1. Elise Butkiewicz M.D., Kamini Geer M.D., Falguni Mehta M.D., Lynn Castaldi M.D. Overlook Family Medicine Residency Program, Summit, NJ CREATING AND SUSTAINING A CULTURE OF SAFETY IN A FAMILY MEDICINE RESIDENCY PROGRAM

2. CLER *Clinical Learning Environment Review (CLER)  *ACGME initiative  *Focuses residency training programs on:  1. establishing quality and safety processes  2. demonstrating their effectiveness  3. sharing successes with other programs  4. instilling in residents the tools to  perpetuate a culture of quality and safety  in their future practice

3. The Impact of Medical Errors To Err is Human: Building a Safer Health System: *Seminal IOM Report 1999 *44-98,000 American deaths/year *8 th leading cause of death; * higher than breast cancer, MVA, AIDS *17-29 billion dollars *Set in motion the modern safety movement

4. Swiss Cheese Model *Based on James Reason’s model of organizational accidents *Harm rarely caused solely by an individual’s mistake *Usually a series of 4-5 systems failures *In depth systems analysis can help prevent errors Figure: http://www.webmm. hrq.gov/case.aspx?caseID=127a. Accessed 10/04/2014.

5. Methods of Case Review *Root cause analysis (RCA) required by Joint Commission for all sentinel events *Morbidity and Mortality conferences *Multidisciplinary case review using a framework to explore all possible contributing factors *Review documentation *Interview key players *Fishbone diagrams, mind maps *Propose systems-based interventions to prevent future incidents *Requires robust incident reporting Wachter RM. Understanding Patient Safety, 2nd edition. McGraw-Hill; 2012.Chapter 14

6. Charles Vincent’s Framework for Categorizing the Root Causes of Errors FrameworkContributory Factors InstitutionalRegulatory; medico-legal environment Organization & Management Financial resources and constraints; Policy standards; Safety culture and priorities Work environmentHeavy work loads; fatigue; availability of essential equipment; degree of administrative support TeamVerbal, written, electronic communication; supervision; willingness to seek help; team leadership Individual staff memberKnowledge and skills; motivation and attitude; physical and mental health TaskUse of protocols; availability of test results; PatientComplexity, seriousness of condition; language; mental state; personality; social factors Derived from: Vincent C. Understanding and responding to adverse events. N Engl J Med 2003; 348:1051-1056.

7. Accessed at: http://img.docstoccdn.com/thumb/orig/119667453.png 10/4/2014http://img.docstoccdn.com/thumb/orig/119667453.png

8. Culture of Safety *Open and frequent reporting of errors/near misses *Open and frequent discussion of errors/near misses *Teamwork *Clear communication *Consistent use of checklists, standardized tools, protocols *Non-punitive culture *Safety champions *Reduction of steep hierarchies/authority gradients *Fighting the culture of low expectations *If you are not sure it is right, assume it is wrong and do whatever it takes to be sure *Strong senior leadership support Wachter RM. Understanding Patient Safety, 2nd edition. McGraw-Hill; 2012.Chapter 15

9. Overlook FM Patient Quality Safety Case Review: History *Non-punitive, open tone set by leader *Risk manager invited *Incident reporting and root cause analysis education *Began to invite nurses, medical assistants, coordinators, receptionists *A variety of AHRQ error categories reviewed: adverse events after hospital discharge, CPOE, diagnostic errors, medication/vaccine errors, medication reconciliation, referral tracking, nursing and patient safety, and rapid response systems *Residents surveyed at start of group and 6 months later

10. Overlook FM Patient Quality Safety Case Review: Structure *Non-punitive open tone *Presenter is protected by the leader *Interdisciplinary *Include hospital administration/risk manager *Use a framework/fishbone diagram to reveal systems causes *Propose systems based solutions *Facilitate administrative linkages to effect systems change *Foster robust incident reporting

11. Effect on Incident Reporting in 6 Months

12. Survey Response

13. Initial focus group discussion Barriers: *Not having the time to file a Quantros report *Not being sure what was worthy of reporting, such as near misses Frustration: *Lack of follow up on an incident after reporting it *Felt like “it went into a black hole” Openness to: *Participating in group meetings to discuss hospital quality and safety concerns

14. Resident Experience *Create linkages to administration to effect systems change *Collapse of hierarchies *Fight the culture of low expectations Linkages: *Risk manager *Director of Nursing (Falguni Mehta, MD) *Medication Management Committee (Lynn Castaldi, MD) *Chief Medical Information Officer (Grace Charles, MD)