An Introduction to Principles of Patient

SafetyCentral Pennsylvania NANT Chapter

Spring Conference – April 15, 2012Gary Merica, R.Ph, MBA/HCM

Director, Patient Safety, WellSpan Health

Objectives

Participants will be able to: Describe the frequency with which patients suffer

unintended harm in hospitals Define a culture of patient safety, and describe

how to measure it Describe 3 significant interventions hospitals can

take to improve their culture of patient safety

Why?Numbers……………..

44,000 – 98,000 1 in 7 16 every quarter 1.7 million 99,000

……………and Names

Josie King David Milne Ben Kolb Michael Colombini

The passing of a hero in Canada

An admonition from the public

Regulatory/legal “Stuff”

Pa Act 13 Licensed practitioners required to report medical

errors and adverse events to their organization Organization must report events to the state Written disclosure letters to patients/families for

Serious Events

CMS Hospital Acquired Conditions

FOREIGN OBJECT RETAINED AFTER SURGERY

AIR EMBOLISM BLOOD

INCOMPATIBILITY PRESSURE ULCER

STAGES III AND IV FALLS AND TRAUMA

CAUTI CLABSI MANIFESTATIONS OF

POOR GLYCEMIC CONTROL

SSI DVT/PE AFTER HIP OR

KNEE REPLACEMENT

CMS Hospital Acquired Conditions

Since 10/1/08, hospitals do not receive the higher payment when: One of these conditions is present as a secondary diagnosis at

discharge And was not present on admission And results in a higher MS-DRG

In March 2011, 8 of the HACs were publicly reported on the CMS Hospital Compare website

Beginning in FFY 2015, hospitals in the worst performing quartile of HAC rates per 1000 eligible discharges will be subject to a 1% reduction in Medicare reimbursement.

Pa Act 1 of 2009: Preventable Serious Adverse Events Act

General rule: A health care provider may not knowingly seek

payment from a health payor or patient:1. For a PSAE, or

2. For any services required to treat the problem created by the PSAE when the event occurred under their control

What is a “Culture of Patient Safety”

Culture The predominating attitudes and behaviors that

characterize the functioning of an organization…or

The collective behaviors, practices, and operational standards, driven by our shared values and beliefs…or

The way we do things around here Safety

Freedom from unintended harm

Attributes of a Culture of Patient Safety

Patient centered, patient first Mutual respect Open communication Highly functioning teams Reporting and learning “Just Culture” approach to safety Peer accountability Crucial Conversations High reliability organization/practitioners

Patient CenteredMutual Respect

1. The American College of Physician Executives (ACPE) physician behavior survey:

• 38.9 percent of the respondents agreed that "physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue.”

2. “There is a difference between hospitals that take care of patients and hospitals that take care of doctors.”

3. ISMP Intimidation Survey:• 40% of clinicians failed to intervene for patient safety due to

fear of a negative encounter

Open Communication

2010 AHRQ Survey on Patient Safety Communication openness (62%)

staff will freely speak up if they see something that may negatively affect patient care (76%) Or…..24 of 100 won’t

staff feel free to question the decisions/actions of those with more authority (47%) Or….. 53 out of 100 don’t

staff are afraid to ask questions when something does not seem right (63%) Or…..37 out of 100 are

Open Communication

Crucial Conversations What makes a conversation “crucial”?

Stakes are high Opinions vary Emotions run strong

Highly Functioning Teams

Crew Resource Management SBAR Briefings/Time-outs/Debriefings Critical language Assertion Situational Awareness Checklists

Pre-procedure Briefing

Team introductions Discuss patient, case – concerns Team accountability Set stage for open communication

Procedural Time-out

Immediately before incision or start of the procedure Entire team is engaged, all activities cease (except

life support) Team positively affirms:

Correct patient Correct procedure Correct site

Note: 16 wrong site surgeries in Pennsylvania per quarter

Post-procedure De-briefing

Clinical/technical – counts, specimens, etc. How did we do? Any changes need to be made?

Peer Accountability

Peer Accountability

In the worst companies, poor performers are first ignored and then transferred

In good companies, bosses eventually deal with problems

In the best companies, everyone holds everyone else accountable – regardless of level or position

High Reliability Organizations

HROs have a preoccupation with the possibility of failure Systems fail People fail HRO’s have a “healthy” recognition of these

potential failures, and actively look to identify and mitigate them prior to patient harm

Just Culture

Why?

The single greatest impediment to error prevention is that “we punish people for making mistakes.”

Lucian Leape, MD

1/25/00 Congressional Testimony

What Does the Data Show?

2010 AHRQ Survey on Patient Safety: Non-punitive environment (44%)

staff feel like mistakes held against them (51%) Or…..49 out of 100 feel this way

feels like person being written up, not event (46%) Or….54 out of 100 feel this way

staff worry that mistakes are kept in their file (35%) Or…. 65 out of 100 worry about this

Who Supports This?

Organizations that advocate for adoption of a Just Culture: National Quality Forum – 2009 Safe Practices for Better

Healthcare: “A just culture should be fostered in which frontline personnel feel comfortable disclosing errors – including their own – while maintaining professional accountability.”

HAP – “HAP recommends that Pa hospitals and health systems strongly consider working with Outcome Engineering to implement a Just Culture model.” (12/05/08)

Who Supports This?

• Organizations that advocate for adoption of a Just Culture:• Pa Patient Safety Authority• Institute for Safe Medication Practices• Joint Commission

• Leadership Standard 03.01.01• Leaders create and maintain a culture of safety and quality throughout

the hospital• The focus of attention is on the performance of systems and

processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated.

Just Culture

Unacceptable to punish all errors and unsafe acts

Equally unacceptable to give blanket immunity to all actions that contributed to an error – evolve from “blameless”, or “non-punitive” culture

Adjust the pendulum

Reporting and Learning

Principles: Predicated on having a reporting environment in which staff

feel comfortable and safe in reporting an observed risk or a mistake.

Looks to create a well established system of accountability Recognizes that human beings are fallible, however also

recognizes that in most circumstances we have control over our behavioral choices

Just Culture

Principles (cont.): Based on “shared accountability” Two inputs into good patient care:

Good system design (management responsibility) Good behavioral choices (staff responsibility)

Measuring Patient Safety:Process, Structure, Outcome

Survey patient safety culture – process & structure National Quality Forum – Safe Practices for Better

Healthcare:

“Healthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk”

Measuring Patient Safety:Process, Structure, Outcome

Observational methodology - process Hand Hygiene – how good are we, and how do

we know? Crew Resource Management – are we just going

through the motions? ISO 9000 auditing requirements - It is considered

healthier for internal auditors to audit outside their usual management line, so as to bring a degree of independence to their judgments.

Measuring Patient Safety:Process, Structure, Outcome

AHRQ Patient Safety Indicators (PSI), CMS Hospital Acquired Conditions – outcome Preventable complications of hospital care

Iatrogenic pneumothorax HAI Blood incompatibility PE/DVT

Change?Never doubt that a small group of thoughtful,

committed citizens can change the world. Indeed, it is the only thing that ever has.

Margaret Mead