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DMC Quality and Medical Safety Programs
DMC Quality and Medical Safety Programs
DMC Corporate Quality Department
Detroit Medical Center©
Revised: February, 2010
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DMC Quality and Medical Safety Programs
Commitment to Quality and Safety
 The Detroit Medical Center is committed to providing
safe, high quality medical care.
 This is part of our mission and it is also reflected by
our certification and accreditation with regulatory
agencies and participation with local, state, and
national quality and safety improvement projects.
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DMC Quality and Medical Safety Programs
Quality and Environmental Management Systems
 The DMC has
incorporated the
requirements of a Quality
Management System
(QMS) as outlined in the
ISO 9001-2008 standards
and an Environmental
Management System
(EMS) as outlined in ISO
14001: 2004 standards
into its quality program.
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DMC Quality and Medical Safety Programs
Foundation for Medical Safety
DMC commitment to medical safety is reflected in our:
 Quality Statement which includes:
 Continuous improvement
 Prevention of medical/health systems errors
 Provision of high quality medical care
 Environmental Statement:
The Detroit Medical Center is dedicated to the health and
safety of its patients, employees, customers, community
and environment.
DMC is committed to:




The prevention of pollution
Compliance with environmental regulations and other requirements
Continuous improvement
Environmental hotline 1.888.484.9200
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DMC Quality and Medical Safety Programs
Improving Quality and Safety
 Most events or errors occur due to process issues:
 Multiple events at multiple levels lead to the event – almost
never just ‘one process’ failure
 Rarely a ‘person’ failure
 By improving our systems and processes, we
improve healthcare quality and safety.
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DMC Quality and Medical Safety Programs
What is Performance Improvement?
 It is an ongoing effort to find new and better ways of
doing things by:
 Getting better results
 Involving the whole organization
 Improving work processes
 Foundation for Performance Improvement – PDCA
(also known as PDSA):
 PLAN
 DO
 CHECK (or STUDY)
 ACT
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DMC Quality and Medical Safety Programs
Performance Improvement
 PLAN:
 What are the goals you want to achieve?
 DO:
 Measure progress towards goals by collecting data.
 CHECK/STUDY:
 Look closely at/Analyze your data to answer these questions:
• How well are we performing?
• Why are we performing well or not well?
• Which areas should we focus on first to improve our processes?
 ACT:
 Make improvements!
 Celebrate success!
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DMC Quality and Medical Safety Programs
What Does Medical Safety Mean?
 It means we constantly look for ways to make the
care or service we provide safer for our patients and
employees.
 We can accomplish this by:
 Identifying conditions that are hazardous and changing
them.
 Acting quickly and appropriately when an incident occurs.
 Making medical safety a regular part of our performance
improvement activities.
 By making concerns for safety part of everything we do.
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DMC Quality and Medical Safety Programs
Medical Safety = Quality Care
 The DMC is committed to adopting the Institute of
Medicine’s 6 aims for improving the quality and safety
of healthcare (see additional information at www.iom)
Healthcare needs to be:
1. Safe: Avoiding injuries to patients from the care that
is intended to help them.
2. Effective: Providing services based on scientific
knowledge to all who could benefit, and refraining
from providing services to those not likely to benefit.
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DMC Quality and Medical Safety Programs
Medical Safety = Quality Care
Healthcare needs to be: continued
3. Patient-centered: Providing care that is respectful of and
responsive to individual patient preferences, needs, and values,
and ensuring that patient values guide all clinical decisions.
4. Timely: Reducing waits and sometimes harmful delays for both
those who receive and those who give care.
5. Efficient: Avoiding waste, including waste of equipment,
supplies, ideas, and energy.
6. Equitable: Providing care that does not vary in quality because
of personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status. A health care system that
achieves major gains in these six areas would be far better at
meeting patient needs.
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DMC Quality and Medical Safety Programs
Healthcare Safety Statistics
40 to 50 Patient Injuries per 100 Hospital Admissions
37 million hospital admissions
X
40 injuries per 100 hospital admissions
=
15 million injuries per year
What can we do to change this?
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DMC Quality and Medical Safety Programs
“Protecting 5 Million Lives from Harm” Campaign
The Institute for Healthcare Improvement’s (IHI)
“Protecting 5 Million Lives from Harm” campaign (See
www.ihi.org for additional information). The aim of the
campaign is to have care that:
 Is standardized and systemized
 Has zero defects
 Is innovative
 Includes system redesign, where necessary
The DMC has committed to participate with the IHI to
protect patients from harm. Everyone is responsible
for the quality and safety of healthcare.
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DMC Quality and Medical Safety Programs
Proven Interventions
The “Protecting 5 Million Lives from Harm” campaign challenges
American hospitals to adopt twelve changes in care that save lives and
reduce patient injuries:
 Deploy Rapid Response Teams…at the first sign of patient decline.
 Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to
prevent deaths from heart attack.
 Prevent Adverse Drug Events (ADEs)…by implementing medication
reconciliation.
 Prevent Central Line Infections…by implementing a series of interdependent,
scientifically grounded steps.
 Prevent Surgical Site Infections…by reliably delivering the correct perioperative
antibiotics at the proper time.
 Prevent Ventilator-Associated Pneumonia…by implementing a series of
interdependent, scientifically grounded steps.
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DMC Quality and Medical Safety Programs
Proven Interventions
Twelve changes in care that save lives and reduce patient injuries:
(continued)
 Prevent Harm from High-Alert Medications... starting with a focus on
anticoagulants, sedatives, narcotics, and insulin.
 Reduce Surgical Complications... by reliably implementing all of the changes in
care recommended by SCIP, the Surgical Care Improvement Project.
 Prevent Pressure Ulcers... by reliably using science-based guidelines for their
prevention.
 Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by
reliably implementing scientifically proven infection control practices.
 Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid
readmissions.
 Get Boards on Board … by defining and spreading the best-known leveraged
processes for hospital Boards of Directors, so that they can become far more
effective in accelerating organizational progress toward safe care.
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DMC Quality and Medical Safety Programs
Institute for Healthcare Improvement (IHI) Web Site
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DMC Quality and Medical Safety Programs
IHI Open School
 The IHI Open School for Health Professions is an interprofessional
educational community that gives students the skills to become
change agents in health care improvement:
 Skills like quality improvement, patient safety, teamwork,
leadership, and patient-centered care
 IHI Open School offers:
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Online courses written by world-renowned faculty
A network of students
Case studies, podcasts, videos, featured articles
IHI Certificates of Completion
 The IHI Open School — including online tools and resources, and
online courses — is open and free for students of all health care
professions and non-students alike.
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DMC Quality and Medical Safety Programs
IHI Improvement Map

The IHI Improvement Map is an open resource, available free of
charge for anyone, anywhere who shares IHI’s mission of
improving healthcare.

User-friendly, online tool used to create an overall improvement
plan, set and align priorities and key process improvements that
lead to exceptional patient care.
Example: Core
Processes for AMI
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DMC Quality and Medical Safety Programs
DMC Improvement Map - Where DMC stands on each of the IHI improvement map core
processes (NOTE: Not necessarily representative of individual DMC facilities).
Excellent - full implementation
Average implementation
Have begun to implement some processes
Poor – have not implemented any processes
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DMC Quality and Medical Safety Programs
Promoting and Maintaining a Safe Medical Climate
 Staff responsibilities:
 Take action to provide necessary care and protect patients in the
event of a unsafe event or error.
 Report all errors, near misses and hazardous conditions (web
based incident reporting system).
 Complete yearly, educational competencies.
 Participate in departmental improvement efforts.
 Be part of interdepartmental, multidisciplinary improvement
teams.
 Share ideas to improve employee or patient safety with supervisor
or quality department.
 Speak-up if you see an opportunity to avoid an unsafe practice or
violation of policy.
 Instruct patients and families to report safety concerns.
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DMC Quality and Medical Safety Programs
Promoting and Maintaining a Safe Medical Climate
 Patient responsibilities –
encourage patients to:
 Provide accurate and
complete information about
present complaints, past
illnesses, hospitalizations
and medicines.
 Ask questions when they do
not understand what they
have been told or what they
are expected to do.
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DMC Quality and Medical Safety Programs
Accreditation
 Accreditation means that an organization has met requirements
related to the delivery of safe, quality care.
 The DMC is surveyed and accredited by many different agencies.
What is Joint Commission?
 The Joint Commission is an accreditation agency that surveys
our hospitals at least once every 3 years.
 The Joint Commission is an accreditation agency who’s
objective is to improve the quality of healthcare provided to the
public by establishing clinical standards; evaluating health care
organizations; rendering accreditation; and providing education
and consultative support to healthcare professionals (See
www.jointcommission.org for additional information)
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DMC Quality and Medical Safety Programs
Quality Improvement
 The DMC participates in many local, state and national
Quality Improvement projects some of which are:
 The National Quality Forum (NQF)
 Leapfrog
 Institute for Healthcare Improvement (IHI)
 Michigan Hospital Association (MHA – Keystone project)
 Greater Detroit Area Health Coalition (GDAHC – Save
Lives-Save Dollars campaign)
 Blue Cross Blue Shield of Michigan
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DMC Quality and Medical Safety Programs
Consumer-Centered Hospital Data
 In recent years, there has been an increased emphasis
on hospital quality and transparency.
 Consumers can find Internet sites to provide
information such as procedure cost, levels of
clinical/patient care, and patient satisfaction scores.
 It is important to remember that all DMC employees
play a role in ensuring that our patients leave with a
satisfying experience.
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DMC Quality and Medical Safety Programs
Hospital Transparency
 Hospital transparency is providing information to
the public on patient safety and quality, cost, and
performance indicators.
 Hospital transparency assists hospitals to become
more efficient, rewards those hospitals that provide
high quality care, and allows consumers to make
informed decisions.
 The DMC provides information on safety and quality
that is publicly reported.
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DMC Quality and Medical Safety Programs
Healthcare Quality Websites
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The Joint Commission www.jointcommission.org
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AHRQ Report Card www.ahrq.gov
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
Features information on the quality of hospitals, medical groups, health
plans, nursing homes and clinical information on evidence based practices.
CMS/Hospital Compare
www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp
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
Provides information regarding hospital accreditation and compliance.
Provides consumers with hospital-reported information on quality,
performance, and customer satisfaction.
Leapfrog Group www.leapfroggroup.org

Provides consumers with hospital information based on its yearly survey of
quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk
procedures, and NQF Safety Goals
 Michigan Hospital Inform www.mihospitalinform.org
www.mihospitalinform.org/

State of Michigan healthcare quality website.
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DMC Quality and Medical Safety Programs
Quality of Care
 As employees of the DMC, it is everyone’s responsibility to
ensure safe, quality care for our patients.
 Also, as an employee, you have the right and duty to speak up if
you feel the quality of care or patient/employee safety is
compromised.
 If you have concerns, first speak to your supervisor. If you are
not satisfied, you may contact the Quality Department or use the
compliance hotline.
 If still your concerns are not addressed, you have the right to
contact the Joint Commission at
http://www.jointcommission.org/GeneralPublic/Complaint/ or
call 1.800.994.6610.
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DMC Quality and Medical Safety Programs
Course Summary
 Both the Quality Management System (QMS) and Environmental
Management System (EMS) are part of our integrated quality
program.
 Medical Safety means we constantly look for ways to make the
care or service we provide safer for our patients and employees.
 The DMC publicly reports it’s quality and safety data.
 Consumers can find Internet sites to provide information such as
procedure cost, levels of clinical/patient care, and patient
satisfaction scores.
 As an employee, you have the right and duty to speak up if you
feel the quality of care or patient/employee safety is compromised.
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DMC Quality and Medical Safety Programs
Thank You
We hope this NetLearning course has been both
informative and helpful. Please feel free to review this
course until you are confident about your knowledge of
the material presented.
Click the Take Test button, located on the left side of the
screen, to complete the requirements for this course.
For future reference this module is available on the
NetLearning Library under the 2010 Core Compliance
category. The NetLearning Library is found on the DMC
Intraweb screen under the NetLearning drop-down list.
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