1. Quality and Medical Safety Programs Page 1 of 26 Quality and Medical Safety Program Employee education competency module 2009 DMC Quality Department Detroit Medical Center© Revised: December, 2008

2. Quality and Medical Safety Programs Page 2 of 26 Commitment to Quality and Safety  The Detroit Medical Center is committed to providing safe, high quality medical care.  This is part of our mission and it is also reflected by our certification and accreditation with regulatory agencies and participation with local, state, and national quality and safety improvement projects.

3. Quality and Medical Safety Programs Page 3 of 26 Quality and Environmental Management Systems  The DMC has incorporated the requirements of a Quality Management System (QMS) as outlined in the ISO 9001-2000 standards and an Environmental Management System (EMS) as outlined in ISO 14001: 2004 standards into its quality program.

4. Quality and Medical Safety Programs Page 4 of 26 Foundation for Medical Safety  Our commitment to Medical Safety is reflected in our:  Environmental Statement  Quality Statement

5. Quality and Medical Safety Programs Page 5 of 26 ENVIRONMENTAL STATEMENT The Detroit Medical Center is dedicated to the health and safety of its patients, employees, customers, community and environment. We are committed to: the prevention of pollution, compliance with environmental regulations and other requirements, and continuous improvement. THINK GREENEnvironmental Hotline 1-888-484-9200THINK CLEAN

6. Quality and Medical Safety Programs Page 6 of 26 QUALITY STATEMENT Quality at the DMC includes:  Continuous improvement  Prevention of medical/health system errors  Provision of high quality medical care

7. Quality and Medical Safety Programs Page 7 of 26 Improving Quality and Safety Most events or errors occur due to process issues  Multiple events at multiple levels lead to the event – almost never just one process failure.  Rarely a “person” failure By improving our systems and processes, we improve healthcare quality and safety.

8. Quality and Medical Safety Programs Page 8 of 26 What is Performance Improvement? It’s an ongoing effort to find new and better ways of doing things.  It’s about:  Getting better results Involving the whole organization Improving work processes Foundation for Performance Improvement: PDCA  Plan  Do  Check  Act

9. Quality and Medical Safety Programs Page 9 of 26 Performance Improvement  Plan  What are the goals you want to achieve?  Do  Measure progress towards goals by collecting data.  Check  Look closely at (analyze) your data to answer these questions: How well are we performing? Why are we performing well (or not well)? Which areas should we focus on first to improve our process?  Act  Make Improvements!  Celebrate success!

10. Quality and Medical Safety Programs Page 10 of 26 Medical Safety  What does Medical Safety mean?  It means we constantly look for ways to make the care or service we provide safer for our patients and employees.  How can we do this?  By identifying conditions that are hazardous and changing them.  By acting quickly and appropriately when an incident occurs.  By making medical safety a regular part of our performance improvement activities.  By making concerns for safety part of everything we do.

11. Quality and Medical Safety Programs Page 11 of 26 Medical Safety = Quality Care  The DMC is committed to adopting the Institute of Medicine’s 6 aims for improving the quality and safety of healthcare

12. Quality and Medical Safety Programs Page 12 of 26 Institute of Medicine 6 aims of improving care Healthcare needs to be: 1.Safe: avoiding injuries to patients from the care that is intended to help them. 2.Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. 3.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. 4.Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. 5.Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy. 6.Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. A health care system that achieves major gains in these six areas would be far better at meeting patient needs.

13. Quality and Medical Safety Programs Page 13 of 26 Healthcare Safety Statistics 40 to 50 Patient Injuries per 100 Hospital Admissions 37 Million Admissions X 40 Injuries per 100 Admissions = 15 Million Injuries per Year What can we do to change this?

14. Quality and Medical Safety Programs Page 14 of 26 Institute for Healthcare Improvement (IHI) “Protecting 5 Million lives from Harm” campaign AIM:  Care that is standardized and systematized  Zero defects  Innovative  System Redesign The DMC has committed to participate with the IHI to protect patients from harm Everyone is responsible for the quality and safety of healthcare

15. Quality and Medical Safety Programs Page 15 of 26 Proven Interventions The 5 Million Lives Campaign challenges American hospitals to adopt 12 changes in care that save lives and reduce patient injuries:  Deploy Rapid Response Teams…at the first sign of patient decline  Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation  Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps  Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time  Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps

16. Quality and Medical Safety Programs Page 16 of 26 Proven Interventions con’t. The 5 Million Lives Campaign challenges American hospitals to adopt 12 changes in care that save lives and reduce patient injuries:  Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin  Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (www.medqic.org/scip)www.medqic.org/scip  Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention  Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices  Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions  Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care

17. Quality and Medical Safety Programs Page 17 of 26 Promoting and Maintaining a Safe Medical Climate  Staff Responsibilities:  Take action to provide necessary care and protect patients in the event of a unsafe event or error.  Report all errors, near misses and hazardous conditions (web based incident reporting system).  Complete yearly, educational competencies.  Participate in departmental improvement efforts.  Be part of interdepartmental, multidisciplinary improvement teams.  Share ideas to improve employee or patient safety with supervisor or quality department  SPEAK UP if you see an opportunity to avoid an unsafe practice or violation of policy  Instruct patients and families to report safety concerns.

18. Quality and Medical Safety Programs Page 18 of 26 Promoting and Maintaining a Safe Medical Climate  Patient Responsibilities:  Encourage patients to: Provide accurate and complete information about present complaints, past illnesses, hospitalizations and medications. Ask questions when they do not understand what they have been told or what they are expected to do.

19. Quality and Medical Safety Programs Page 19 of 26 Accreditation  Accreditation means that an organization has met requirements related to the delivery of safe, quality care.  The DMC is surveyed and accredited by many different agencies.  The Joint Commission is one of these agencies and comes to our hospitals at least once every 3 years. What is Joint Commission?  The Joint Commission is an accreditation agency who’s objective is to improve the quality of healthcare provided to the public by establishing clinical standards; evaluating health care organizations; rendering accreditation; and providing education and consultative support to healthcare professionals.

20. Quality and Medical Safety Programs Page 20 of 26 Hospital Transparency  Hospital “transparency” is providing information to the public on patient safety & quality, cost, and performance indicators  Transparency assists hospitals to become more efficient, rewards those hospitals that provide high quality care, and allows consumers to make informed decisions  The DMC provides information on safety and quality that is publicly reported

21. Quality and Medical Safety Programs Page 21 of 26  The DMC participates in many local, state and national Quality Improvement projects some of which are:  The National Quality Forum (NQF)  Leapfrog  Institute for Healthcare Improvement (IHI)  Michigan Hospital Association (MHA – Keystone project)  Greater Detroit Area Health Coalition (GDAHC – Save Lives-Save Dollars campaign)  Blue Cross Blue Shield of Michigan Quality Improvement

22. Quality and Medical Safety Programs Page 22 of 26 Consumer Centered Hospital Data  In recent years, there has been an increased emphasis on hospital quality and transparency  Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores  It is important to remember that all DMC employees play a role in ensuring that our patients leave with a satisfying experience

23. Quality and Medical Safety Programs Page 23 of 26 Healthcare Quality Websites  The Joint Commission www.jointcommission.org The Joint Commission  Provides information regarding hospital accreditation and compliance  AHRQ Report Card www.ahrq.gov AHRQ Report Card  Features information on the quality of hospitals, medical groups, health plans, and nursing homes  CMS/Hospital Compare www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp CMS/Hospital Compare  Provides consumers with hospital-reported information on quality, performance, and customer satisfaction  Leapfrog Group www.leapfroggroup.org Leapfrog Group  Provides consumers with hospital information based on its yearly survey of quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk procedures, and NQF Safety Goals  Michigan Hospital Inform http://www.mihospitalinform.org/ Michigan Hospital Inform  State of Michigan healthcare quality website

24. Quality and Medical Safety Programs Page 24 of 26 Quality of Care  As employees of the DMC, it is everyone’s responsibility to ensure safe, quality care for our patients.  Also, as an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.  If you have concerns, first speak to your supervisor. If you are not satisfied, you may contact the Quality Department or use the compliance hotline.  If still your concerns are not addressed, you have the right to contact the Joint Commission at complaint@jointcommission.org or call 1-800-994-6610. complaint@jointcommission.org

25. Quality and Medical Safety Programs Page 25 of 26 Quality and Medical Safety Programs Summary Both the Quality Management System (QMS) and Environmental Management System (EMS) are part of our integrated quality program. Medical Safety means we constantly look for ways to make the care or service we provide safer for our patients and employees. The DMC publicly reports it’s quality and safety data. Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores. As an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.

26. Quality and Medical Safety Programs Page 26 of 26 Summary We hope this NetLearning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Click any of the following menu selections located on the left side of the screen: Take Test button to complete the requirements for this course My Records button to return to your CBL Courses to Complete list Exit button to close the Student Interface