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Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a This material (Comp12_Unit8a) was developed by Johns Hopkins University, funded.

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Presentation on theme: "Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a This material (Comp12_Unit8a) was developed by Johns Hopkins University, funded."— Presentation transcript:

1 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a This material (Comp12_Unit8a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

2 HIT and Infecting a Patient Safety Culture Learning Objective ─ Lecture a Apply QI tools to the analysis of HIT errors. 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

3 Dr. Peter Pronovost 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

4 Dr. Peter Pronovost 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

5 Key Topics 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

6 Apollo Mission 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

7 Apollo Mission 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

8 HIT 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

9 National Health Care Quality 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

10 BSI Checklist Wash your hands. Clean your skin with Chlorhexidine. Avoid placing catheters in the groin. Use full barrier precautions. Ask every day if you still need the catheter. 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

11 Science of Safety Standardize Care 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

12 Science of Safety Independent Checks 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

13 Science of Safety 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

14 At Hopkins 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

15 Science of Safety Learn from Every Defect 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

16 Checklist 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

17 Rates 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

18 The BSI Story 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

19 Michigan 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

20 The Model 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

21 Toyota 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

22 HIT and Infecting a Patient Safety Culture Summary ─ Lecture a Despite massive efforts, quality & safety have not significantly improved. It takes teamwork and cooperation. National efforts to improve central line BSI rates have been hugely successful. Standardization, independent checks, and learning from every defect are keys to success. 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

23 HIT Infecting a Patient Safety Culture References ─ Lecture a References ABC News. Toyota CEO Apologizes to His Customers: 'I Am Deeply Sorry.’ Brian Ross. Available from: http://abcnews.go.com/Blotter/toyota-ceo-apologizes-deeply/story?id=9700622#.Tt0C9tVArCY Pronovost, P. (October, 2010). Speech presented at the Legg Mason Capital Management Thought Leader Forum. Quality Matters. A Conversation with Peter Pronovost About Patient Safety Available from: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2010/April-May-2010/Q--A.aspx http://www.commonwealthfund.org/Newsletters/Quality-Matters/2010/April-May-2010/Q--A.aspx Images Slide 3: Dr. Peter Pronovost Listens to a Patient’s Heart. The photo was taken during filming for Program One - "Silent Killer" at Johns Hopkins University's Hospital and Children's Center for the RAM Campaign. Available from: http://www.ramcampaign.org/pages/campaign_photos.htm http://www.ramcampaign.org/pages/campaign_photos.htm Slide 4: Dr. Peter Pronovost. The photo was taken during filming for Program One - "Silent Killer" at Johns Hopkins University's Hospital and Children's Center for the RAM Campaign. Available from: http://www.ramcampaign.org/pages/campaign_photos.htm http://www.ramcampaign.org/pages/campaign_photos.htm Slide 5: Key Topics. Courtesy Dr. Anna Maria Izquierdo-Porrera Slide 6: Earthrise Over the Lunar horizon.(NASA photo ID AS11-44-6552). Available from: http://nssdc.gsfc.nasa.gov/planetary/lunar/apollo11.html http://nssdc.gsfc.nasa.gov/planetary/lunar/apollo11.html Slide 7: Planet Earth from the Moon. (NASA photo ID AS11-36-5355). Available from: http://nssdc.gsfc.nasa.gov/planetary/lunar/apollo11.html http://nssdc.gsfc.nasa.gov/planetary/lunar/apollo11.html Slide 8: A Collage of Association Logos for Agencies Involved in HIT. Image Sources: AHRQ. http://www.ahrq.gov/; Parent Safety. http://www.patientsafety.gov/ World Health Organization; www.who.int; Joint Commission. http://www.jointcommission.org/;Institute for Safe Medication Practice. http://www.ismp.org;Patient Safety. http://www.patientsafety.org; Nursing World. http://www.nursingworld.org; ECRI. https://www.ecri.org;http://www.ahrq.gov/http://www.patientsafety.gov/ www.who.int http://www.jointcommission.org/http://www.ismp.org http://www.patientsafety.orghttp://www.nursingworld.orghttps://www.ecri.org AMA. http://www.ama-assn.org/http://www.ama-assn.org/ 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

24 HIT Infecting a Patient Safety Culture References ─ Lecture a Images Slide 9: National Healthcare Disparities Reports and National Healthcare Quality Report. Available from: http://www.ahrq.gov/qual/qrdr09.htm http://www.ahrq.gov/qual/qrdr09.htm Slide 11: A Clinician Prepares a Syringe While a Patient Looks On. American Health Information Management Association (AHIMA). Available from: http://informaticsnursing.net/?page_id=119http://informaticsnursing.net/?page_id=119 Slide 12: Automotive Seatbelt. Wikimedia Commons Gerdbrendel. Available from: http://en.wikipedia.org/wiki/User:Gerdbrendel http://en.wikipedia.org/wiki/User:Gerdbrendel Slide 13: David H. Berger, M.D.,Houston VA. Available from: http://www.houston.va.gov/pressreleases/news_20050207.asp http://www.houston.va.gov/pressreleases/news_20050207.asp Slide 14: Nurse. CDC. Available from: http://www.cdc.gov/ncbddd/fasd/training.htmlhttp://www.cdc.gov/ncbddd/fasd/training.html Slide 15: Surgery Dept. of Defense. Available from: http://www.defense.gov/photos/newsphoto.aspx?newsphotoid=6052 http://www.defense.gov/photos/newsphoto.aspx?newsphotoid=6052 Slide 16: Blood Infection Checklist at Johns Hopkins. Available from: http://www.hopkinsmedicine.orghttp://www.hopkinsmedicine.org Slide 17: Swan-Ganz- Heparin Coated Catheter. FDA. Available from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/newsletter.cfm?news=48 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/news/newsletter.cfm?news=48 Slide 18: Safety Score Card. The BSI Report Card – Dr. Peter Pronovost. Available from: http://www.mhaonline.org/File%20Library/Quality/CLABSI/1-Leading-Change-Who-Are-We-Where-Are-We- Going.pdf Slide 19: Overview of STOP-BSI Program. Peter Pronovost, MD, PhD Available from: http://www.mhaonline.org/File%20Library/Quality/CLABSI/1-Leading-Change-Who-Are-We-Where-Are-We- Going.pdf http://www.mhaonline.org/File%20Library/Quality/CLABSI/1-Leading-Change-Who-Are-We-Where-Are-We- Going.pdf Slide 20: The Model. Available from: http://www.hopkinsmedicine.orghttp://www.hopkinsmedicine.org Slide 21: Dr. Peter Pronovost. Available from: http://www.ramcampaign.org/pages/images/Dr_Pronovost_large.jpghttp://www.ramcampaign.org/pages/images/Dr_Pronovost_large.jpg 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement HIT and Infecting a Patient Safety Culture Lecture a

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