Patient Safety It’s the Way WeCare Buffy Key Sr. Vice President, Quality and Operations Cookeville Regional Medical Center Cookeville, Tennessee

Building Healthier Communities Exceptional Care to Every Patient Every Day Building Healthier Communities 247 bed regional referral center Located in Cookeville, Tennessee Serves 14 county region of over 350,000 residents in upper Cumberland Region of Middle Tennessee 60% Medicare population

Exceptional Care to Every Patient Every Day 52,503 1,504 12,893 Emergency Room Visits Newborn Deliveries Inpatient Admissions 162,392 8,049 3,954 Outpatient Visits Surgeries Heart Procedures 195 2,214 169 Physicians Employees Volunteers

Isn’t Healthcare Safe? Exceptional Care to Every Patient Every Day IOM Report – 1999 “up to 98,000 people a year die because of medical mistakes in hospitals” “To Err is Human” report - IOM IOM Report – 1999 “up to 98,000 people a year die because of medical mistakes in hospitals” “To Err is Human” report - IOM Medical Errors - 2017 “10% of all U.S. deaths are now due to medical error” “3rd highest cause of death in the U.S. is medical error” “Medical errors are an under-recognized cause of death” John Hopkins Study, 05/3/16 “Unwarranted variation is endemic in health care. Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in health care. Research on preventing medical errors from occurring is needed to address the problem.” Martin Makary, MD, MPH, - Professor Surgery at Johns Hopkins University School of Medicine, authority on health reform

Exceptional Care to Every Patient Every Day AIM FOR ZERO Our Safety Imperative GOAL Build Systems to prevent variation and errors for patients HOW? LEAN Thinking Principles Root Cause Problem Solving Preventing Errors and Harm

ü ü ü Leaning Thinking Principles Exceptional Care to Every Patient Every Day Leaning Thinking Principles ü ü ü Waste, quality, and safety Value Pursue IDEAL state Principle Examples Have the courage to identify the wasted steps (DOWNTIME) that may need to be eliminated in a process to achieve the best quality/ safety outcome Valuable vs Non-valuable steps To achieve IDEAL, what should the process look like? Dept. Role Value Add Non-Value OR Surgeon Operating on a patient Waiting for procedure to start Inpatient Unit Nurse Administration of Meds Copying information from one computer system to another

Cultural Obstacles Exceptional Care to Every Patient Every Day • shift from ‘naming, blaming, and shaming’ to learning from errors, using knowledge gained to prevent future errors • perceptions about medical errors; providers may view as ‘individual issue rather than a ‘system issue’ • leadership may even publicly criticize their own organizations saying is there is ‘no excuse’ for such errors Violations and Errors, Lapses, and Slips • violations (intentional and avoidable) 27.6% of all adverse events • errors (lapses – mental errors) slips – physical errors

Root Cause/ Event Analysis Problem Solving Exceptional Care to Every Patient Every Day Root Cause/ Event Analysis Problem Solving Ask Why Instead of Who Finding Root Cause by using 5 Why’s Three Most Common Problems - In Problem Solving Assuming you know what the problem is without actually see what is happening Assuming you know how to fix a problem without finding out what is causing it Assuming the action you have taken to fix a problem is working without checking to see if it is actually doing what is expected

Preventing Errors and Harm Exceptional Care to Every Patient Every Day Preventing Errors and Harm The Science of Improvement Moving beyond Blaming Individuals Darrie Eason Case Create Quality at the Source via Error Proofing Make it Harder to Create the Error Make it Impossible to Create the Error SIGNS may not work! Saying “be careful” may not either! EXAMPLES OF ERROR PROOFING: Banned Abbreviations CPOE for handwriting error Pre-surgical verification, marking the site, time-out process Stopping the Line

Conclusion SUGGESTED FACTS: Exceptional Care to Every Patient Every Day Conclusion SUGGESTED FACTS: ü Hospitals are full of… ü Be careful… ü Always asking… Smart, conscientious employees yet errors and patient harm still occur. If telling people to ‘be careful’ were effective, we would have already eliminated quality and patient safety problems! Error proofing is a mindset that we have to adopt – always asking why the error occurred.

Community Impact Exceptional Care to Every Patient Every Day Impact the welfare of the Community Build a healthier community Provide exceptional care to every patient every day