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

2. 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

3. 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

4. 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
“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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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