1. Leading a Patient Safety Program Madeleine Biondolillo, MD Massachusetts Department of Public Health Gordon Schiff, MD Brigham & Women’s Hospital; Harvard Medical School

2. Objectives By the end of this module you will be able to: 1. Explain the relationship between patient safety and the risk of medical malpractice. 2. Describe the characteristics of a patient safety program for primary care. 3. Identify staff in your practice who would best manage a patient safety program.

3. A Patient Safety Example “Freedom from accidental injury” (IOM 1999) 3 Gordy Schiff, MD

4. JAMA 12/14/2011

5. NEJM 8/18/11 Proportion of Physicians Facing a Malpractice Claim Annually.

6. Amount of Malpractice Payments, According to Specialty. NEJM 8/18/11

10. Patient Safety & Medical Malpractice Safety and Malpractice Risk: Two sides to the same coin With all the demands on primary care practices, how do you improve? Outcomes = systems + culture 10

11. System “interdependent elements interacting to achieve a common aim” Institute of Medicine, 1999 The office practice setting is a complex system Work processes produce the outcomes that patients experience. When something goes wrong, the root cause is likely a bad process, not a bad person; Handoffs are key To improve flawed systems, examine and improve the work processes - make them as safe and reliable as possible

12. PROMISES Federal grant helping primary care settings improve patient safety and malpractice. 3 processes: referral follow-up; lab test tracking; and medication management +1: communications What keeps you up at night? 12 Madeleine Biondolillo, MD

13. How to Improve 13 Patient Safety Program is not about unique or bountiful resources Learn to creatively use available resources All staff members have two jobs: doing the job and improving it Detecting problems Solving problems Spreading solutions Leadership must model and support the principles S. Spear The High Velocity Edge, 2010

14. From the Front Lines But the referral, if you think of a giant circle, the patient is now in the center. (Practice Manager) The PROMISES program works. Attacking it in small fundamental bites, and mapping out the process and finding out where the actual problems are is a process that I hope everyone learns. (Practice Manager) When you look back now, you think, ‘how did we not do that 18 months ago?’ (Practice Manager)

15. Value of Community/Coaching Seeing all the practices, and having somebody ask the same question that you might have been thinking, was extremely valuable. (Practice Manager)

16. Starting a Massachusetts Patient Safety Program 16

17. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from Patients Deal with errors: When Things Go Wrong

18. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

19. Safety Culture –Structure Support the safety culture by participating in and modeling the values of a safe culture Collaboration and teamwork Clear and open communication Safety on all meeting agendas Work to build improved processes - Avoid “Shame and blame” Safety discussed at Independent Practice Association meetings (if applicable)

20. Safety Culture - Process Recognition that to err is human Driving out fear so people aren’t afraid to ask questions or share things that go wrong Organizational emphasis on learning from mistakes When dealing with adverse events, replacing blame and fear with learning and improvement. Leaders model commitment for trust to needed overcome fear and take risks to make change

21. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

22. Managing Patient Safety Patient safety is everyone’s job, but a team needs a coordinator. Point person to ensure that: Your improvement team meets regularly. Schedule safety discussion for all meetings. Identify and follow up on adverse events. Designate a safety contact. Make this clear and accessible for patients and families.

23. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

24. Quality Improvement Methods Testing Small-scale Changes Identify problems together Gather some data Agree on shared aims Brainstorm ideas Test solutions Measure for improvement Learn and test the next step

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26. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

27. Learning from Patients Patients offer a valuable and unique perspective on your practices and safety culture Develop a method for patients and family communication to voice safety concerns Conduct a periodic patient survey Review results, suggestions at staff meetings Engage patients in improvement initiatives

28. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

29. WTGW Disclose and discuss all significant events First ensure patient safety by providing any needed further care Express and act with empathy Provide feedback and follow through Support clinicians as well as patients 29

30. Primary Care Patient Safety Checklist Massachusetts: Safety in all settings? Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

31. Success Story Same thing happened with a 62 year old Portuguese guy who didn’t want to have a colonoscopy, and I convinced him to do the FIT. It came back positive...with a big, big tumor growing, still within the polyp. He got partial resection of the colon, and he is cured. - Dr. Folch

32. PROMISES Curriculum 1. Leading a Patient Safety Program 2. Leadership Case Study 3. Improving Your Primary Care Practice #1 4. Improvement Case Study 5. Improving Your Primary Care Practice #2 6. Communication Case Study 7. Communication 8. Test and Referral Management Follow Up 9. Test Results Case Study 10. Referrals Case Study 11. Medication Management 12. “When Things Go Wrong in the Ambulatory Setting” 13. Sustaining Change 14. Patient Engagement 32 http://www.brighamandwomens.org/PBRN/promises Getting Started Continuous Improvement Improving Process Communications

33. Get Started Today Think about areas of vulnerability Share the Outpatient Courses with your colleagues. Watch sessions at your next staff meeting Choose a staff members who would like to help start the work Identify a staff member for your safety program Reach out to others  Your professional association  Your malpractice insurer  Your patients 33

34. A Few References PATIENT SAFETY MANUAL: “GUIDELINE FOR PATIENT SAFETY PROGRAMS IN ALL HEALTHCARE SETTINGS” APPROVED BY HCQCC COUNCIL - MAY 16, 2012 High Velocity Edge, S. Spear 2010 34