1. DMC Quality and Medical Safety Programs
DMC Corporate Quality Department
Detroit Medical Center©
Revised: February, 2010

2. Commitment to Quality and Safety
The Detroit Medical Center is committed to providing safe, high quality medical care.
This is part of our mission and it is also reflected by our certification and accreditation with regulatory agencies and participation with local, state, and national quality and safety improvement projects.

3. Quality and Environmental Management Systems
The DMC has incorporated the requirements of a Quality Management System (QMS) as outlined in the ISO standards and an Environmental Management System (EMS) as outlined in ISO 14001: 2004 standards into its quality program.

4. Foundation for Medical Safety
DMC commitment to medical safety is reflected in our:
Quality Statement which includes:
Continuous improvement
Prevention of medical/health systems errors
Provision of high quality medical care
Environmental Statement:
The Detroit Medical Center is dedicated to the health and safety of its patients, employees, customers, community and environment.
DMC is committed to:
The prevention of pollution
Compliance with environmental regulations and other requirements
Environmental hotline

5. Improving Quality and Safety
Most events or errors occur due to process issues:
Multiple events at multiple levels lead to the event – almost never just ‘one process’ failure
Rarely a ‘person’ failure
By improving our systems and processes, we improve healthcare quality and safety.

6. What is Performance Improvement?
It is an ongoing effort to find new and better ways of doing things by:
Getting better results
Involving the whole organization
Improving work processes
Foundation for Performance Improvement – PDCA (also known as PDSA):
PLAN DO
CHECK (or STUDY)
ACT

7. Performance Improvement
PLAN:
What are the goals you want to achieve?
DO:
Measure progress towards goals by collecting data.
CHECK/STUDY:
Look closely at/Analyze your data to answer these questions:
How well are we performing?
Why are we performing well or not well?
Which areas should we focus on first to improve our processes?
ACT:
Make improvements!
Celebrate success!

8. What Does Medical Safety Mean?
It means we constantly look for ways to make the care or service we provide safer for our patients and employees.
We can accomplish this by:
Identifying conditions that are hazardous and changing them.
Acting quickly and appropriately when an incident occurs.
Making medical safety a regular part of our performance improvement activities.
By making concerns for safety part of everything we do.

9. Medical Safety = Quality Care
The DMC is committed to adopting the Institute of Medicine’s 6 aims for improving the quality and safety of healthcare (see additional information at
Healthcare needs to be:
Safe: Avoiding injuries to patients from the care that is intended to help them.
Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

10. Medical Safety = Quality Care
Healthcare needs to be: continued
Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. A health care system that achieves major gains in these six areas would be far better at meeting patient needs.

11. Healthcare Safety Statistics
40 to 50 Patient Injuries per 100 Hospital Admissions
37 million hospital admissions X
40 injuries per 100 hospital admissions =
15 million injuries per year
What can we do to change this?

12. “Protecting 5 Million Lives from Harm” Campaign
The Institute for Healthcare Improvement’s (IHI)
“Protecting 5 Million Lives from Harm” campaign (See
for additional information). The aim of the
campaign is to have care that:
Is standardized and systemized
Has zero defects
Is innovative
Includes system redesign, where necessary
The DMC has committed to participate with the IHI to
protect patients from harm. Everyone is responsible
for the quality and safety of healthcare.

13. Proven Interventions
The “Protecting 5 Million Lives from Harm” campaign challenges
American hospitals to adopt twelve changes in care that save lives and
reduce patient injuries:
Deploy Rapid Response Teams…at the first sign of patient decline.
Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack.
Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation.
Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps.
Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time.
Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps. 

14. Proven Interventions
Twelve changes in care that save lives and reduce patient injuries:
(continued)
Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin.
Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project.
Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention.
Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices.
Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions.
Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care.

15. Institute for Healthcare Improvement (IHI) Web Site

16. IHI Open School
The IHI Open School for Health Professions is an interprofessional educational community that gives students the skills to become change agents in health care improvement:
Skills like quality improvement, patient safety, teamwork, leadership, and patient-centered care
IHI Open School offers:
Online courses written by world-renowned faculty 
A network of students 
Case studies, podcasts, videos, featured articles
IHI Certificates of Completion
The IHI Open School — including online tools and resources, and online courses — is open and free for students of all health care professions and non-students alike.

17. IHI Improvement Map
The IHI Improvement Map is an open resource, available free of charge for anyone, anywhere who shares IHI’s mission of improving healthcare.
User-friendly, online tool used to create an overall improvement plan, set and align priorities and key process improvements that lead to exceptional patient care.
Example: Core Processes for AMI

18. DMC Improvement Map - Where DMC stands on each of the IHI improvement map core processes (NOTE: Not necessarily representative of individual DMC facilities).

19. Promoting and Maintaining a Safe Medical Climate
Staff responsibilities:
Take action to provide necessary care and protect patients in the event of a unsafe event or error.
Report all errors, near misses and hazardous conditions (web based incident reporting system).
Complete yearly, educational competencies.
Participate in departmental improvement efforts.
Be part of interdepartmental, multidisciplinary improvement teams.
Share ideas to improve employee or patient safety with supervisor or quality department.
Speak-up if you see an opportunity to avoid an unsafe practice or violation of policy.
Instruct patients and families to report safety concerns.

20. Promoting and Maintaining a Safe Medical Climate
Patient responsibilities – encourage patients to:
Provide accurate and complete information about present complaints, past illnesses, hospitalizations and medicines.
Ask questions when they do not understand what they have been told or what they are expected to do.

21. Accreditation
Accreditation means that an organization has met requirements related to the delivery of safe, quality care.
The DMC is surveyed and accredited by many different agencies.
What is Joint Commission?
The Joint Commission is an accreditation agency that surveys our hospitals at least once every 3 years.
The Joint Commission is an accreditation agency who’s objective is to improve the quality of healthcare provided to the public by establishing clinical standards; evaluating health care organizations; rendering accreditation; and providing education and consultative support to healthcare professionals (See for additional information)

22. Quality Improvement
The DMC participates in many local, state and national Quality Improvement projects some of which are:
The National Quality Forum (NQF)
Leapfrog
Institute for Healthcare Improvement (IHI)
Michigan Hospital Association (MHA – Keystone project)
Greater Detroit Area Health Coalition (GDAHC – Save Lives-Save Dollars campaign)
Blue Cross Blue Shield of Michigan

23. Consumer-Centered Hospital Data
In recent years, there has been an increased emphasis on hospital quality and transparency.
Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores.
It is important to remember that all DMC employees play a role in ensuring that our patients leave with a satisfying experience.

24. Hospital Transparency
Hospital transparency is providing information to the public on patient safety and quality, cost, and performance indicators.
Hospital transparency assists hospitals to become more efficient, rewards those hospitals that provide high quality care, and allows consumers to make informed decisions.
The DMC provides information on safety and quality that is publicly reported.

25. Healthcare Quality Websites
The Joint Commission
Provides information regarding hospital accreditation and compliance.
AHRQ Report Card
Features information on the quality of hospitals, medical groups, health plans, nursing homes and clinical information on evidence based practices.
CMS/Hospital Compare
Provides consumers with hospital-reported information on quality, performance, and customer satisfaction.
Leapfrog Group
Provides consumers with hospital information based on its yearly survey of quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk procedures, and NQF Safety Goals
Michigan Hospital Inform
State of Michigan healthcare quality website.
The Joint Commission
Provides information regarding hospital accreditation and compliance.
AHRQ Report Card
Features information on the quality of hospitals, medical groups, health plans, nursing homes and clinical information on evidence based practices.
CMS/Hospital Compare
Provides consumers with hospital-reported information on quality, performance, and customer satisfaction.
Leapfrog Group
Provides consumers with hospital information based on its yearly survey of quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk procedures, and NQF Safety Goals
Michigan Hospital Inform
State of Michigan healthcare quality website.

26. Quality of Care
As employees of the DMC, it is everyone’s responsibility to ensure safe, quality care for our patients.
Also, as an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.
If you have concerns, first speak to your supervisor. If you are not satisfied, you may contact the Quality Department or use the compliance hotline.
If still your concerns are not addressed, you have the right to contact the Joint Commission at or call

27. Course Summary
Both the Quality Management System (QMS) and Environmental
Management System (EMS) are part of our integrated quality
program.
Medical Safety means we constantly look for ways to make the
care or service we provide safer for our patients and employees.
The DMC publicly reports it’s quality and safety data.
Consumers can find Internet sites to provide information such as
procedure cost, levels of clinical/patient care, and patient
satisfaction scores.
As an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.

28. Thank You
We hope this NetLearning course has been both informative and helpful. Please feel free to review this course until you are confident about your knowledge of the material presented.
Click the Take Test button, located on the left side of the screen, to complete the requirements for this course.
For future reference this module is available on the NetLearning Library under the 2010 Core Compliance category. The NetLearning Library is found on the DMC Intraweb screen under the NetLearning drop-down list.