5We know that patient safety is the bedrock of quality care Institute of Medicine: Quality Care
6IOM elements of “Quality” Safe: avoiding injuries to patients from the care that is intended to help themTimely: reducing waits and sometimes harmful delays for both those who receive and those who give careEffective: 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: avoiding waste, in particular waste of equipment, supplies, ideas, and energyEquitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic statusPatient-Centered: providing care that is respectful of and responsive toindividual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions“STEEEP” Framework outlined by the Institute of Medicine (“IOM”)
7We preach “quality” but can we say we have a true “culture of safety” “The way we do things around here”SafetyAvoiding injuries from care intended to help patients
8Can everyone in our clinic name five ways to improve patient safety ?
9AHRQ Five Steps to Safer Health Care 1. Ask questions if you have doubts or concerns.2. Keep and bring a list of ALL the medicines you take.3. Get the results of any test or procedure.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.
10Delivering on our Promise of Quality Medical Care Quality CarePatient Safety
11Patient Safety & Quality Medical Care Two fundamental questions guide us, as a world-classacademic family medicine center, and in this order:1.How can we help the patient?2.In doing so, what can we learn?
12Patient Safety Campaign WVU Dept Family Medicine-East Div Patient Safety KickoffSystem of Reporting and Analyzing ErrorRegular Patient Safety Grand RoundsCreate a Culture of Safety
13Patient Safety Kickoff Entire office assembled off-site for lunch meeting January 2005Present : Epidemiology of Medical ErrorPresent : Creating a Culture of Patient Safety
14System to Report and Analyze Error Electronic Occurrence Reporting SystemQuantros/Dr Quality/ORMWeb basedWe encourage ALL staff to file reports onlinePatient injuryAdverse drug reactionsNear-missesNon-putative, can be filed anonymously
15https://qxpert.quantros.com/orm/jsp/JeffersonLogin.jspClick 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
16Resident Physicians Reporting and Analyzing Error All residents are REQUIRED to self report their own “medical errors”.Electronic format is confidential and Peer Review protected.Encourages reflection and honesty expected in physiciansNon-putative focus on systems-based analysisWill formulate basis of Patient Safety Grand Rounds topics
17Patient Safety Grand Rounds Bimonthly – residents, faculty, students, invited clinic staffBased on resident’s self reported medical error or near missClinical case presentedSystems-based analysis of the errorPresent patient safety literature that supports recommendationsCase Report and analysis is written up and reviewed with Chair prior to required submission to AHRQ M&M
18Create a Culture of Patient Safety Enhance clinic library with Patient Safety materialsJournal of Patient SafetyPatient Safety & Quality Healthcare JournalSeminal textbooksCrossing the Quality ChasmTo Err is HumanEnhance clinic technology for Patient SafetyClinic wide Lexicomp/Drug Interaction software on all computers and handheldsRedesign Clinic Web PageMedication ChartsOffice Visit preparation/safety tips
19Create a Culture of Patient Safety AHRQ Patient Safety Culture SurveyOutpatient format available in PDF or WordResults display template on PowerPointInvolve entire clinic in patient safety culture surveyPatient focus groups to inform clinic about patient stakeholder perspectivesClinic leadership makes “Patient Safety Rounds”
21Overall Perceptions of Safety Sample culture Survey result slide:Overall Perceptions of SafetySurvey Items% Strongly Disagree/ % Neither % Strongly Agree/Disagree Agree1. Patient safety is never sacrificed to get morework done. (A15)2. Our procedures and systems are good atpreventing errors from happening. (A18)R3. It is just by chance that more seriousmistakes don’t happen around here. (A10)R4. We have patient safety problems in thisunit. (A17)R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.Page
22Quality Primary Care for the 21st Century Safe Patient CareConsistent Best PracticesGreat Patient Service
23Ambulatory Patient Safety Culture Create a Culture of SafetyCulture = the way we do things around hereCulture of Safety RequirementsVisualize a safe systemNon-punitive environmentLeadership supportQuality CarePatient Safety
24Ambulatory Patient Safety Capture errors that occurAnalyze errorsFollow-up on analysisSafety projects will emergeMedicationEMRCommunicationsTeam workTest resultsPt education about safetyQuality CarePatient Safety
25First Class Patient Safety will require everyone’s best efforts