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Making a
Patient Safety Program Work
Karen Frush, MD
Chief Patient Safety Officer
Duke University Health System
August 21, 2005
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Duke University Health System
Making a Patient Safety Program Work:
A Practical Approach
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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
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Duke University Health System
Duke University Health System
Patient 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
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Duke University Health System
Our Defining
Event: The
Transplant
Mismatch
How could this
happen at
Duke?
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Duke University Health System
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Duke University Health System
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)
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Duke University Health System
What is Patient Safety?
In its simplest form,
patient safety is
“prevention of harm to
patients.”
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Duke University Health System
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
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Duke University Health System
Background Relationship Between
Quality
and Patient Safety
Patient safety is a component under the umbrella of
clinical quality.
CLINICAL QUALITY
Effectiveness
Safety
Timeliness
Patient
Patient
Centeredness
Efficiency
Equity
Institute of Medicine I (1999)
Institute of Medicine II (2001)
Duke University Health System
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Duke University Health System
Patient Safety Program
“Most errors are made by good but fallible
people, working in a challenged and
imperfect system.”
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Duke University Health System
Isn’t it easier
just to get a
CT?
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Duke University Health System
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Duke University Health System
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.
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Duke University Health System
Making a Patient Safety Program Work:
Establish a Culture of Safety

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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
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Duke University Health System
Making a Patient Safety Program Work:
Build an infrastructure

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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?
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Duke University Health System
The Johns Hopkins Comprehensive
Unit-based Safety Program
1.
2.
3.
4.
5.
6.
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
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Duke University Health System
Safety WalkRounds
Allan 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
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Fully supported by back office quality analysis
Fully integrated into Operations committees
Requiring rigorous application to detail in every step
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Duke University Health System
Safety WalkRounds
Asking the right questions

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
“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…
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Duke University Health System
Making a Patient Safety Program Work:
Design improvements into the system

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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
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Duke University Health System
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
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Duke University Health System
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
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Duke University Health System
Making a Patient Safety Program Work:
Measure results and monitor progress

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CMS Quality Metrics
AHRQ Patient Safety Indicators
JCAHO National Patient Safety Goals
IHI 100,000 Lives Campaign
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Duke University Health System
The Centers for Medicare and Medicaid
Services
www.hospitalcompare.hhs.gov
Quality measures:
Heart Attack (AMI) Care
Heart Failure Care
Pneumonia Care
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Duke University Health System
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)
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Duke University Health System
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”
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Duke University Health System
Making a Patient Safety Program Work:
Implement change via local safety teams
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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
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Duke University Health System
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
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Duke University Health System
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)
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Duke University Health System
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
29
Duke University Health System