Quality Improvement Principles of Quality and Safety for HIT Lecture b This material (Comp12_Unit2b) was developed by Johns Hopkins University, funded.

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Quality Improvement Principles of Quality and Safety for HIT Lecture b This material (Comp12_Unit2b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

Principles of Quality and Safety for HIT Learning Objectives ─ Lecture b Investigate the fallibility of people and systems. Describe the ways that every system is designed to achieve the results it gets. Apply the basic principles of safe design. Explain the ways that teams make wise decisions with diverse and independent input. 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Principles of Safe Design Standardize. –Eliminate steps if possible. Create independent checks. Learn when things go wrong. –What happened? –Why did it happen? –What did you do to reduce risk? –How do you know it worked? 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Standardize 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Eliminate Steps 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Create Independent Checks 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Basic Components and Processes of Communication 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

The Jelly Bean Test 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

When you feel something say something! Don’t Play Man Down 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Your Role Assume things will go wrong Develop lenses to see systems Work to Mitigate Technical and Teamwork Hazards –Standardize work –Create independent checks –Learn from mistakes Make wise decisions by getting input from others Keep the patient the north star 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Principles of Quality and Safety for HIT 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Principles of Quality and Safety for HIT Summary ─ Lecture b In this unit we’ve learned about the ways that teams make wise decisions with diverse and independent input. We’ve also explored the importance of communication and especially the place of critical listening. 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b

Principles of Quality and Safety for HIT References References Dayton, E. Joint Commission Journal, Jan Johns Hopkins Hospital. Josie King. Available: Reason, J. BMJ 2000;320: Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Principles of Quality and Safety for HIT Lecture b Images Slide 4: A Woman Peers into a Microscope to Examine a Circuit Board. Courtesy National Science Foundation. Available from Slide 5: A Bank of ATMs. Creative Commons: Piotrus. Available from: Slide 6. A Three-Point Seat Belt in a Lincoln Town Car. Courtesy Creative Commons Gerdbrendel. Available from: Slide 7: Basic Components of Communication. Courtesy Elizabeth Dayton, Joint Commission Journal, Jan Slide 8. Jelly Beans. Creative Commons Brandon D Available from: beans.jpghttp://3.bp.blogspot.com/-oxxwjc9sQp8/TbCxyVKPtWI/AAAAAAAAAcA/NkPtINLsFjw/s1600/jelly- beans.jpg Slide 9: Johns Hopkins lacrosse team. Courtesy Johns Hopkins University. Slide 11. Josie King. Courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Available from: