Unit 9a: The BSI Story HIT Infecting a Patient Safety Culture This material was developed by Johns Hopkins University, funded by the Department of Health.

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Presentation transcript:

Unit 9a: The BSI Story HIT Infecting a Patient Safety Culture This material 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 IU24OC

At the end of this segment, the student will be able to: Apply QI tools to the analysis of HIT errors Objectives Component 12/Unit 9 2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Peter Pronovost Component 12/Unit 9 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: 2005 Crosskeys Media®

Component 12/Unit 9 4 Health IT Workforce Curriculum Version 2.0/Spring 2011 Peter Pronovost Image Source: 2005 Crosskeys Media®

Key Topics The checklist: why was it successful? What is this thing called “culture”? How can we prevent projects from failing? Component 12/Unit 9 5 Health IT Workforce Curriculum Version 2.0/Spring 2011

Component 12/Unit 9 6 Health IT Workforce Curriculum Version 2.0/Spring 2011 Apollo Mission Image Source: MS Clipart

Apollo Mission Component 12/Unit 9 7 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

HIT Component 12/Unit 9 8 Health IT Workforce Curriculum Version 2.0/Spring 2011

Component 12/Unit 9 9 Health IT Workforce Curriculum Version 2.0/Spring 2011 National Health Care Quality Image Source: AHRQ.gov

BSI Checklist Wash your hands Clean you skin with Chlorhexidine Avoid placing catheters in the groin Use full barrier precautions Ask every day if you still need the catheter. Component 12/Unit 9 10 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

Science of Safety Standardize Care Component 12/Unit 9 11 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

Science of Safety Independent Checks Component 12/Unit 9 12 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

Science of Safety Component 12/Unit 9 13 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

Doctors Component 12/Unit 9 14 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

Component 12/Unit 9 15 Health IT Workforce Curriculum Version 2.0/Spring 2011 At Hopkins Image Source: MS Clipart

[insert picture of surgical team operating] Component 12/Unit 9 16 Health IT Workforce Curriculum Version 2.0/Spring 2011 Speaking Up Image Source: MS Clipart

Component 12/Unit 9 17 Health IT Workforce Curriculum Version 2.0/Spring 2011 Magic Wand Image Sources: MS Clipart

Component 12/Unit 9 18 Health IT Workforce Curriculum Version 2.0/Spring 2011 Science of Safety Learn from Every Defect Image Source: MS Clipart

Component 12/Unit 9 19 Health IT Workforce Curriculum Version 2.0/Spring 2011 Checklist

Component 12/Unit 9 20 Health IT Workforce Curriculum Version 2.0/Spring 2011 Emergency Room Image Source: MS Clipart

Component 12/Unit 9 21 Health IT Workforce Curriculum Version 2.0/Spring 2011 Rates Image Source: MS Clipart

The BSI Story Component 12/Unit 9 22 Health IT Workforce Curriculum Version 2.0/Spring 2011 Image Source: MS Clipart

Component 12/Unit 9 23 Health IT Workforce Curriculum Version 2.0/Spring 2011 Michigan Image Source: MS Clipart

Component 12/Unit 9 24 Health IT Workforce Curriculum Version 2.0/Spring 2011 The U.S. Image Source: MS Clipart

Component 12/Unit 9 25 Health IT Workforce Curriculum Version 2.0/Spring 2011 The Model Image Source: MS Clipart

Component 12/Unit 9 26 Health IT Workforce Curriculum Version 2.0/Spring 2011 OR Image Source: MS Clipart

Component 12/Unit 9 27 Health IT Workforce Curriculum Version 2.0/Spring 2011 Toyota Image Source: 2005 Crosskeys Media®

Summary 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. Component 12/Unit 9 28 Health IT Workforce Curriculum Version 2.0/Spring 2011