patient safety in the health delivery “system” where we have been? where are we now? where must...
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Patient Safety In the Health Delivery “System”
Where we have been?
Where are we now?
Where must we go?
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