Transcript RISK MANAGEMENT & PATIENT SAFETY

ORIENTATION FOR
STUDENTS
PATIENT SAFETY
PERFORMANCE IMPROVEMENT
Quality & Risk
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
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!!!
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
PATIENT SAFETY & QUALITY
- EXAMPLE ACTIVITIES &
SOURCES








Application / Credentialing
Orientation
Job Descriptions
Evaluations
Continuing Education
Policies / Procedures
Regulatory Compliance
(Environmental) Safety









Documentation
External Alerts / Guidelines -reviewed
Third party reports
Complaints
Infection Control
Internal Surveys
Occurrence Reporting
Monitors / Screens / Profiles
Peer Review
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
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

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

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
DO THE RIGHT THING
At 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
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
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
Plan, Do, Study &
Act
Oconee Memorial
#1
Hospital
Plan Do
utilizes the
the
improvement
and the data
PDSA
methodology to
continuously measure,
assess,
and improve processes
and outcomes.
Act
#4
to hold the
gain and
continue
improvement
the
improvement
and the
data collection
Study
the results
of the
implementation
#3
#2
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
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
Other “Issues”






Confidentiality & Other Patient’s Rights
Issues
Documentation
Regulatory Compliance
Workplace Safety
Equipment / Product Usage
Appropriate Communication
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
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
NOTHING WILL CHANGE
UNLESS YOU CHANGE IT
SAFETY IS AN INDIVIDUAL &
COLLECTIVE RESPONSIBILITY