1. The Quality Colloquium at Harvard University August 27, 2003 Patient Safety Organizational Readiness Assessment Tool Louis H. Diamond, MDBeverly A. Collins, MD Vice President & Medical DirectorMedical Director MedstatDelmarva Foundation for Medical Care

2. Copyright 2003 Thomson Medstat2 Harvard Quality Colloquium 8-27-03 Employee survey An Agenda to Improve Patient Safety Leadership buy-in and commitment Conduct Organizational Readiness Assessment* Establish a non- blame culture Train staff in the safety sciences Make errors visible** Conduct root cause analysis Implement best practice Disseminate and facilitate adoption of best practice *Dimensions: Strategic, Cultural, etc. **Employee reporting, patient reporting, medical record review, data mining ***Point of care and near term Make tools available to patients and healthcare professionals***

3. Copyright 2003 Thomson Medstat3 Harvard Quality Colloquium 8-27-03 Crossing the Quality Chasm Leadership Statement of Purpose Prioritize Organizational Changes New Set Principles Create IT Infrastructure EBM Decision Support Tool Prepare Workforce Restructure Payment Reward Improvement Ref: Adapted from IOM Report: March 01.

4. Copyright 2003 Thomson Medstat4 Harvard Quality Colloquium 8-27-03 Discussion Outline Overview of the Patient Safety Organizational Assessment Tool (PSOAT) Conceptual Framework Project Steps Results of Delmarva Assessment

5. Copyright 2003 Thomson Medstat5 Harvard Quality Colloquium 8-27-03 Objectives of the Assessment Use an evidence-based process to: –Provide gap analysis –Highlight practices that contribute to errors –Jump start safety programs –Comply with regulatory requirements

6. Copyright 2003 Thomson Medstat6 Harvard Quality Colloquium 8-27-03 Patient Safety Organizational Assessment Tool Description Content –100+ focused practices from the literature organized by: Strategic Structural Cultural Technical Medication Administration Patient Involvement

7. Copyright 2003 Thomson Medstat7 Harvard Quality Colloquium 8-27-03 Literature Sources National Patient Safety Foundation, Institute of Medicine Agency for Healthcare Research and Quality Literature Citation Systems –PubMed, MEDLINE, MDConsult MEDSTAT internal resources –Clinical reference database (6000+ references) Medical and Patient Safety web sites and listservs Web engines

8. Copyright 2003 Thomson Medstat8 Harvard Quality Colloquium 8-27-03 Description of Shortell Framework Shortell S. Assessing the impact of Continuous Quality Improvement on Clinical Practice: What it will take to accelerate progress. The Milbank Quarterly, 76(4) 1998

9. Copyright 2003 Thomson Medstat9 Harvard Quality Colloquium 8-27-03 Impact on Quality Improvement Shortell S. Assessing the impact of Continuous Quality Improvement on Clinical Practice: What it will take to accelerate progress. The Milbank Quarterly, 76(4) 1998 X = fully present

10. Copyright 2003 Thomson Medstat10 Harvard Quality Colloquium 8-27-03 Impact on Safety Improvement Cultural no blame process focused Strategic mission executive leadership Technical training information systems Patient Safety Structural committees information sharing Ref: Shortell: Milbank Quarterly, 76(4)1998

11. Copyright 2003 Thomson Medstat11 Harvard Quality Colloquium 8-27-03 Value to Participating Avoid costs Focus resources/attention Market to community Increase collaboration

12. Copyright 2003 Thomson Medstat12 Harvard Quality Colloquium 8-27-03 Project Steps Delmarva and MEDSTAT partner to customize and offer tool to MD and DC health care organizations Invitation to participants 42 organizations assigned IDs; 24 completed Bedsize - 8 had =150 beds Results aggregated and analyzed Obtain participant feedback

13. Copyright 2003 Thomson Medstat13 Harvard Quality Colloquium 8-27-03 Findings

14. Copyright 2003 Thomson Medstat14 Harvard Quality Colloquium 8-27-03 Overview of Results: Level of Action Medication Administration Structural Strategic Patient Involvement Cultural Technical High Action Low Action

15. Copyright 2003 Thomson Medstat15 Harvard Quality Colloquium 8-27-03 Percentage Response by Section Response *No Action – Answered 1 or 2 on assessment tool. 1 = Not considering the practice; 2 = Discussed the practice, but no action taken to put into place. **High Action – Answered 4 or 5 on assessment tool. 4 = Considerable action taken to put practice into place; 5 = The practice is fully implemented in organization. # of Questions 101 17 24101137 2

16. Copyright 2003 Thomson Medstat16 Harvard Quality Colloquium 8-27-03 Difference by Bed Size: Patient Involvement Response *No Action – Answered 1 or 2 on assessment tool. 1 = Not considering the practice; 2 = Discussed the practice, but no action taken to put practice into place. **High Action – Answered 4 or 5 on assessment tool. 4 = Considerable action taken to put practice into place; 5 = The practice is fully implemented in organization.

17. Copyright 2003 Thomson Medstat17 Harvard Quality Colloquium 8-27-03 Strategic - Low vs. High Action: 17 Questions

18. Copyright 2003 Thomson Medstat18 Harvard Quality Colloquium 8-27-03 Structural - Low vs. High Action: 24 Questions

19. Copyright 2003 Thomson Medstat19 Harvard Quality Colloquium 8-27-03 Cultural - Low vs. High Action: 10 Questions

20. Copyright 2003 Thomson Medstat20 Harvard Quality Colloquium 8-27-03 Technical - Low vs. High Action: 11 Questions

21. Copyright 2003 Thomson Medstat21 Harvard Quality Colloquium 8-27-03 Medication Safety - Low vs. High Action: 37 Questions

22. Copyright 2003 Thomson Medstat22 Harvard Quality Colloquium 8-27-03 Medication Safety - Low vs. High Action: 37 Questions

23. Copyright 2003 Thomson Medstat23 Harvard Quality Colloquium 8-27-03 Medication Safety - Low vs. High Action: 37 Questions

24. Copyright 2003 Thomson Medstat24 Harvard Quality Colloquium 8-27-03 Recommendations Based Upon Survey Results

25. Copyright 2003 Thomson Medstat25 Harvard Quality Colloquium 8-27-03 Strategic/Structural Incorporate patient safety into mission statement Improve policy and departmental standards to incorporate safety discussion into operational meetings

26. Copyright 2003 Thomson Medstat26 Harvard Quality Colloquium 8-27-03 Cultural Raise awareness at all levels of organization Reward staff for improvements; consider alternative reward systems Celebrate achievements Gather baseline staff perceptions for both information and awareness

27. Copyright 2003 Thomson Medstat27 Harvard Quality Colloquium 8-27-03

28. Copyright 2003 Thomson Medstat28 Harvard Quality Colloquium 8-27-03 Technical Bar coding for patient identification, patient tracking, CPOE Explore other techniques for potential error review e.g. user centered design Electronic decision support for clinicians

29. Copyright 2003 Thomson Medstat29 Harvard Quality Colloquium 8-27-03 Medication Safety Standard policies in place to monitor patients on hazardous drugs Availability of medication information system to all clinical staff dealing with a patient Bar-coding to detect adverse drug reaction and other administration errors at point of care

30. Copyright 2003 Thomson Medstat30 Harvard Quality Colloquium 8-27-03 Patient Involvement Educate patients and families on key safety issues regarding their care while hospitalized Educate patients and families about medication safety after discharge Develop safety educational programs geared towards patients Be mindful of following hand washing procedures

31. Copyright 2003 Thomson Medstat31 Harvard Quality Colloquium 8-27-03

32. Copyright 2003 Thomson Medstat32 Harvard Quality Colloquium 8-27-03

33. Copyright 2003 Thomson Medstat33 Harvard Quality Colloquium 8-27-03 Questions Discussion &

34. Copyright 2003 Thomson Medstat34 Harvard Quality Colloquium 8-27-03 Contacts Louis H. Diamond Medstat 4301 Connecticut Avenue, NW, Suite 330 Washington, DC 20008 202-719-7833Fax: 202-719-7866 Email: louis.diamond@medstat.comlouis.diamond@medstat.com Beverly A. Collins Delmarva Foundation for Medical Care 7240 Parkway Drive, Suite 400 Hanover, MD 21076 410-712-7404Fax: 410-712-4357 Email: bcollins@dfmc.orgbcollins@dfmc.org