ORIENTATION FOR STUDENTS

PATIENT SAFETY

PERFORMANCE IMPROVEMENT

Quality & Risk

RISK MANAGEMENT, PERFORMANCE IMPROVEMENT, & PATIENT SAFETY An organizational QUALITY

PERFORMANCE program exists to:• Evaluate and improve processes that enhance

patient safety and result in quality service• Educate and involve staff in processes

• Identify events and other opportunities that allow for process review and improvement

WHAT IS PERFORMANCE IMPROVEMENT?

Performance Improvement is EVERY staff person’s concern

It is the assessing of how things are done or turn out and how to make them better

No matter what your job, you play an important role in helping OMH provide safe quality patient care.

Performance Improvement is vital to our organization and your department’s goals!

• IT IS HOW WE ARE JUDGED!!!

What is the Current Climate?

Public trust at an all time low• Institute of Medicine Reports (12/99 & 3/01)• Headlines about fraud / medical mistakes• Increased co pays and denials / decreased

access• Legislation• Staffing shortages heavily reported• Patient / family expectations increasing as to

clinical and non clinical services

PATIENT SAFETY & QUALITY - EXAMPLE ACTIVITIES & SOURCES Application / Credentialing Orientation Job Descriptions Evaluations Continuing Education Policies / Procedures Regulatory Compliance (Environmental) Safety

Documentation External Alerts / Guidelines -reviewed Third party reports Complaints Infection Control Internal Surveys Occurrence Reporting Monitors / Screens / Profiles Peer Review

JCAHO Patient Safety Goals

Focus on previously reported Sentinel Events

Are surveyed as an “all or none” Can change every year Evidenced - based and require “culture

change” Seven goals / 13 aspects

2003-04 Patient Safety Goals

Patient identification• Use of 2 unique identifiers• Use of “time out” prior to invasive procedure

Effective communication• “Read back” on verbal / phone orders• Standardize abbreviations / list those not to be

used

Safe use of high-alert medications• Remove concentrated electrolytes• Standardize / limit drug concentrations

Eliminate wrong site, patient, procedure surgery• Pre-op verification process• Site marking

Safe use of infusion pumps• Free-flow protection

Effectiveness of clinical alarm systems• PM and testing of systems• Settings - parameters, audible for

distance/competing noise Nosocomial Infections reduced and

Monitored• CDC Guidelines adopted and implemented• Tracking of serious injury / death related to

nosocomial infection

DO THE RIGHT THINGAt 99% :

2 airplanes will crash during landing at O’Hare airport per day

1 new hire a year will have falsified their application

One Xray study each day will be done wrong or misread

17 Lab studies would be reported incorrectly each day

Measuring Performance Improvement & Safe Care

• It is important to objectively know we are doing a good job

• Measuring where we are and that we have done to improve must be done using data

• Data comes from lots of sources.. Sometimes even you !

• Data then is analyzed (interpreted)• And then changes are sometimes made and re

measured

STRIVE FOR 100% QUALITY Because at 99%: The wrong procedure would be performed in

surgery once a week Every two months a baby would be dropped

to the floor at delivery 8 bills a day will be for too much and contain

errors One EMS call each week would fail to meet

EMTALA regulations

Plan, Do, Study & Plan, Do, Study & ActAct

Oconee Memorial Hospital

utilizes the

PDSA

methodology to continuously measure,

assess,

and improve processes

and outcomes.

PlanPlanthe

improvementand the data

DoDothe improvement and the data collection

StudyStudythe results of the implementation

ActActto hold the

gain and continue

improvement

#1#1

#2#2

#3#3

#4#4

OMH SPECIFIC ACTIVITIES ADDRESSING PI / PATIENT SAFETY Organization-wide initiative - MISSION Routine monitoring of outcomes / events Timely reporting and evaluation of events /

complaints with process the focus Use of external information as a source for

process change Departmental initiatives to enhance processes

COMMON PATIENT SAFETY ISSUES Medication orders-prescribing, dispensing,

administering, verbal/phone orders Recognition / knowledge of patient

condition & failure to respond to information on patient status

Communication breakdown with patient or staff

Procedure error- skill, appropriate application

Other “Issues”

Confidentiality & Other Patient’s Rights Issues

Documentation Regulatory Compliance Workplace Safety Equipment / Product Usage Appropriate Communication

COMMON BARRIERS to GOOD PI / PATIENT SAFETY Lack of consistency Lack of knowledge / understanding Lack of commitment Not involving staff in the process evaluation Lack of willingness to change Failure to admit to mistakes Lack of communication

Examples of OMH Patient Safety Initiatives Medication Safety Fall Prevention External Information as resource Patient Confidentiality (HIPAA) Policy Revisions

• Universal Protocol for correct surgery• Patient Identification• Disclosure

NOTHING WILL CHANGE UNLESS YOU CHANGE IT

SAFETY IS AN INDIVIDUAL & COLLECTIVE RESPONSIBILITY