1. Creating a Culture of Patient Safety
WVU Department of Family Medicine
RCB HSC- Eastern Division
Konrad C. Nau, MD

2. We work in a complex environment

3. We value quality medical care
UHA STATEMENT OF VALUES
We will provide high-quality service and responsiveness to our patients and to each other that exceed expectations

4. We know that error happens

5. We know that patient safety is the bedrock of quality care
Institute of Medicine: Quality Care

6. IOM elements of “Quality”
Safe: avoiding injuries to patients from the care that is intended to help them
Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care
Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse)
Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and energy
Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
Patient-Centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
“STEEEP” Framework outlined by the Institute of Medicine (“IOM”)

7. We preach “quality” but can we say we have a true “culture of safety”
“The way we do things around here”
Safety
Avoiding injuries from care intended to help patients

8. Can everyone in our clinic name five ways to improve patient safety ?

9. AHRQ Five Steps to Safer Health Care
1. Ask questions if you have doubts or concerns.
2. Keep and bring a list of ALL the medicines you take.
3. Get the results of any test or procedure.
4. Talk to your doctor about which hospital is best for your health needs..
5. Make sure you understand what will happen if you need surgery.

10. Delivering on our Promise of Quality Medical Care
Quality Care
Patient Safety

11. Patient Safety & Quality Medical Care
Two fundamental questions guide us, as a world-class
academic family medicine center, and in this order:
1.How can we help the patient?
2.In doing so, what can we learn?

12. Patient Safety Campaign WVU Dept Family Medicine-East Div
Patient Safety Kickoff
System of Reporting and Analyzing Error
Regular Patient Safety Grand Rounds
Create a Culture of Safety

13. Patient Safety Kickoff
Entire office assembled off-site for lunch meeting January 2005
Present : Epidemiology of Medical Error
Present : Creating a Culture of Patient Safety

14. System to Report and Analyze Error
Electronic Occurrence Reporting System
Quantros/Dr Quality/ORM
Web based
We encourage ALL staff to file reports online
Patient injury
Adverse drug reactions
Near-misses
Non-putative, can be filed anonymously

15.
              
Click here to report an occurrence (a.k.a. variance or incident) anonymously. You do not need a User ID or Password to do this. Please assist us in creating a safer healthcare environment for the customers we serve

16. Resident Physicians Reporting and Analyzing Error
All residents are REQUIRED to self report their own “medical errors”.
Electronic format is confidential and Peer Review protected.
Encourages reflection and honesty expected in physicians
Non-putative focus on systems-based analysis
Will formulate basis of Patient Safety Grand Rounds topics

17. Patient Safety Grand Rounds
Bimonthly – residents, faculty, students, invited clinic staff
Based on resident’s self reported medical error or near miss
Clinical case presented
Systems-based analysis of the error
Present patient safety literature that supports recommendations
Case Report and analysis is written up and reviewed with Chair prior to required submission to AHRQ M&M

18. Create a Culture of Patient Safety
Enhance clinic library with Patient Safety materials
Journal of Patient Safety
Patient Safety & Quality Healthcare Journal
Seminal textbooks
Crossing the Quality Chasm
To Err is Human
Enhance clinic technology for Patient Safety
Clinic wide Lexicomp/Drug Interaction software on all computers and handhelds
Redesign Clinic Web Page
Medication Charts
Office Visit preparation/safety tips

19. Create a Culture of Patient Safety
AHRQ Patient Safety Culture Survey
Outpatient format available in PDF or Word
Results display template on PowerPoint
Involve entire clinic in patient safety culture survey
Patient focus groups to inform clinic about patient stakeholder perspectives
Clinic leadership makes “Patient Safety Rounds”

20. Patient Safety Culture Survey

21. Overall Perceptions of Safety
Sample culture Survey result slide:
Overall Perceptions of Safety
Survey Items
% Strongly Disagree/ % Neither % Strongly Agree/
Disagree Agree
1. Patient safety is never sacrificed to get more
work done. (A15)
2. Our procedures and systems are good at
preventing errors from happening. (A18)
R3. It is just by chance that more serious
mistakes don’t happen around here. (A10)
R4. We have patient safety problems in this
unit. (A17)
R Indicates reversed-worded items.
NOTE: The item letter and number in parentheses indicate the item’s survey location.
Page

22. Quality Primary Care for the 21st Century
Safe Patient Care
Consistent Best Practices
Great Patient Service

23. Ambulatory Patient Safety Culture
Create a Culture of Safety
Culture = the way we do things around here
Culture of Safety Requirements
Visualize a safe system
Non-punitive environment
Leadership support
Quality Care
Patient Safety

24. Ambulatory Patient Safety
Capture errors that occur
Analyze errors
Follow-up on analysis
Safety projects will emerge
Medication
EMR
Communications
Team work
Test results
Pt education about safety
Quality Care
Patient Safety

25. First Class Patient Safety will require everyone’s best efforts

26. We need creativity

27. We need enthusiasm
We need you.