Presentation is loading. Please wait.

Presentation is loading. Please wait.

Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital.

Similar presentations


Presentation on theme: "Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital."— Presentation transcript:

1 Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital

2

3 Your patients deserve it Insurance payers demand it

4  CMS monitors and reports outcome  Patients have access to National Database  APSF provides advisories regarding equipment, techniques and drugs.  Most important: Focus on safety because you owe it to your patients ◦ Eliminate “never”events ◦ Reduce high frequency risks.  CLABSI  VAP Protect your Reputation and Reimbursement

5  A foreign object is retained within a patient´s body after surgery.  The development of an air embolism within a patient´s body.  A patient blood transfusion with incompatible blood.  A patient´s development of stage III or stage IV pressure ulcers.  Patient injuries resulting from accidental falls and other trauma

6  A patient has of poor glycemic control  A patient develops a catheter-associated urinary tract infection.  A patient develops a vascular catheter-associated infection.  A patient develops a surgical site infection following: ◦ A coronary artery bypass graft - mediastinitis; ◦ Bariatric surgery, ◦ Orthopedic procedures, including, but not limited to, such procedures performed on the spine, neck, shoulder and elbow.  A patient develops deep vein thrombosis

7  Increased Patient Satisfaction  Staff engagement  Collaborative teambuilding across lines  Lean Sigma work flow gains  Financial rewards

8

9 Continuous Unit Based Safety Program

10  Improve safety culture and learn from mistakes  Can be implemented throughout organization  Values the wisdom of front line staff  Linked with improvement in clinical outcomes  Empowers staff to be actively involved  Reduces barriers between staff and senior leadership. Armstrong Institute for Patient Safety

11  Build a CUSP ◦ Must include ALL stakeholders ◦ All CUSP members have an equal say ◦ Engage Hospital leadership ◦ Seek type 2 solutions ◦ Make a long term commitment Armstrong Institute for Patient Safety

12  Assemble a CUSP Team  Assess your Safety Culture  Learn/Teach the Science of Safety  Identify Defects  Form Executive Partnerships  Learn from Defects  Develop Tools for Improvement Armstrong Institute for Patient Safety

13  Transdisciplinary and collaborative  Team Leader  Surgeon Champion  Anesthesia Champion  Nursing Champion  Executive Champion  Frontline staff (PACU, ICU, OR, Surgical floors Armstrong Institute for Patient Safety

14  Formal Survey (AHRQ) ◦ HSOPS – Hospital survey of patient safety  NPSF has excellent PDF download  content/uploads/2011/10/PLS_1102_SS.pdf content/uploads/2011/10/PLS_1102_SS.pdf ◦ Local Survey  How will our next patient be injured?  What can we do to prevent it?

15  The Health foundation, November 2011  As Safety Culture increased; ◦ Readmission rates decreased ◦ Length of ICU stay decreased ◦ Complications decreased ◦ Medication errors decreased ◦ Adverse events decreased ◦ Patient satisfaction increased

16  Every system is perfectly designed to achieve the results it gets  Understand the principles of safe design ◦ Standardize, checklists, learn from mistakes  Recognize that principles apply to technical and team work  Teams make wise decisions when there is diverse and independent input Armstrong Institute for Patient Safety

17  How will the next patient be injured?  What can be done to prevent this harm? ◦ Surgical site infection? ◦ Production pressure? ◦ Communication?  Prioritize your effort ◦ Severity of harm ◦ Frequency of harm

18  Executive member is essential ◦ Stimulates discussion ◦ Helps prioritize efforts ◦ Can lobby C-Level for policy change ◦ Access to resources ◦ Helps resolve inter-department issues ◦ Must be committed and available for safety rounds

19  What Happened?  Why did it happen?  What did you do to reduce the risk?  How do you know the risk was reduced?

20  Executive member is essential ◦ Stimulates discussion ◦ Helps prioritize efforts ◦ Can lobby C-Level for policy change ◦ Access to resources ◦ Helps resolve inter-department issues ◦ Must be committed and available for safety rounds

21  CUSP for Safe Surgery website ◦ Technical tools  Briefing/Debriefing tools  Checklists ◦ Adaptive Tools  Perioperative daily huddle  Shadowing other professionals.

22 CUSP is an ongoing process, and is never truly finished. Armstrong Institute for Patient Safety

23 So…How will your next patient be harmed? What will you do to prevent it?


Download ppt "Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital."

Similar presentations


Ads by Google