A prospective assessment that identifies and improves steps in a process thereby reasonably ensuring a safe and clinically desirable outcome. • A systematic approach to identify and prevent product and process problems before they occur. • Allows us to identify ways in which a process, current or future, could potentially break down or fail to perform its desired function

16. The Value of Near Miss Reporting Actual Event Near Miss Near Miss Near Miss Near Miss Near Miss Near Miss Near Miss Near Miss

17. Serious Harm/Requires Intervention Reaches Patient/Requires Monitoring Severity Reaches patient/no harm Frequency Near Miss Weak Program Model The Mishap Diamond

18. Serious Severity Harm/Intervention Reaches Patient/Requires Monitoring Frequency Reaches Patient/No Harm Near Miss Strong Program Model The Mishap Pyramid

19. Case Study Can you identify the failures?

20. Discussion: Organizational Culture and Patient Safety

21. Serving Texas Hospitals/Health Systems