“The Difference Physicians Can Make in Improving Safe Care”readmissions by July 1, 2014. The...
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© Copyright, The Joint Commission “The Difference Physicians Can Make in Improving Safe Care” Ana Pujols McKee, MD Executive Vice President and Chief Medical Officer The Joint Commission June 14, 2013
Transcript of “The Difference Physicians Can Make in Improving Safe Care”readmissions by July 1, 2014. The...
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“The Difference Physicians Can
Make in Improving Safe Care”
Ana Pujols McKee, MD
Executive Vice President and Chief Medical Officer
The Joint Commission
June 14, 2013
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We are three 501 3(c) Companies
All people always
experience the safest,
highest quality, best-value
health care across all
settings.
One Vision
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Total Reported Reviewable Sentinel Events by Year
1995 through 2012
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. Therefore, these data are not an
epidemiologic data set and no conclusions should be drawn about the actual relative
frequency of events or trends in events over time.
46
122
284
401 449 429 460
545 550
607 691
790
927 938 920
1243
901
0
200
400
600
800
1000
1200
1400
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Nu
mb
er
of
Revie
wab
le E
ven
ts
Rep
ort
ed
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Most Frequently Reviewed Sentinel Event
Categories by Year
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. Therefore these data are not an
epidemiologic data set and no conclusions should be drawn about the actual relative
frequency of events or trends in events over time.
*Other includes: Unexpected Additional Care/Extended Care, and Psychological Impact
2010 2011 2012
Unintended retention of a Foreign Body
Unintended Retention of a Foreign Body
Unintended Retention of a Foreign Body
Delay In Treatment Wrong-patient, wrong-site,
wrong-procedure Wrong-patient, wrong-site,
wrong-procedure
Wrong-patient, wrong-site, wrong-procedure
Delay In Treatment Delay In Treatment
Op/Post-op Complication Op/Post-op Complication Suicide
Suicide Suicide Op/Post-op Complication
Fall Fall Fall
Medication Error Other Unanticipated Event* Other Unanticipated Event*
Other Unanticipated Event Criminal Event Criminal Event
Perinatal Death/Injury Medication Error Medication Error
Criminal Event Medical Equipment-Related Perinatal Death/Injury
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TJC’s Physician Engagement
Goals
Help physician leaders in our
accredited organizations to meet or
preferably exceed their patient safety
and performance improvement goals
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Aspiring Higher:
Organizations will need to achieve optimal physician
engagement
Overall Physician
Indifference
Some Physicians
Participate Some of the
Time
Optimal Physician
Engagement
Searching for
Stability
Building for Success Achieving
Superior
Performance
Quality and Safety Continuum
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Beyond Accreditation
Performance Measurement
National Patient
Safety Goals
Performance Improvement
Standards Development
Intra –Cycle Monitoring
Sentinel Event Review and Analytics
Complaint Analysis
Sentinel Event Alerts
Advocacy
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Diverse Tools and Services to Support an
Organization’s Journey in Performance Excellence
Your Organization
On-site Evaluation Primarily
Tracer Methodology
RCA Reviews
for Sentinel Events
Sentinel Event Alerts
High Reliability
Portal
National Patient Safety Goals
Booster Packs
Electronic Manual
Leading Practices Library
Targeted Solutions
Tool
Health Care
Acquired Infection
Portal
Core Measures Solution
Exchange
OPPE And
FPPE
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A Major Shift in Practice and
Performance Improvement
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Organizational Approach to
Performance Improvement
Centralized Department Decentralized Resources
Unit Based Clinical
Leadership Teams
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Hospital of the University of Pennsylvania
Developed and implemented the “Blueprint for Quality” strategy plan with the goal to eliminate preventable deaths and preventable readmissions by July 1, 2014. The Blueprint has 5 imperatives:
– Accountability for perfect care, Patient and family centered care, Reducing un-necessary variations in care, Improving transitions in care, Increasing provider advocacy and engagement
• A hallmark of the accountability imperative lies in the Unit Based Clinical Leadership teams who are accountable for quality, safety and patient experience outcomes for their patient populations
– The UBCL consists of a physician and nurse leader as well as a quality improvement manager
From 2008-2012, Penn’s “Blueprint for Quality” resulted in substantial improvements in the following areas:
– 45% in risk adjusted mortality
– 85% in central line blood stream infections
– 80% in catheter associated urinary track infections
– 13% in 30 day heart failure readmission (2009 – 2012)
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RPI, Safety Culture & Leadership
Essential and
foundational
components of
High Reliability-
consistent
excellence over
long periods
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Robust Process Improvement™(RPI) – A
New Way in Delivering Results
Toolkits or
“Bundles”
Protocols
Checklists
Usual Approaches: “One-size-fits-all” works well only in
very limited circumstances: •Process varies little from place to place
•Causes of failure are few and common
RPI
Many causes of the same problem
Key causes different
from place to place
Each cause requires a different strategy
New Generation of Best Practices:
Complex processes require RPI to
produce solutions – customized to an
organization’s most important causes
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Memorial Hermann’s Story:
Getting to Zero
Leadership commitment to zero
MH Woodlands Hospital was among the 8 Center hospitals that carried out the hand hygiene project and got impressive results
2010: MH committed to use TST to improve hand hygiene system-wide (12 hospitals)
Baseline (150 inpatient units) = 44%
– Range (12 hospitals ): from 21% to 65%
– Aim: to exceed 90%
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Baseline
Compliance
44%
TJC Hand Hygiene Compliance Center for Transforming Healthcare
50%
55%
60%
65%
70%
75%
80%
85%
90%
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12
Secret Observations Compliance Rate
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Ventilator Associated Pneumonias (VAP)
Mean = 0.95
Mean = 0.5
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Adult ICU Central Line Associated Blood Stream Infections (CLABSI)
Mean = 0.79
Mean = 0.45
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Woodlands: Zero Hospital Central Line Blood Stream Infections
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Ventilator Associated Pneumonias (VAP)
Mean = 0.95
Mean = 0.5
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Memorial Hermann’s Story:
Getting to Zero
Leadership commitment to zero
MH Woodlands Hospital was among the 8 Center hospitals that carried out the hand hygiene project and got impressive results
2010: MH committed to use TST to improve hand hygiene system-wide (12 hospitals)
Baseline (150 inpatient units) = 44%
– Range (12 hospitals ): from 21% to 65%
– Aim: to exceed 90%
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How can the OSMAP and TJC
help physicians and physician
leaders improve safety and
quality?
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The Joint Commission Disclaimer
These slides are current as of June 14,
2013. The Joint Commission reserves the
right to change the content of the
information, as appropriate.
This presentation is copyrighted to The Joint
Commission and cannot be reproduced or
otherwise distributed without express written
permission by the speaker. Distribution of the
speaker’s presentation other than in PDF
format is expressly prohibited.
