patient safety in the health delivery “system” where we have been? where are we now? where must...

Patient Safety In the Health Delivery “System”

Where we have been?

Where are we now?

Where must we go?

Jim Conwayjconway@ihi.org

Are We Making Progress?Absolutely!

• Engaging People within/across organizations– Patients, families, staff, leadership, governance

• Setting Aims– All or nothing

• Confronting Realities– Suffering, harm, tragedy, death, waste

• Implementing Interventions – Leapfrog/NQF, IHI Campaigns, Keystone, SCIP

• Using Tools and Science– Lean, Six Sigma, Toyota, RCA, FMEA

Are We Making Progress?Absolutely!

• Implementing New Standards– Joint Commission

• Conducting Research• Having Conversations

– Disclosure, fair and just culture, transparency, shared learning

• Seeing Results– Elimination of VAP, SSI, CLI, Pressure Ulcers,

preventable harm

ARE WE SAFER?What’s the Bottom Line: Health Care System

• YES, in many organizations more of the time• BUT, there is exceptional variation

– Within organizations– Among organizations

• NOT safer for every patient every time– Not safer for every staff member every time

WHY DID WE FAIL TO ACHIEVE RECOMMENDATIONS

First, It’s a Failure of Leadership•Set the expectation•Position for success•Hold accountable

•Over time

In a New US Survey of Hospital Governance and the Quality of Care…

• Only 20% of board chairs reported the board chair, board itself, or a subcommittee as one of the two most influential forces on quality.

• Among the low performing hospitals, no respondent reported their performance as worse than the typical US hospital.

• A little over half identified clinical quality as one of the two top priorities for board oversight.

• Fewer than one-third of nonprofit hospitals had formal board training programs that included quality.

Jha A, Epstein A. Health Aff (Millwood). 2010;29(1): published online 6 November 2009; 10.1377/hlthaff.2009.0297] 6

ACHE Annual Top 3 SurveyTop Issues Confronting Hospital CEOs

Issue 2004 2005 2006 2007 2008 2009

Financial challenges 71% 67% 72% 70% 77% 76%

Health Care Reform -- -- -- -- -- 53%

Care— uninsured 36% 35% 37% 38% 41% 37%

Pt Safety & Quality -- -- -- -- 43% 32%

MD/hosp. relations 32% 33% 40% 35% 32% 25%

Gov. mandates 19% 16% 23% 22% 26% 20%

Patient satisfaction 13% 18% 16% 17% 22% 15%

Personnel shortages 33% 36% 30% 30% 30% 13%

Patient safety 16% 20% 27% 29% -- --

Quality 18% 23% 29% 33% -- --

Notes: QI and Safety combined in 2008, Others below 10% in 2008 included technology, NFP status, and disaster preparedness

WHY DID WE FAIL TO ACHIEVE RECOMMENDATIONS

• Other reasons:– “Sorry seams to be the hardest word”– Lots of projects and not transformation– Failure to focus and prioritize– Over dependency on people– Lack of urgency – Tolerate poor performance among peers– Ineffective measures and limited transparency– Education /competency standards not required

WHAT WILL IT TAKE, OUR PRIORITIES• Values-based leadership at every level• Poor performance declared unacceptable

– Burden, responsibility, power

• Organized around the patient and family• Urgency and everywhere• Clarity of our aim; do what by when• Transformation built a foundation of reliability

– NQF Safe Practice, IHI Improvement Map, Joint Commission– Across the system

• Measurement / Transparency / Alignment

Which preventable death is ok?

Hospital Trustee

If you knew, why didn’t you do?

Bristol Inquiry