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

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 Patient Safety Why is Patient Safety So Important?

Patient Safety Movement 2006 Patient Safety and Quality Improvement Act of 2005 Executive Memo from President DoD MedTeams® ED Study Institute for Healthcare Improvement 100K lives Campaign “To Err is Human” IOM Report T eam STEPPS JCAHO National Patient Safety Goals National Implementation of TeamSTEPPS Adoption by Military Health System from

5 What should be the foundation of health care quality and patient safety? IOM Report – 2001 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 Hazards Event Occurs Inadequate Technology Distractions Inadequate Communication Mixed Messages

10 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 Contributing Factors to Error

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

Actual Event Near Miss The Value of Near Miss Reporting

The Mishap Diamond

The Mishap Pyramid

Case Study Can you identify the failures?

20 Discussion: Organizational Culture and Patient Safety

Serving Texas Hospitals/Health Systems 21