1. Trends in Patient Safety
Kenneth Grubbs MBA, RN
Assistant Vice President, Programs
National Patient Safety Foundation
October 13, 2011
West Palm Beach, FL

2. NPSF Programs Stand Up for Patient Safety:
Lucian Leape Institute
Stand Up for Patient Safety:
Hospital-based & Ambulatory
Partnership for Clear Health Communication
Patient & Family Program
Research & Grants
Patient Safety Awareness Week
Publications:
Current Awareness
Focus
Corporate Council
Annual Congress
American Society of Professionals in Patient Safety (ASPPS) 2

3. Mission of NPSF
The National Patient Safety Foundation has been diligently pursuing one mission since its founding in 1997 — to improve the safety of the healthcare system for the patients and families it serves.

4. Patient Safety Timeline
1997
1999
2001
2002
2005
2011

5. How Do We Compare? (Graph created by Lucien Leape)
Dr. Lucian Leape, considered by some as the father of patient safety, created this graph to show how healthcare’s safety performance compares to other high risk industries. This chart demonstrates that you’d have to ride a European railroad 10 million times before there was a fatality. While being admitted to a hospital is an order of magnitude safer than bungee jumping.
The problem usually isn’t the fault of the workers, and most injuries are due to systems failures.

6. Quality (Continuous, sometimes proactive, often reactive)
The Balance
Quality (Continuous, sometimes proactive, often reactive)
Risk
(Mostly Reactive)
Patient Safety
(Proactive)
How do we achieve a balance –
Often patient safety gets confused with risk and quality.
Traditionally risk management is the mostly reactive arm of an organization while quality is continuous, sometimes proactive but often times reactive.
Patient safety is the overarching umbrella that is the proactive approach to improving care.

7. Requisites for Safe Care
Safe, Learning Culture
Safety sciences and competencies
Leadership
Transparency
Teaming/Learning
Adoption and spread of best practices
Minimize unwarranted variation
Focus on outcomes and process/patient experience
Accountability

8. Patient Safety and Teams
Shape behavior
Define the team
Provider/care team/staff
Patient
Accountability
Evidence based practice – pushing teams
Stop the line
Speak Up
Every individual has a role to play
Simulations role in shaping team behavior
Evaluate critical transitions in care (Internal and External)
Team behavior modeling
Coaching/mentoring

9. Accountability & Teams
Organizational and individual
Imperative for a safe system
Not just after an even or things go wrong, , but proactively in order to ensure that we are aiming for zero defect
Accountability: Educate the new, Coach the weak and discipline conscious reckless behaviors
It is everyone’s Job
Only ‘I’ can hold myself and others accountable

10. Accountability
Organization
Care Team
Individual
Practitioner
PATIENT
Collective Accountability, Mutual Accountability, Shared Accountability

11. Accountability – The Mindset
Systems thinking with passion because it is all about the patient
Patient safety is the way we do business & quality is the best business case – organizational mindset
Patient safety is in everything we do at the bedside to provide care – practitioner and staff mindset

12. Signs of Accountability for Safety in a Healthcare Organization
A general sense of urgency to resolve issues, including changing current behaviors and processes
Appropriate indignation, even outrage, when blatant failures occur
Talking issues through until completion in a timely manner
Clarity as to roles and procedures
A willingness to engage and solve problems
Active and open communication in all directions
A general sense that safety and quality is expected, rewarded and supported as a part of what the organization does, thus creating a powerful climate of support
Thomas R. Krause, PhD, Chairman of the Board
Behavioral Sciences Technologies, Inc.
NPSF Leadership Day 2010

13. Patient Safety & Care Delivery Process
Hazards
Reality
Ideal
Errors
Swiss Cheese Model
J. Reason 13

14. Patient Safety Workflow Design
Consider critical transitions of care – internal & external
Increased integration of health information technology
Technology on ideal process flow
Clinical input
Complexity of future technology
Role of simulation
Human factors
Why are we doing the things we are doing?

15. Contact Information
Kenneth Grubbs, MBA,RN
AVP Programs
Office: