1 © 2007 TMIT Role of Radiology in Institutional Healthcare Quality and Safety SCARD 2007

2 © 2007 TMIT I attended the 2003 SCARD Meeting in Vancouver

3 © 2007 TMIT 2007 Audience Mix

4 © 2007 TMIT 2003 Audience Mix N= 65

5 © 2007 TMIT Patient safety is recognized as being everyone's responsibility, not just that of the management team

6 © 2007 TMIT Patient safety is recognized as being everyone’s responsibility, not just that of the management team.

7 © 2007 TMIT Top management anticipates staff will inevitably make errors, and trains them to detect and recover them

8 © 2007 TMIT Top management anticipates that staff will inevitably make errors, and trains them to detect and recover them.

9 © 2007 TMIT Top Managers both non-clinician & clinician are genuinely committed to the goals of Patient Safety and provide adequate resources

10 © 2007 TMIT Top managers- both non-clinician and clinician- are genuinely committed to the goals of patient safety and provide adequate resources to serve this end.

11 © 2007 TMIT Safety-related issues are considered at high- level meetings on a regular basis, not just after some bad event.

12 © 2007 TMIT Safety-related issues are considered at high-level meetings on a regular basis, and not just after some bad event.

13 © 2007 TMIT Past events are thoroughly reviewed at high-level Management and the lessons learned are implemented as global reforms not local fixes

14 © 2007 TMIT Past events are thoroughly reviewed at high-level meetings and the lessons learned are implemented as “global reforms” rather than “local fixes.”

15 © 2007 TMIT After some event, the primary aim of Sr Mgt is to identify the failed defenses and improve them vs. seeking to blame staff at the "sharp end"

16 © 2007 TMIT After some event, the primary aim of senior management is to identify the failed defenses and improve them, rather than seeking to blame individuals at the “sharp end”.

17 © 2007 TMIT Senior management adopts proactive stance towards patient safety. That is it does some or all of the following: takes steps to identify recurrent error traps and remove them

18 © 2007 TMIT Senior management adopts proactive stance towards patient safety. That is it does some or all of the following: takes steps to identify recurrent error traps and remove them…

19 © 2007 TMIT Senior management recognizes that fixing error provoking factors is easier than stopping fleeting psychological problems such as distractions, inattention, and forgetfulness

20 © 2007 TMIT Senior management recognizes that fixing error provoking factors is easier than stopping fleeting psychological problems such as distractions, inattention, and forgetfulness.

21 © 2007 TMIT It is understood that the effective management of patient safety, just like any other management process, depends critically on the collection, analysis and dissemination of relevant information

22 © 2007 TMIT It is understood that the effective management of patient safety, just like any other management process, depends critically on the collection, analysis and dissemination of relevant information.

23 © 2007 TMIT Management recognizes the necessity of combining reactive outcome data with proactive process information - this entails far more than occasional audits

24 © 2007 TMIT Management recognizes the necessity of combining reactive outcome data with proactive process information. This entails far more than occasional audits.

25 © 2007 TMIT Staff from a wide variety of departments and levels regularly attend meetings related to patient safety

26 © 2007 TMIT Staff from a wide variety of departments and levels regularly attend meetings related to patient safety.

27 © 2007 TMIT Assignments to a safety-related function are seen as "fast-track" appointments, not "dead end" appointments

28 © 2007 TMIT Assignments to a safety-related function are seen as “fast-track” appointments, not “dead end” appointments.

29 © 2007 TMIT It is understood that commercial goals, financial constraints, and patient safety issues can be in conflict and that mechanisms exist to identify and resolve such conflicts

30 © 2007 TMIT It is understood that commercial goals, financial constraints, and patient safety issues can be in conflict and that mechanisms exist to identify and resolve such conflicts.

31 © 2007 TMIT Policies are in place to encourage anyone and everyone to raise patient safety issues

32 © 2007 TMIT Policies are in place to encourage anyone and everyone to raise patient safety issues.

33 © 2007 TMIT The institution recognizes the critical dependence of a safety management process on the trust of the workforce - particularly in regard to reporting systems

34 © 2007 TMIT The institution recognizes the critical dependence of a safety management process on the trust of the workforce - particularly in regard to reporting systems.

35 © 2007 TMIT There is a consistent policy for reporting and responding to incidents across all professional groups within the institution

36 © 2007 TMIT There is a consistent policy for reporting and responding to incidents across all professional groups within the institution.

37 © 2007 TMIT Disciplinary policies are based on an agreed distinction between acceptable and unacceptable behavior

38 © 2007 TMIT Disciplinary policies are based on an agreed distinction between acceptable and unacceptable behavior.

39 © 2007 TMIT Clinical supervisors and managers train and reinforce their staff in practicing the mental as well as technical skill necessary to achieve safe and effective performance

40 © 2007 TMIT Clinical supervisors and managers train and reinforce their staff in practicing the mental as well as technical skill necessary to achieve safe and effective performance.

41 © 2007 TMIT The institution has in place a rapid, useful, and intelligible feedback channels to communicate the lessons learned from both reactive and proactive safety information systems

42 © 2007 TMIT The institution has in place a rapid, useful, and intelligible feedback channels to communicate the lessons learned from both reactive and proactive safety information systems.

43 © 2007 TMIT The institution has the will and the resources to acknowledge its failures, to apologize for them, and to reassure the victims that the lessons learned from these mishap will help prevent their recurrence

44 © 2007 TMIT The institution has the will and the resources to acknowledge its failures, to apologize for them, and to reassure the victims that the lessons learned from these mishap will help prevent their recurrence.