Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "1 Creating a Culture of Patient Safety WVU Department of Family Medicine RCB HSC- Eastern Division Konrad C. Nau, MD."— Presentation transcript:

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

2 2 We work in a complex environment

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

4 4 We know that error happens

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

6 6 IOM elements of “Quality” Safe:Safe: avoiding injuries to patients from the care that is intended to help them Timely:Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care Effective: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:Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and energy Equitable:Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status Patient-Centered: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 7 We preach “quality” but can we say we have a true “culture of safety” CultureCulture –“The way we do things around here” SafetySafety –Avoiding injuries from care intended to help patients

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

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

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

11 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 12 Patient Safety Campaign WVU Dept Family Medicine-East Div 1.Patient Safety Kickoff 2.System of Reporting and Analyzing Error 3.Regular Patient Safety Grand Rounds 4.Create a Culture of Safety

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

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

15 15 https://qxpert.quantros.com/orm/jsp /JeffersonLogin.jsp 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 16 Resident Physicians Reporting and Analyzing Error All residents are REQUIRED to self report their own “medical errors”.All residents are REQUIRED to self report their own “medical errors”. Electronic format is confidential and Peer Review protected.Electronic format is confidential and Peer Review protected. Encourages reflection and honesty expected in physiciansEncourages reflection and honesty expected in physicians Non-putative focus on systems-based analysisNon-putative focus on systems-based analysis Will formulate basis of Patient Safety Grand Rounds topicsWill formulate basis of Patient Safety Grand Rounds topics

17 17 Patient Safety Grand Rounds Bimonthly – residents, faculty, students, invited clinic staffBimonthly – residents, faculty, students, invited clinic staff Based on resident’s self reported medical error or near missBased 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 18 Create a Culture of Patient Safety Enhance clinic library with Patient Safety materialsEnhance clinic library with Patient Safety materials –Journal of Patient Safety –Patient Safety & Quality Healthcare Journal –Seminal textbooks Crossing the Quality ChasmCrossing the Quality Chasm To Err is HumanTo Err is Human Enhance clinic technology for Patient SafetyEnhance clinic technology for Patient Safety –Clinic wide Lexicomp/Drug Interaction software on all computers and handhelds –Redesign Clinic Web Page Medication ChartsMedication Charts Office Visit preparation/safety tipsOffice Visit preparation/safety tips

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

20 20 Patient Safety Culture Survey

21 21 Overall Perceptions of Safety Overall Perceptions of Safety R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree 1.Patient safety is never sacrificed to get more 1.Patient safety is never sacrificed to get more work done. (A15) work done. (A15) 2.Our procedures and systems are good at 2.Our procedures and systems are good at preventing errors from happening. (A18)preventing errors from happening. (A18) R 3.It is just by chance that more serious R 3.It is just by chance that more serious mistakes don’t happen around here. (A10)mistakes don’t happen around here. (A10) R 4.We have patient safety problems in this R 4.We have patient safety problems in this unit. (A17)unit. (A17) Page Sample culture Survey result slide :

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

23 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 Patient Safety Quality Care

24 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 Patient Safety Quality Care

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

26 26 We need creativity

27 27 We need enthusiasm We need you.


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

Similar presentations


Ads by Google