1. Risk Management / CQI Nutr 564: Management Summer 2005

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3. Objectives: Review issues on patient safety Identify components of quality assurance processes Describe a ‘culture of safety’ Characterize ‘risk’ situations in health care

4. TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM Health care in the United States is not as safe as it should be--and can be At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies I N S T I T U T E O F M E D I C I N E Shaping the Future for Health November 1999

5. Patient Safety 2005 proposed budget for patient safety is $84 million. The Centers for Medicare & Medicaid Services (CMS) has made it clear that patient safety is indistinguishable from quality of care.

6. Risk Management / CQI What are Medical Errors? Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place Where do they happen: Medical errors can occur anywhere in the health care system: Hospitals Clinics Outpatient Surgery CentersDoctors' Offices Nursing Homes Pharmacies Patients' Homes http://www ahrq gov/consumer/20tips htm

8. Concept Discussion What is an SOC? Review the table on P. 5 of the “Docs Need SOCs”. Can you add any additional activities where a health center’s quality counts? What type of teams might best support the quality improvement process outlined in this document?

9. Risk Management / CQI Quality Assurance is a dynamic, systematic process that assures the delivery of high-quality care to clients

10. Risk Management / CQI QA Process Identify or define the problem Establish a method to evaluate the problem Set a timeline for data collection Collect the data Analyze the results Discuss the findings and make conclusions Suggest alternatives to rectify the problem Try a solution – evaluate Develop a system to monitor the success Implement a system to reevaluate the plan with set time criteria

11. Risk Management / CQI Clinical Indicators Clinical Indicators: Measurement tool used to monitor and evaluate quality Process indictor Outcome indicator Rate-based indicator

12. Risk Management / CQI Process Indicator - measures an activity Easy to Measure May not directly impact safety Process Indicators - Examples Volume Indicators / Service Trends Screening Patient Satisfaction

13. Risk Management / CQI Outcome Indicator Measures what happens after an activity Outcome Indicator Examples: Weight loss Infection Infection

14. Risk Management / CQI Rate-based indicator: Assesses an event for which a certain proportion of the events that occur are expected Rate-based indicator: Example: Proportion of patients NPO 24 hours after surgery Example: Proportion of patients NPO 24 hours after surgery

15. Prevention Quality Indicators: The PQIs are a set of measures that can be used with hospital inpatient discharge data to identify "ambulatory care sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease.

16. Prevention Quality Indicators: Diabetes short-term complication AR Perforated appendix AR Diabetes long-term complication ARPediatric asthma AR Chronic obstructive pulmonary disease Pediatric gastroenteritis Low birth weight rateHypertension AR Congestive heart failure ARDehydration AR Bacterial pneumonia ARUrinary tract infection AR Angina admission without procedureUncontrolled diabetes AR Adult asthma AR Rate of lower-extremity amputation among patients with diabetes AR = admission rate Prevention Quality Indicators: developed by Stanford University under a contract with the (AHRQ)

17. In-Patient Quality Indicators Complications of AnesthesiaDeath in Low-Mortality DRGs Decubitus UlcerFailure to Rescue Foreign Body Left During ProcedureIatrogenic Pneumothorax Selected Infections due to Medical CarePostoperative Hip Fracture Postoperative Respiratory FailureBirth Trauma – Injury to Neonate Postoperative SepsisPostoperative Wound Dehiscence Accidental Puncture or LacerationTransfusion Reaction Postoperative Physiologic and Metabolic Derangements Postoperative Pulmonary Embolism or Deep Vein Thrombosis Postoperative Hemorrhage or Hematoma Obstetric Trauma with or without 3 rd Degree Lacerations– Vaginal with Instrument; Vaginal without Instrument; Cesarean Delivery Instrument; Vaginal without Instrument; Cesarean Delivery

18. Risk Management / CQI Elements of successful CQI projects Team effort in design Employee involvement at all levels Quality is part of job description Safety in participation Continuous effort

19. Culture of Safety Ideal People would report error System would assess error System would assess error Take corrective action Take corrective action Monitor for additional sources of error Monitor for additional sources of error without fear of punishment Liang BA, MD, PhD, JD

20. Concept Discussion: Review the questionnaire “Hospital Survey on Patient Safety Culture”. What is your reaction to this questionnaire? How do you envision using such a questionnaire in a facility? Does the document ‘Docs Need SOCs” convey a culture of safety?

21. Culture of Safety A safety culture can be defined as: a set of values, beliefs, and norms about – what's important, – how to behave, and – what attitudes are appropriate when it comes to patient safety in a workgroup. The safety culture is the product of – individual and group values, – attitudes, – perceptions, – competencies, and – patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management.

22. Culture of Safety A safety culture A positive safety culture is characterized by – communications founded on mutual trust, – by shared perceptions of the importance of safety, and – by confidence in the efficacy of preventive measures.

23. Culture of Safety The ten dimensions of patient safety culture 1. Supervisor/manager expectations and actions promoting patient safety 2. Organizational learning—Continuous improvement 3. Teamwork within units 4. Communication openness 5. Feedback and communication about error 6. Nonpunitive response to error (no shame and blame) 7. Staffing 8. Hospital management support for patient safety 9. Teamwork across hospital units 10. Hospital handoffs and transitions

24. Culture of Safety Dr. David Hunt (CMS) 1. Intent: An organization must intentionally look for adverse events and the systems that may need attention. The intention is for improvement of systems, not malpractice avoidance. 2. Relevance: “What” is being looked at is important. There are several relevant topics from which to choose. 3. Transparency: If the problem is hidden under shame and blame, it will not be transparent; only by bringing it out in the sunlight can problems be addressed.

25. Concept Discussion: Does the document ‘Docs Need SOCs” convey a culture of safety?

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27. Risk Management Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself

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29. Concept Discussion: Seattle Times article Picture this same scenario 20 years ago. Describe what you envision would be a traditional management approach to such an event? Do you agree with the approach described in this article? What factors might influence a family’s decision to take legal action?

30. Concept Discussion: Other safety issues in a health care facility. What are high risk areas in food service? How can a culture of a safety be applied to staff training

31. Risk Management / CQI Clinical Nutrition and Food Service Systems High risk areas *

32. Risk Management / CQI Clinical Nutrition and Food Service Systems

33. Risk Management / CQI Clinical Nutrition and Food Service Systems

34. Risk Management / CQI Clinical Nutrition and Food Service Systems High risk areas * Equipment - knives / blades * Wet floors * Cleaning solutions * High turnover in personnel