1. ADVANCING PATIENT SAFETY: MULTIDISCIPLINARY STRATEGIES Kenneth W. Kizer, M.D., M.P.H. President and CEO The National Quality Forum NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

2. The Paradox of American Healthcare Quality W Highly trained practitioners, wide- spread state-of-the-art technology, unparalled biomedical research, unequaled expenditures W Overuse, underuse and misuse problems are common, serious and systemic in nature—and largely preventable NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

3. QUALITY IMPROVEMENT SHOULD BE HEALTHCARE’S ESSENTIAL BUSINESS STRATEGY NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

4. Key Quality Drivers 1. Rising healthcare expenditures 2. New technology/drugs 3. Changing purchaser attitudes 4. Consumer demand 5. Patient safety concerns NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

5. Key QI Drivers It’s the right thing to do! NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

6. Healthcare Quality Healthcare quality begins with ensuring patient safety! NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

7. Terminology What is Patient Safety? Terminology What is Patient Safety? Patient safety is freedom from injury or illness resulting from the processes of healthcare. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

8. Healthcare Errors – Not a New Problem “I would give great praise to the physician whose mistakes are small for perfect accuracy is seldom to be seen” Hippocrates NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

9. Terminology Code Words for Medical Errors Terminology Code Words for Medical Errors NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING W Adverse event, adverse clinical event W Adverse outcome, adverse clinical outcome W Medical mishap; sentinel events W Unplanned clinical occurrence; unexpected occurrence; untoward incident W Therapeutic misadventure W Peri-therapeutic accident W Iatrogenic complication/ injury W Hospital acquired complication

10. Healthcare Errors – How Big is the Problem? W 3-38% of hospitalized patients affected by iatrogenic injury or illness W 44,000-98,000 hospital deaths/year (IOM) W 2-35% of hospitalized patients suffer adverse drug events (average 7%) W >7,000 ADE deaths/year W 2 million nosocomial infections/year NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

11. Patient Safety - Who is Doing What? W Federal government (HCFA, AHRQ, VA, QuIC) W State governments W Accrediting organizations (JCAHO, NCQA) W Professional societies (AMA, AHA, others) W Business/Purchasers (Leapfrog Group) W Private groups (ISMP, NPSF, others) W The National Quality Forum NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

12. Role of NQF in Patient Safety W Endorsed “Patient Safety: Call to Action” W To standardize hospital performance measures W To develop compendium of “best practices” W To develop list of “never events” and design national state-based reporting system NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

13. Patient Safety Strategies 1.Make patient safety improvement a leadership priority. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

14. Patient Safety Strategies 2.Make a clear organizational commitment to patient safety (as reflected by infrastructure, dedicated resources and use of safe practices). NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

15. Patient Safety Strategies 3.Create a healthcare culture of safety. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

16. What is a Healthcare Culture of Safety? A culture of safety is an integrated pattern of individual and organizational behavior, and its underlying philosophy and values, that continuously seeks to minimize hazards and patient harm that may result from the processes of healthcare. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

17. What is a Healthcare Culture of Safety? 1. Acknowledges high-risk, error-prone nature of modern healthcare 2. Widespread shared acceptance of responsibility for risk reduction 3. Encourages open communication about safety concerns in a non-punitive environment; freedom of fear in reporting problems 4. Facilitates reporting of errors and safety concerns NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

18. What is a Healthcare Culture of Safety? (cont.) 5. Learns from errors 6. Embraces accountability for patient safety 7. Ensures organizational structure, processes, goals and rewards are aligned with improving patient safety NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

19. Patient Safety Strategies 4. Initiate routine self assessments (audits). NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

20. Healthcare Errors Most Likely to Occur When: W Many and varied interactions with technology W Many individuals involved in care; multiple handoffs for care W High acuity of illness or injury W Ambient environment prone to distraction W Need for rapid decisions; time-pressured W High volume, unpredictable patient flow NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

21. Patient Safety Strategies 5.Implement “safe practices”. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

22. Patient Safety - Design Management Design work so that it is easy to do it right and hard to do it wrong. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

23. Patient Safety - Design Management 1. Reduce reliance on memory 2. Simplify processes (reduce steps) 3. Standardize 4. Utilize constraints and forcing functions 5. Use protocols and checklists NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

24. Patient Safety - Design Management 6. Recognize fatigue’s effect on performance 7. Require education and training for safety 8. Promote teamwork 9. Reduce known sources of confusion NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

25. Illustrative Safe Practices NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

26. Safe Practices W Educate patients and family members about their medications W Implement mechanisms to ensure follow-up W Prominently display critical, patient- specific information on every record W Ensure dose adjustment in children and elderly persons NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

27. Safe Practices W Limit accessibility to and control the use of high-hazard drugs (KCl, epi, etc.) W Insist on the use of protocols for highly toxic drugs or those with a narrow therapeutic range W Insist on the use of clinical guidelines and critical pathways NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

28. Safe Practices W Avoid use of abbreviations (or at least standardize them) W Avoid verbal orders (or insist on repeat back when done) W Use pre-printed orders NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

29. Safe Practices W Utilize pharmacy-based IV admixture programs W Utilize unit dosing W Use weight-based heparin protocols W Standardize approaches and processes for drug storage locations, internal packaging or labeling and delivery NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

30. Safe Practices W Use automated pharmacy dispensing systems W Insist on pharmacist availability 24/7/365 and participation on rounds W Utilize automated/barcode medication administration control systems NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

31. Safe Practices W Implement electronic medical record and automated prescriber order entry W Use electronic prescription systems NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

32. Safe Practices W Limit the number of kinds of commonly used equipment W Utilize bar coding for transfusions W Implement a restraint-free policy W Increase the number of autopsies NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

33. Forward Looking Safe Practices W Require machine-readable labeling (bar coding) for all pharmaceuticals W Preferentially purchase products that have labels with name, strength and warnings prominently displayed and that otherwise incorporate human factors evaluation NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

34. Forward Looking Safe Practices W Preferentially purchase and utilize “unit of use” packaged drugs W Preferentially purchase IV solutions with contents and concentration prominently displayed on both sides of container NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

35. Patient Safety Strategies 6.Incorporate patient safety education into professional training and continuing education. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

36. Patient Safety Strategies 7.Ensure that there is clear accountability for patient safety. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

37. What Does It Mean To Be Accountable? 1. Acknowledge error and resultant injury 2. Apologize; say you are sorry 3. Provide restorative or remedial care 4. Conduct root cause analysis 5. Fix system or process problems NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

38. Patient Safety Strategies 8.Deal with professional misconduct promptly and decisively. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

39. Patient Safety Strategies 9.Create a non-punitive environment for healthcare error reporting. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

40. Patient Safety Strategies 10.Support patient safety research. NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING

41. “Grant me the courage to realize my daily mistakes so that tomorrow I shall be able to see and understand in a better light what I could not comprehend in the dim light of yesterday” Maimonides (1135-1204) NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING