1. ORIENTATION FOR STUDENTS PATIENT SAFETY PERFORMANCE IMPROVEMENT Quality & Risk

2. RISK MANAGEMENT, PERFORMANCE IMPROVEMENT, & PATIENT SAFETY w An organizational QUALITY PERFORMANCE program exists to: Evaluate and improve processes that enhance patient safety and result in quality service Educate and involve staff in processes Identify events and other opportunities that allow for process review and improvement

3. WHAT IS PERFORMANCE IMPROVEMENT? w Performance Improvement is EVERY staff person’s concern w It is the assessing of how things are done or turn out and how to make them better w No matter what your job, you play an important role in helping OMH provide safe quality patient care. w Performance Improvement is vital to our organization and your department’s goals! IT IS HOW WE ARE JUDGED!!!

4. What is the Current Climate? w Public trust at an all time low Institute of Medicine Reports (12/99 & 3/01) Headlines about fraud / medical mistakes Increased co pays and denials / decreased access Legislation Staffing shortages heavily reported Patient / family expectations increasing as to clinical and non clinical services

5. PATIENT SAFETY & QUALITY - EXAMPLE ACTIVITIES & SOURCES w Application / Credentialing w Orientation w Job Descriptions w Evaluations w Continuing Education w Policies / Procedures w Regulatory Compliance w (Environmental) Safety

6. w Documentation w External Alerts / Guidelines -reviewed w Third party reports w Complaints w Infection Control w Internal Surveys w Occurrence Reporting w Monitors / Screens / Profiles w Peer Review

7. JCAHO Patient Safety Goals w Focus on previously reported Sentinel Events w Are surveyed as an “all or none” w Can change every year w Evidenced - based and require “culture change” w Seven goals / 13 aspects

8. 2003-04 Patient Safety Goals w Patient identification Use of 2 unique identifiers Use of “time out” prior to invasive procedure w Effective communication “Read back” on verbal / phone orders Standardize abbreviations / list those not to be used

9. w Safe use of high-alert medications Remove concentrated electrolytes Standardize / limit drug concentrations w Eliminate wrong site, patient, procedure surgery Pre-op verification process Site marking

10. w Safe use of infusion pumps Free-flow protection w Effectiveness of clinical alarm systems PM and testing of systems Settings - parameters, audible for distance/competing noise w Nosocomial Infections reduced and Monitored CDC Guidelines adopted and implemented Tracking of serious injury / death related to nosocomial infection

11. DO THE RIGHT THING At 99% : w 2 airplanes will crash during landing at O’Hare airport per day w 1 new hire a year will have falsified their application w One Xray study each day will be done wrong or misread w 17 Lab studies would be reported incorrectly each day

12. Measuring Performance Improvement & Safe Care It is important to objectively know we are doing a good job Measuring where we are and that we have done to improve must be done using data Data comes from lots of sources.. Sometimes even you ! Data then is analyzed (interpreted) And then changes are sometimes made and re measured

13. STRIVE FOR 100% QUALITY Because at 99%: w The wrong procedure would be performed in surgery once a week w Every two months a baby would be dropped to the floor at delivery w 8 bills a day will be for too much and contain errors w One EMS call each week would fail to meet EMTALA regulations

14. Plan, Do, Study & Act Oconee Memorial Hospital utilizes the PDSA methodology to continuously measure, assess, and improve processes and outcomes. Plan the improvement and the dataDo the improvement and the data collection Study the results of the implementationAct to hold the gain and continue improvement #1 #2 #3 #4

15. OMH SPECIFIC ACTIVITIES ADDRESSING PI / PATIENT SAFETY w Organization-wide initiative - MISSION w Routine monitoring of outcomes / events w Timely reporting and evaluation of events / complaints with process the focus w Use of external information as a source for process change w Departmental initiatives to enhance processes

16. COMMON PATIENT SAFETY ISSUES w Medication orders-prescribing, dispensing, administering, verbal/phone orders w Recognition / knowledge of patient condition & failure to respond to information on patient status w Communication breakdown with patient or staff w Procedure error- skill, appropriate application

17. Other “Issues” w Confidentiality & Other Patient’s Rights Issues w Documentation w Regulatory Compliance w Workplace Safety w Equipment / Product Usage w Appropriate Communication

18. COMMON BARRIERS to GOOD PI / PATIENT SAFETY w Lack of consistency w Lack of knowledge / understanding w Lack of commitment w Not involving staff in the process evaluation w Lack of willingness to change w Failure to admit to mistakes w Lack of communication

19. Examples of OMH Patient Safety Initiatives w Medication Safety w Fall Prevention w External Information as resource w Patient Confidentiality (HIPAA) w Policy Revisions Universal Protocol for correct surgery Patient Identification Disclosure

20. NOTHING WILL CHANGE UNLESS YOU CHANGE IT SAFETY IS AN INDIVIDUAL & COLLECTIVE RESPONSIBILITY