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Kelly Shipley, RHIA QI Director ESRD Network of Texas Slide 2 Distinguish the relationship between quality and patient safety Describe the steps in implementing a patient safety program Apply patient safety improvement tools in a dialysis environment Slide 3 Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge. Institute of Medicine Slide 4 Hippocrates As to diseases make a habit of two things - to help, or at least, to do no harm. Epidemics I Quality = to Help Safety = Do No Harm Slide 5 Cost of Quality Cost of Errors Formulas to show how actions can pay off ACAVERAGE COST sum of event costs/number of events BCRBENEFIT-COST RATIO cost avoided/cost of intervention CERCOST-EFFECTIVENESS RATIO cost of intervention/# of prevented events CSCOST SAVINGS (# of avoided events) X (average cost per event) (cost of intervention) VHA, Root Cause Analysis i& Improvement in the Healthcare Sector, ASQ Slide 6 Medical Errors may be fifth leading cause of death 1 Medical Errors Third leading cause of death 2 Institute of Medicine/CDC 1997 1 JAMA, 2000 2 Slide 7 TacticsAccountability Support teamwork through Crew Resource Management Educators, medical staff, nursing and health care leaders Encourage appropriate adherence to clinical guidelines to improve quality & reduce liability risk Medical staff & health care leaders, medical processional societies, health care purchasers & payers Continue to leverage pt. safety initiatives via regulatory/oversight bodies Accrediting, licensing & regulatory bodies, PSOs, purchasers & payers Leverage the creation of cultures of patient safety in health care org. Administrators, medical and nursing leaders P4P strategies provide incentives to focus on improvements in pt. safety & health care quality CMS and private-sector healthcare purchasers and payers Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury, Joint Commission Slide 8 SafeEffectiveEfficientPatient -CenteredTimelyEquitable Crossing the Quality Chasm: A New Health System for the 21st Century, IOM Slide 9 Just Culture vs Blame or No Blame Culture People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue. Don Norman, The Design of Everyday Things The Just Culture Community, Natl Patient Safety Foundation Slide 10 Health & Safety Survey to Improve Patient Safety in ESRD (RPA) Patients Professionals Hospital Survey on Patient Safety Culture - an assessment tool from Agency for Healthcare Research and Quality (AHRQ) Joint Commission, Leapfrog Survey, NQF Discussing & Reporting Events Near Miss, Close Calls, Sentinel Events, Adverse Events Mandatory versus voluntary reporting Disclosure Patient Safety Culture Where do we stand? Slide 11 RPA, March 2007 Slide 12 Think about your hospital work area/unit Never Rarely Some- times Most of the time Alway s 1.We are given feedback about changes put into place based on event reports 2.Staff will freely speak up if they see something that may negatively affect patient care 3.We are informed about errors that happen in this unit 4.Staff feel free to question the decisions or actions of those with more authority 5.In this unit, we discuss ways to prevent errors from happening again 6.Staff are afraid to ask questions when something does not seem right SECTION C: Communications How often do the following things happen in your work area/unit? Mark your answer by filling in the circle. Slide 13 (a) Standard: Program scope. (1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. Slide 14 (2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. Slide 15 (c) Standard: Prioritizing improvement activities. The dialysis facility must set priorities for performance improvement, considering prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes or patient safety. The facility must immediately correct any identified problems that threaten the health and safety of patients. Slide 16 Slide 17 Assess Leadership Commitment Current environment Have to or want to? System Who, What, When, Where, How Flowchart Data Management Reporting, Responding, Proactive vs Reactive Analysis Improvement Communication Training, Education Patient Involvement Disclosure Slide 18 Resources Patient involvement examples Disclosure Slide 19 Concepts Sharp end vs Blunt end Swiss Cheese Model Human Behavior Model Analysis Root Cause Analysis (RCA) Failure Modes Effects Analysis (FMEA) Hardwiring for safety Reminder Systems vs Equipment Design Checklists CQI Tools Slide 20 Error Categories Active Errors or Failures Point of contact with patient Generally readily apparent Involve frontline staff Sharp End errors Latent Errors or Conditions Less apparent failures that contribute to error downstream Removed from direct patient care processes that support care Blunt End errors Sharp-Active Blunt-Latent Slide 21 Slide 22 Sharp End Active Failures nurse administers wrong med nurse administers med to wrong patient anesthesiologist administers wrong drug through unlabeled syringe Blunt End Latent Failures incomplete pt info unclear communication of drug order no independent double checks lack of computer warnings drug storage issues unclear policies & procedures Sharp End: Immediate Cause(s) Blunt End: Root Cause(s) Contributing Factors Medication Administration Slide 23 Complex System Latent Failure Model Institution Organization Profession Team Individual Technical DEFENSES Accident Challenge Authority? Incomplete procedures Propaganda Missions? Time pressures Responsibility shifting Inadequate Training & Supervision Deferred maintenance Broken Monitor LATENT FAILURES Attention distractions Triggers The World Slide 24 Reason, J., Managing the Risks of Organizational Accidents Slide 25 Process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of sentinel events A root cause is the most fundamental reason for the failure of a process The goal of RCA is to find out What happened? Why did it happen? What do you do to prevent it from happening again? Slide 26 Focuses primarily on systems & processes, not individual performance Progresses from special causes in clinical processes to common causes in organizational processes Repeatedly digs deeper by asking Why Then, when answered, asks Why? again and again Identifies changes that could be made in systems & processes that would reduce the risk of such events occuring in the future Is thorough and credible Slide 27 Problem Statement: You are on your way home from work and your car stops in the middle of the road. 1. Why did your car stop? Because it ran out of gas 2. Why did it run out of gas? Because I didnt buy gas on my way to work 3. Why didnt you buy gas in the morning? Because I didnt have any money 4. Why didnt you have any money? Because I lost it all last night in a poker game 5. Why did you lose your money in last nights poker game? Because Im not very good at bluffing when I dont have a good hand Slide 28 Insert graph from JC of most common root causes Slide 29 Slide 30 RCA reporting tool Dialysis sent event & or near miss case scenarios (Audience participation) Slide 31 Action plan is key! Slide 32 A systematic, structured approach to process improvement in the design and process development stage through identifying ways that a process can fail, why it might fail, and how it can be made safer. Slide 33 Origin - aerospace industry in 1960s Key tool for improving safety Goals: prevent defects, enhance safety, increase customer satisfaction. Standardized approach Proactive approach vs. reactive response Another tool to add to your PI toolkit Slide 34 Criteria: High Risk High Cost Problem Prone Low Volume Staff & Physician input, Committees Sources: Sentinel Event Alert, ISMP Industry news Cedars-Sinai Hospital, Christus Spohn Hospital South Slide 35 Number of reported Sentinel Events related to Anticoagulants 1997 2007* Drug Involved #Cause Of Event# Heparin21Wrong Drug3 Warfarin6Wrong Dose7 Enezapron3Improper Monitoring9 Unknown2Pump Malfunction/Error5 Outcome of Patients:#Given without order2 Death28Not reordered2 Loss of Function6Unknown4 * Joint Commission SE database Slide 36 Facilitator Team members closest to the process Content expert member(s), ad-hoc Slide 37 FAILURE MODEEFFECT Wrong drug/route/form of administration on physician order Inaccurate clinical data B, T, D, ADR Wrong administration times selected in Rx Delayed therapy; omission Misprogram pumpOverdose; subtherapeutic dose B, T, D, ADR Failure Mode: -ways in which a process could break down or fail to perform Cause: why the failure mode occur Effect: what could happen if a failure mode occurred Slide 38 Assign Severity rating the consequence of the failure should it occur. Assign Occurrence rating the probability or frequency of the failure occurring. Assign Detection rating the probability of the failure being detected before the impact of the effect is realized. Slide 39 Processe s & Sub- processe s Failure Modes CausesEffects Severity Rating Occurrence (Probability) Rating Detection Rating Critical Index A. Prescribing Physician prescribes order failure to initiate standard order set/prepri nted order no pre- existing order set, not followed/ dont agree w/protocols, numerous modification s therapy may not meet the standard of care B,T,ADR, D 1066360 pre- printed orders incomplet e no standard process for making selections on forms, human factors therapy may not meet the standard of care, wrong drug/dose ferquency 103260 Slide 40 Criticality Index (CI) score used (severity rating x occurrence rating x detection rating) Evaluation of Failure Modes with High CI Order Failure Modes Preparing Drug Pump Failure Modes (programming, rate changes, equipment design) Administration Documentation & Verification Slide 41 Slide 42 Slide 43 Slide 44 Questions