1 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD XX 2 © 2010 TMIT Slide Deck Overview Slide Set Includes:  Section 1: NQF-Endorsed ® Safe Practices for Better Healthcare Overview  Section 2: Harmonization Partners  Section 3:The Problem  Section 4: Practice Specifications  Section 5: Example Implementation Approaches  Section 6: Front-line Resources

3 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Overview Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

4 © 2010 TMIT 2010 NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness

5 © 2010 TMIT Culture SP NQF Report

CHAPTER 7: Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central Line-Associated Blood Stream Infection Prevention Surgical-Site Infection Prevention Daily Care of the Ventilated Patient MDRO Prevention Catheter-Associated UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- and Site-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention VTE Prevention Anticoag. Therapy VAP Prevention Central Line-Assoc. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Leadership Structures and Systems Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge Systems Patient Care Info. Labeling Diag. Studies Culture Meas., FB., and Interv. Structures and Systems Risk and Hazards Team Training and Skill Bldg. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]  Culture of Safety Leadership Structures and Systems  Culture Measurement, Feedback, and Intervention  Teamwork Training and Skill Building  Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Diagnostic Studies  Discharge Systems  Safe Adoption of Computerized Prescriber Order Entry CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Structures and Systems CHAPTER 8: Condition- and Site-Specific Practices Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control Pediatric Imaging

7 © 2010 TMIT Harmonization Partners Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

8 © 2010 TMIT Harmonization – The Quality Choir

9 © 2010 TMIT The Patient – Our Conductor

© 2006 HCC, Inc. CD XX 10 © 2010 TMIT The Objective Risks and Hazards  Ensure that patient safety risks and hazards are continuously identified and communicated to all levels of the organization, that mitigation activities are aggressively undertaken to minimize harm to patients, and that patient safety information is communicated to the appropriate external organizations. [Institute for Healthcare Improvement, How to Improve: Medication Systems, N.D.; Pizzi, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, 2001]

11 © 2010 TMIT The Problem Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD XX 12 © 2010 TMIT The Problem

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© 2006 HCC, Inc. CD XX 17 © 2010 TMIT The Problem Frequency  Medical errors have been associated with subsequent personal distress, decreased empathy, and increased probability of making another medical error  Risk mitigation is typically not integrated across an organization  Clinicians significantly underreport medical errors  A culture of name, blame, and shame behaviors and the fear of malpractice liability have been major barriers to performance improvement  Zero must be the goal for adverse events [West, JAMA 2006 Sep 6;296(9):1071-8; Kaldjian, J Gen Intern Med 2007 Jul;22(7):988-96; Kaldjian, Arch Intern Med 2008 Jan 14;168(1):40-6; The Joint Commission, 2009 Accreditation Requirements Chapter, 2009]

© 2006 HCC, Inc. CD XX 18 © 2010 TMIT The Problem Severity  The severity of harm due to the absence of coordinated patient safety programs cannot be accurately estimated  However, recent studies have shown that as many as 15% of Medicare beneficiaries experience serious harm in hospitals  Readmission and mortality rates of seniors after acute care hospital admissions may be much higher than previously presumed [Boutwell, Reducing Re-hospitalizations in a State or Region: Minicourse M1, 2008; Levinson, Office of Inspector General. Adverse events in hospitals: overview of key issues, 2008; Denham, J Patient Saf 2009 Mar;5(1):42-52]

© 2006 HCC, Inc. CD XX 19 © 2010 TMIT The Problem Preventability  Healthcare organizations can identify and mitigate patient safety risks and hazards by using a number of internal methods  Patient safety organizations that provide federal protection of information should increase the sharing of adverse event information and lessons learned  Supply adequate resources to cover the cost of strategies regularly evaluated for effectiveness [Helmreich, BMJ 2000 Mar 18;320(7237):781-5; Carthey, Qual Health Care 2001 Mar;10(1):29-32; Marx, Qual Saf Health Care 2003 Dec;12 Suppl 2:ii33-8; Wreathall, Qual Saf Health Care 2004 Jun;13(3):206-12; Milch, J Gen Intern Med 2006 Feb;21(2):165-70; Centers for Medicare & Medicaid Services, Hospital Conditions of Participation: Patients’ Rights, 2008]

20 © 2010 TMIT Practice Specifications Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD XX 21 © 2010 TMIT Additional Specifications

© 2006 HCC, Inc. CD XX 22 © 2010 TMIT Safe Practice Statement Identification and Mitigation of Risks and Hazards  Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm.

© 2006 HCC, Inc. CD XX 23 © 2010 TMIT Additional Specifications Risk and Hazard Identification Activities  Risks and hazards should be identified on an ongoing basis from multiple sources  The risk and hazard analysis should integrate the information gained from multiple sources to provide organization-wide context  The organizational culture should be framed by a focus on system (not individual) errors and blame-free reporting, and should use data from risk assessment to create a just culture [Institute of Medicine, Patient Safety: Achieving a New Standard for Care, 2004; Agency for Healthcare Research and Quality, National Healthcare Disparities Report 2008, 2009; Nuckols, Jt Comm J Qual Patient Saf 2009 Mar;35(3):139-45; Pronovost, Clin Chest Med 2009 Mar;30(1):169-79]

© 2006 HCC, Inc. CD XX 24 © 2010 TMIT Additional Specifications Retrospective Identification  Use a number of retrospective measures and indicators to identify risk from historical data  Specific steps should be taken to ensure that the lessons learned are communicated across the organization and applied in other care settings  Some retrospective identification and analysis activities are triggered by adverse events  Retrospective identification of risks and hazards should occur regularly, and progress reports should be generated as frequently as needed [Nuckols, Jt Comm J Qual Patient Saf 2009 Mar;35(3):139-45]

© 2006 HCC, Inc. CD XX 25 © 2010 TMIT Additional Specifications Real-Time and Near Real-time Identification  Evaluate real-time or near real-time tools for their value in risk identification for the areas of high risk  Consider using trigger, observational, and technology tools  A structured, proactive risk assessment should be undertaken to identify risks and hazards in order to prevent harm and error  Evaluate the prospective or proactive tools and methods in order to identify risks [Institute of Medicine, Patient Safety: Achieving a New Standard for Care, 2004; Alemi, Qual Manag Health Care 2007 Oct-Dec;16(4):300-10; Hovor, Qual Manag Health Care 2007 Oct-Dec;16(4):349-53; Adler, J Patient Saf 2008 Dec;4(4):245-9; Emily, Risk Anal 2009 Apr;29(4):565-75; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010]

© 2006 HCC, Inc. CD XX 26 © 2010 TMIT Additional Specifications Integrated Organization-Wide Risk Assessment  The systematic integration of information about risks and hazards across the organization should be undertaken to optimally prevent systems failures  At least annually, create frequent progress and summary of reports annually for risk management, complaints/customer service, disclosure support, culture measurement, and other information  Information should be provided to the governance board and senior administrative leadership continually [Centers for Disease Control and Prevention, Emergency Preparedness and Response, N.D.; Centers for Disease Control and Prevention, Pandemic Influenza Resources; N.D.; APIC, Pandemics, 2008; Boothman, Journal of Health & Life Sciences Law 2009 Jan;2(2):125-59; Chiozza, Clin Chim Acta 2009 Jun;404(1):75-8; McDonald, Full Disclosure and Residency Education, 2008]

© 2006 HCC, Inc. CD XX 27 © 2010 TMIT Additional Specifications Risk Mitigation Activities  Every organization has a unique risk profile and should carefully design performance improvement projects that target prioritized risk areas Performance Improvement Programs  Organizations should provide documentation of performance improvement programs [Denham, J Patient Saf 2005 Mar;1(1):41-55; Pronovost, Health Aff (Millwood) 2009 May-Jun;28(3):w479-89; Damiani, Med Sci Monit 2009 Jul;15(7):RA157-66; Denham, J Patient Saf 2009 Sep;5(3):188-96; Wayre, Healthc Financ Manage 2009 Jan;63(1):86-91; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010]

© 2006 HCC, Inc. CD XX 28 © 2010 TMIT Additional Specifications Specific Risk-Assessment and Mitigation Activities  Organizations should document evidence of high performance or actions taken to close common patient safety gaps for the patient safety risk areas, such as:  Falls  Malnutrition  Pneumatic Tourniquets  Aspiration  Workforce Fatigue [Weingart, Jt Comm J Qual Patient Saf 2009 Apr;35(4):206-15; Yeo, JAMA 2009 Sep 23;302(12):1301-8; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook 2010]

29 © 2010 TMIT Example Implementation Approaches Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

© 2006 HCC, Inc. CD XX 30 © 2010 TMIT Example Implementation Approaches

© 2006 HCC, Inc. CD XX 31 © 2010 TMIT Example Implementation Approaches  Have the organization’s leaders partner with front-line caregivers to design a path for the adoption of this safe practice’s activities  Periodically assess tools used for prospective, near real-time, and retrospective risk identification and mitigation  New risk identification opportunities are presented through the use of evolving trigger tools, such as the Global Trigger Tool  Evaluate the risk areas identified by purchasers to be high priority to them [Centers for Disease Control and Prevention, Legionellosis Resource Site (Legionnaires' Disease and Pontiac Fever), N.D.; Centers for Medicare & Medicaid Services, CMS Proposes to Expand Quality Program for Hospital Inpatient Services in FY 2009, 2008; Centers for Medicare & Medicaid Services, Hospital-Acquired Conditions Overview, 2008; Mills, Qual Saf Health Care 2008 Feb;17(1):37-46; Percarpio, Jt Comm J Qual Patient Saf 2008 Jul;34(7):391-8; Wu, JAMA 2008 Feb 13;299(6):685- 7; Griffin, IHI Global Trigger Tool for Measuring Adverse Events (Second Edition), 2009]

© 2006 HCC, Inc. CD XX 32 © 2010 TMIT Example Implementation Approaches Strategies of Progressive Organizations  Some organizations have declared that governance board members must spend equal time in meetings and activities on financial issues and quality/safety issues  Organizations have embraced patient safety and risk reduction as their primary competitive initiatives  High-performing organizations provide feedback to staff on improvements that resulted from adverse event reporting [McDonald, Full Disclosure and Residency Education; 2008; Gallagher, JAMA 2009;302(6):669-77; McDonald, Responding to Patient Safety Incidents: The Seven Pillars; 2009]

33 © 2010 TMIT Front-line Resources Safe Practice 4 Risks and Hazards Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

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35 © 2010 TMIT The 3 Ts of Leadership Engagement: Truth, Trust, and Teamwork Charles Denham

36 © 2010 TMIT Poster available in Spanish [

© 2006 HCC, Inc. CD XX 37 © 2010 TMIT NQF & TMIT National Webinar Series Leadership and Leadership Principles for Safety (Safe Practices 1-4)  Charles R. Denham, MD – Leadership and Culture Practices: New Roles for Leaders  Peter B. Angood, MD – Important National Highlights Regarding Leadership and Culture  James Conway, MS – Bringing Boards On-board: Critical Issues in 2009  Dan Ford, MBA – Patient Perspective on Medication Management Safe Practices  Go to: (July 16, 2009)