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March 29, 2006 Project Overview, Recommendations and Reactor Panel.

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1 March 29, 2006 Project Overview, Recommendations and Reactor Panel

2 MH&SC Conference Slide 2 Introduction and SCPS Project Overview Tom Simmer, MD Chair, State Commission on Patient Safety Chief Medical Officer and Senior Vice President Blue Cross Blue Shield of Michigan

3 MH&SC Conference Slide 3 Review of Presentation Format 1.Project overview 2.Recommendations 3.Reactor panel Questions and answersQuestions and answers

4 MH&SC Conference Slide 4 State Commission on Patient Safety created by PA State Commission on Patient Safety created by PA –Passed 05/27/04 and repealed 11/27/05 Mission: To examine ways to improve patient safety and reduce medical errors in MichiganMission: To examine ways to improve patient safety and reduce medical errors in Michigan –Conduct at least two public hearings –Review patient safety initiatives, causes of harm –Issue written report with recommendations Creation and charge

5 MH&SC Conference Slide 5 Michigan Health and Safety CommissionMichigan Health and Safety Commission –Formed in 2000 to improve quality of care in Michigan –Broad array of stakeholders representing providers, payers and patients –Successful track record through collaboration In Fall 2004, MH&SC was designated to serve as the State Commission on Patient SafetyIn Fall 2004, MH&SC was designated to serve as the State Commission on Patient Safety Designation of MH&SC as Commission

6 MH&SC Conference Slide 6 Held three public hearings in November 2004 (Southfield, Lansing and Traverse City)Held three public hearings in November 2004 (Southfield, Lansing and Traverse City) –Sent 279 invitations and placed ads in local papers Received 77 oral and written testimoniesReceived 77 oral and written testimonies –353 individual recommendations –Diverse respondents, including consumers, providers, employers, educators, and others Consulted with two groups to help fulfill chargeConsulted with two groups to help fulfill charge –Analytic Team: Content experts –Review Panel: Subgroup of MH&SC and two experts Process: Commission

7 MH&SC Conference Slide 7 Structure Health-care Stakeholders and Public Meetings Health-care Stakeholders and Public Meetings Testimony from Public Hearings Testimony from Public Hearings Analytic Team Diane Valade, Chair Analytic Team Diane Valade, Chair Coded and Drafted Recommen- dations Coded and Drafted Recommen- dations Review Panel Beverley McDonald, Chair Review Panel Beverley McDonald, Chair Improved Recommendations Improved Recommendations State Commission on Patient Safety (MH&SC) Tom Simmer, MD, Chair State Commission on Patient Safety (MH&SC) Tom Simmer, MD, Chair Draft & Final Report Draft & Final Report

8 MH&SC Conference Slide 8 Process: Analytic Team Developed impartial, qualitative process to collect each submitter’s recommendations for creating a safer health care environmentDeveloped impartial, qualitative process to collect each submitter’s recommendations for creating a safer health care environment Organized individual bits of testimony into higher-level clustersOrganized individual bits of testimony into higher-level clusters Reviewed relevant research/literatureReviewed relevant research/literature Drafted recommendations for Review PanelDrafted recommendations for Review Panel

9 MH&SC Conference Slide 9 Reviewed each recommendation in combination with relevant testimony, research, and rationaleReviewed each recommendation in combination with relevant testimony, research, and rationale Considered feasibility and needs for legislation, funding, incentives, and additional researchConsidered feasibility and needs for legislation, funding, incentives, and additional research Further refined groupings and language to strengthen recommendationsFurther refined groupings and language to strengthen recommendations Process: Review Panel

10 MH&SC Conference Slide 10 Oversaw Analytic Team and Review PanelOversaw Analytic Team and Review Panel Held two public meetings to report progressHeld two public meetings to report progress –April and June 2005 Reached consensus regarding recommended objectives and action stepsReached consensus regarding recommended objectives and action steps Developed and submitted final reportDeveloped and submitted final report Agreed to promote recommendations to ensure that report doesn’t “gather dust”Agreed to promote recommendations to ensure that report doesn’t “gather dust” Process: Commission

11 MH&SC Conference Slide 11 Framework helped to:Framework helped to: –Present groups of recommendations for review –Identify areas missed by the testimony –Organize the final report Chose framework from Institute of Medicine’s early report, To Err is Human (1999)Chose framework from Institute of Medicine’s early report, To Err is Human (1999) –Develop leadership and knowledge –Identify and learn from errors –Implement safety systems in health care organizations –Set performance standards and expectations Framework

12 Model of Safe Care in Michigan Four outermost categories suggested by the IOM. In the next ring inward are objectives from the SCPS’s final report. At the center are patients and families surrounded by some of the stakeholders needed to achieve safer care.

13 MH&SC Conference Slide 13 Broad applicabilityBroad applicability –Intended to engage individuals and organizations across the entire continuum of care Role of patients and familiesRole of patients and families –No “to-do” list; instead, patient/family voice incorporated throughout to remind health professionals, organizations, and policymakers to make a permanent place for patients and families at the table Role of purchasers and payersRole of purchasers and payers –Urged to participate actively by providing financial and nonfinancial incentives, research grants, subsidies, rewards, and public recognition to support recommendations Understanding the report

14 MH&SC Conference Slide 14 It is critical that we all continue to transform the culture of health care toward safetyIt is critical that we all continue to transform the culture of health care toward safety –Acknowledge the complexity of health care interactions –Choose to learn, not blame, when the unexpected happens –Set competition aside when it comes to patient safety Commission report provides a detailed, workable plan to achieve long-term culture changeCommission report provides a detailed, workable plan to achieve long-term culture change Will only happen with engagement of individuals and organizations around the stateWill only happen with engagement of individuals and organizations around the state At the heart of change: culture

15 MH&SC Conference Slide 15 From Testimony to Recommendations Larry Wagenknecht, RPh Vice Chair, Michigan Health and Safety Coalition CEO, Michigan Pharmacists Association

16 MH&SC Conference Slide 16 From the testimony “Be bold and don’t hold back. All patients deserve a safe environment... The State of Michigan should be assuming a lead role in creating a safer environment for patients.” —Hospital

17 MH&SC Conference Slide 17 From the testimony “This state is in a unique position to help shape the national quality and safety agenda.” —Professional Organization

18 Model of Safe Care in Michigan Four outermost categories suggested by the IOM. In the next ring inward are objectives from the SCPS’s final report. At the center are patients and families surrounded by some of the stakeholders needed to achieve safer care.

19 MH&SC Conference Slide 19 Build a culture of safety From the Testimony “We need to promote an environment in which the first response is not to assign blame, censure, or sue, but to look at how and why an error occurred, and take steps to avoid it in the future.” —Provider Objective Continue to transform Michigan’s health care culture to one characterized by a commitment to safety, learning, collaboration, and systems thinking.Continue to transform Michigan’s health care culture to one characterized by a commitment to safety, learning, collaboration, and systems thinking. Reinforce a culture in which the state of Michigan, all clinical and administrative leaders who influence health care delivery, all persons involved in the caregiving process, and those who use health care services act consistently from a deep commitment to decreasing harm to patients.Reinforce a culture in which the state of Michigan, all clinical and administrative leaders who influence health care delivery, all persons involved in the caregiving process, and those who use health care services act consistently from a deep commitment to decreasing harm to patients.

20 MH&SC Conference Slide 20 StateState –Provide strong leadership for statewide change to improve patient safety across the continuum of care. Health care providersHealth care providers –Assess culture periodically to gauge progress and identify needed changes. AllAll –Recognize that patients are the cornerstone of the health care system. –Build environments that support understanding what happened and why when medical errors and near misses occur, rather than assigning blame or finding fault. Sample action steps

21 MH&SC Conference Slide 21 Establish a statewide patient safety center Objective Establish and fund the Michigan Center for Safe Health Care as a statewide center for leadership, information, and advocacy to reduce patient harm across a range of health care settings.Establish and fund the Michigan Center for Safe Health Care as a statewide center for leadership, information, and advocacy to reduce patient harm across a range of health care settings. From the Testimony “So each institution doesn’t have to reinvent the wheel, I think it’s important to develop a means where institutions can share their solutions, share best practices…” —Hospital “… consider a … state Center for Patient Safety to look out for the health and safety of Michigan residents.” —Professional Association

22 MH&SC Conference Slide 22 To achieve its objectives, the Center should:To achieve its objectives, the Center should: –Be a 501(c)(3) non-profit –Represent a broad array of stakeholders and provide a balanced, unbiased, nonpunitive environment –Not be a governmental body and be independent of any individual health care provider or professional organization Primary function: to coordinate implementation of the Commission’s recommendations across the statePrimary function: to coordinate implementation of the Commission’s recommendations across the state –Cultivate collaboration –Promote active involvement of patients/families –Collect and disseminate information and tools –Monitor improvement and promote progress –Shape relevant public policy Model act provides specifics

23 MH&SC Conference Slide 23 Collect and use data about errors and near misses Objective Establish and fund a statewide voluntary, confidential, peer ‑ protected, nonpunitive error reporting system.Establish and fund a statewide voluntary, confidential, peer ‑ protected, nonpunitive error reporting system. Ensure that important findings are disseminated regularly to improve health care safety.Ensure that important findings are disseminated regularly to improve health care safety. Complement, to the extent possible, emerging national data definitions and measurement criteria.Complement, to the extent possible, emerging national data definitions and measurement criteria. From the Testimony “State leadership is needed to create an environment where clinicians can learn from mistakes. …Creating a learning environment in which it is expected that mistakes and close calls are shared goes a long way toward creating a culture where safety is a priority.” —Professional Organization

24 MH&SC Conference Slide 24 StateState –Provide sufficient, reliable, ongoing funding for the reporting system from a combination of public and private sources as part of the funding package for the Michigan Center for Safe Health Care. CenterCenter –Design system; collect reports of adverse events and near misses; return useful information to participants. Health care providersHealth care providers –Participate in system design; submit data; take action based on findings. Sample action steps

25 MH&SC Conference Slide 25 Protect patient safety data and sources Objective Protect patient safety data and reporting activities under statute without denying patients and families access to information through normal channels when medical errors or unexpected events occur.Protect patient safety data and reporting activities under statute without denying patients and families access to information through normal channels when medical errors or unexpected events occur. From the Testimony “The fear of litigation is a limiting factor in the ability to aggregate and identify issues that have or could cause patient harm. If we (patient safety leaders) can timely identify errors and near misses, we can prevent their recurrence…” —Insurer

26 MH&SC Conference Slide 26 StateState –Align protection strategies with emerging federal legislation and rules. –Provide additional protection, if necessary, to support statewide patient safety improvement. –Advocate at the federal level for an evaluation of the effectiveness of the new law. If a federal evaluation is not planned, conduct a state-level assessment to ensure that goals are being met. Sample action steps

27 MH&SC Conference Slide 27 Measure and reward performance Objective Establish or adopt standards for patient safety performance across the continuum of careEstablish or adopt standards for patient safety performance across the continuum of care Develop or adopt a common vocabulary and standardized data definitionsDevelop or adopt a common vocabulary and standardized data definitions Set dynamic benchmarks to measure progressSet dynamic benchmarks to measure progress Use the measured performance of Michigan’s health care providers to inform ongoing improvement effortsUse the measured performance of Michigan’s health care providers to inform ongoing improvement efforts Reward excellence.Reward excellence. From the Testimony “Measuring harm is challenging and the science of how to do it needs to advance.” —Professional Association “A statewide emphasis on key goals would help focus organizations on the few key performance indicators versus a broad and changing lists resembling the ‘flavor of the month.’” —Other Industry

28 MH&SC Conference Slide 28 CenterCenter –Convene and lead a group of stakeholders to develop or adopt common vocabulary and recommend statewide standards –Collect and aggregate provider data for learning Health care providersHealth care providers –Participate in measure development –Collect and submit data to gauge progress –Use results to prompt further improvement Sample action steps

29 MH&SC Conference Slide 29 Address workforce shortages effectively Objective Address health care workforce shortages without compromising patient safety while improving practice environments and the availability of qualified health professionals.Address health care workforce shortages without compromising patient safety while improving practice environments and the availability of qualified health professionals. From the Testimony “[Advocates for long-term care residents] are keenly aware of the effect of inadequate staffing on their loved ones in nursing homes...” —Consumer “An area of concern for the medical community as a whole continues to be workforce retention.” —Professional Organization

30 MH&SC Conference Slide 30 StateState –Implement recommendations from the Health Care Workforce Development in Michigan Advisory Roundtable. Health care providersHealth care providers –Match the quantity and qualifications of staff on duty to patient needs. –Acknowledge human limitations and the serious potential for harm caused by fatigue-related performance and an aging workforce. –Use national consensus standards and measures to monitor and evaluate the effectiveness of staffing practices. Sample action steps

31 MH&SC Conference Slide 31 Design facilities and processes for safety Objective Adapt tools and methods from human factors engineering, facility design, and industries with demonstrated error prevention records to improve patient safety in health care.Adapt tools and methods from human factors engineering, facility design, and industries with demonstrated error prevention records to improve patient safety in health care. Prevent or correct system defects in ways that respond to patient and staff needs rather than training staff or teaching patients to accommodate poor system design.Prevent or correct system defects in ways that respond to patient and staff needs rather than training staff or teaching patients to accommodate poor system design. From the Testimony “Humans are humans, distractions are distractions and a miscommunication will result in an error no matter where you are. Therefore, the lessons learned about reducing errors in…other industries can be applied directly to health-care programs to immediately benefit both health-care professionals and patients today.” —Other Industry

32 MH&SC Conference Slide 32 Safer designSafer design –Tubing connectors that can only be used for one purpose –Surgical trays that change color when they are sterile Safer processesSafer processes –Providing a quiet, well-lit space for medication preparation –Verifying patient identification before blood draws and labs –Asking patients to mark surgical sites –Asking patients to confirm the name, purpose and instructions for each medication they receive at a pharmacy Examples of …

33 MH&SC Conference Slide 33 StateState –Require healthcare failure modes and effects analysis (HFMEA) or equivalent with all new Certificate of Need applications. CenterCenter –Promote existing tools (HFMEA, root cause analysis, usability testing) and low-cost or no-cost approaches to work design and redesign. Health care providersHealth care providers –Consider environmental factors—noise, light, distances, fatigue and limits to human memory—when designing or redesigning physical plants and care processes. –Borrow strategies and tools from other industries, such as forcing functions, bar codes, and simulators for learning. Sample action steps

34 MH&SC Conference Slide 34 Improve communication of critical information Objective Promote improved use of communication and technology to ensure that information critical to patient safety (e.g., health history, medication history, and critical lab values) is available to patients and health care providers within and across organizational boundaries.Promote improved use of communication and technology to ensure that information critical to patient safety (e.g., health history, medication history, and critical lab values) is available to patients and health care providers within and across organizational boundaries. From the Testimony “IT infrastructure, including an electronic medical record, is part of [improving communication] because it is not a tool to just help us link better, but a tool that has to be coupled with culture change and our ability to work together as human beings.” —Professional Organization

35 MH&SC Conference Slide 35 StateState –Continue collaboration among Michigan Department of Community Health, Michigan Department of Information Technology, and private sector stakeholders. CenterCenter –Work to ensure that Michigan’s interests, perspectives and concerns regarding health care IT are represented as national IT standards are developed. Health care providersHealth care providers –Until compatible IT systems are developed, use available technology (e.g., copy and fax machines) to ensure that critical information travels with the patient. Sample action steps

36 MH&SC Conference Slide 36 Involve patients as active health care partners Objective Empower consumers/patients/clients/ residents and their families/caregivers/ advocates to better assume their roles as partners in the health care encounter.Empower consumers/patients/clients/ residents and their families/caregivers/ advocates to better assume their roles as partners in the health care encounter. Promote open and clear communication between patients/families and health professionals about health issues, treatments, patient safety concerns, and adverse events.Promote open and clear communication between patients/families and health professionals about health issues, treatments, patient safety concerns, and adverse events. Embed the consumer/patient voice in the structure and process of designing safe care.Embed the consumer/patient voice in the structure and process of designing safe care. From the Testimony “…respect for patients, families, nurses and all health-care workers must be so fundamental that jobs and hospital privileges are at risk if standards are not met.” —Educator “Families need to be involved at every step of the way.” —Consumer

37 MH&SC Conference Slide 37 StateState –Include consumer/patient/family representatives in the membership of state-level bodies and organizations. CenterCenter –Establish an ongoing statewide awareness and education campaign. Coordinate with programs targeting clinicians. Health care providersHealth care providers –Support the patient/family role in error prevention by encouraging patients to communicate openly with health professionals and staff, and by providing tools and opportunities for patients to comment on safety issues. Sample action steps

38 MH&SC Conference Slide 38 Embrace safety in health professions education Objective Weave the teaching and demonstration of patient safety principles, knowledge and skills into health professions education and continuing education requirements.Weave the teaching and demonstration of patient safety principles, knowledge and skills into health professions education and continuing education requirements. From the Testimony “Health care safety is in itself a discipline and has not as yet been widely incorporated into educational programs.” —Provider “The state should serve as the forum to align the various professional societies and organizations to promote standardization across education and training curriculums.” —Provider

39 MH&SC Conference Slide 39 StateState –Promote through the professional licensing process the acquisition of knowledge and skills of patient safety Educators of health professionalsEducators of health professionals –Train health professionals to understand patient safety from a systems perspective; identify the potential for errors and hazards; and design improvements. Professional societies and organizationsProfessional societies and organizations –Promote standardization across education and training curricula for all health care settings so health professionals learn similarly about the types of processes and systems that impede safety and might lead to harm. Sample action steps

40 MH&SC Conference Slide 40 Emphasize collaboration among organizations Objective Expedite the translation of patient safety-related evidence into practice, accelerate the spread of successful programs and processes for improving patient safety, and promote creative problem solving for patient safety challenges through cross-organization collaboration.Expedite the translation of patient safety-related evidence into practice, accelerate the spread of successful programs and processes for improving patient safety, and promote creative problem solving for patient safety challenges through cross-organization collaboration. From the Testimony “Continued efforts to help health-care organizations to engage with each other will lessen the steep learning curve and the ability to build on each other’s experiences.” —Hospital “Effective multi-disciplinary team functioning and communication are critical.” —Provider

41 MH&SC Conference Slide 41 CenterCenter –Foster cross ‑ organization collaborative efforts designed to develop creative solutions to patient safety challenges by leveraging Michigan’s considerable knowledge, skills and resources. Health care providersHealth care providers –Support and participate in cross-organization collaborative learning and problem solving. –Build in timely evaluation of collaborative interventions. Look both at collaborative processes and structures, and at the achievement of desired outcomes. Sample action steps

42 MH&SC Conference Slide 42 Support teamwork within organizations Objective Improve teamwork across disciplines by providing training and support for cross- disciplinary teams.Improve teamwork across disciplines by providing training and support for cross- disciplinary teams. From the Testimony “Effective multi-disciplinary team functioning and communication are critical.” —Provider

43 MH&SC Conference Slide 43 CenterCenter –Serve as a clearinghouse to identify and disseminate “best practices” for building teams to improve patient safety. Health care providersHealth care providers –Provide support necessary for teams to fulfill their charge. –Recruit team members with a broad mix of skills and knowledge. Include patients/families when appropriate. –Pay particular attention to social dynamics that can inhibit communication Educators of health professionalsEducators of health professionals –Include cross ‑ disciplinary teamwork skill development. Sample action steps

44 MH&SC Conference Slide 44 Regulate and license with safety in mind Objective Explore use of the state’s licensing and regulation functions to improve the culture and processes of safety among health professionals and organizations.Explore use of the state’s licensing and regulation functions to improve the culture and processes of safety among health professionals and organizations. From the Testimony “The licensing boards in Michigan should be given the flexibility to use non- disciplinary approaches to deal with practitioners involved in medication errors” “The licensing boards in Michigan should be given the flexibility to use non- disciplinary approaches to deal with practitioners involved in medication errors ”—Educator

45 MH&SC Conference Slide 45 StateState –Review the structure and functions of Michigan’s health professions licensing boards to strengthen their ability to address patient safety issues. –Educate licensing board members about the science of safety so they can identify system-related errors and communicate such findings to applicable health care organizations and professional associations. –Evaluate the state’s health care facility licensing/regulatory requirements to promote specific desired behaviors among health care organizations. Sample action steps

46 Model of Safe Care in Michigan Four outermost categories suggested by the IOM. In the next ring inward are objectives from the SCPS’s final report. At the center are patients and families surrounded by some of the stakeholders needed to achieve safer care.

47 MH&SC Conference Slide 47 Create the Michigan Center for Safe Health CareCreate the Michigan Center for Safe Health Care –Provide a needed focal point with this freestanding, non- profit center representing diverse health care stakeholders Establish a statewide voluntary, confidential, nonpunitive health care error reporting systemEstablish a statewide voluntary, confidential, nonpunitive health care error reporting system –Keep focus on prevention; share lessons learned to guide prevention efforts –Protect data from unintended uses without denying patients and families access to information through normal channels Both require action from Legislature and GovernorBoth require action from Legislature and Governor Most ambitious recommendations

48 MH&SC Conference Slide 48 Patient safety standards are established across the continuum of carePatient safety standards are established across the continuum of care Patients and family members are engaged as active, valued members of the health care teamPatients and family members are engaged as active, valued members of the health care team Critical information travels with each patient through the systemCritical information travels with each patient through the system The quantity/qualifications of staff are matched with patient needThe quantity/qualifications of staff are matched with patient need Factors such as light, noise, and fatigue are taken into consideration when facilities and processes are being designedFactors such as light, noise, and fatigue are taken into consideration when facilities and processes are being designed Effective cross-disciplinary teams and cross-organization collaborations flourishEffective cross-disciplinary teams and cross-organization collaborations flourish Patient safety principles, knowledge and skills are woven into health professions education programsPatient safety principles, knowledge and skills are woven into health professions education programs The state’s licensing/regulation function is used to improve safetyThe state’s licensing/regulation function is used to improve safety Today, we can all work to make sure…

49 MH&SC Conference Slide 49 Gather support for Model Act to establish Michigan Center for Safe Health CareGather support for Model Act to establish Michigan Center for Safe Health Care Promote recommendations that can be addressed immediatelyPromote recommendations that can be addressed immediately It’s all of our responsibility to ensure that the concepts don’t sit idleIt’s all of our responsibility to ensure that the concepts don’t sit idle Moving forward

50 MH&SC Conference Slide 50 Reactor Panel Jan Christensen, Michigan Department of Community Health Beverley McDonald, Michigan Consumer Health Care Coalition Greg Forzley, MD, Michigan State Medical Society John Saalwaechter, MD, Michigan Association of Health Plans Margaret Freundl, RN, Michigan Nurses Association Marsha Manning, RN, General Motors Corporation

51 MH&SC Conference Slide 51 Q&A Tom Simmer, MD Chair, State Commission on Patient Safety Chief Medical Officer and Senior Vice President, Blue Cross Blue Shield of Michigan

52 MH&SC Conference Slide 52 The State Commission on Patient Safety Report can be found at: The State Commission on Patient Safety Report can be found at:

53 MH&SC Conference Slide 53 Appendices

54 MH&SC Conference Slide 54 Appendix A

55 MH&SC Conference Slide 55 Appendix B


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