Turning Ideas Into Action

1. Turning Ideas Into Action Shon Dwyer, BSN, MBA Corporate Director Quality Improvement University of Michigan Hospitals and Health Centers May 1, 2003

2. Turning Ideas Into Action • Patient Safety Toolkit • Facilitated Sessions Many thanks to UMHHC staff: • Susan Anderson, Risk Management • Candace Friedman, Infection Control • Debbie Guglielmo, Quality Improvement • John Mitchell, Pharmacy • Pat Schmidt, Quality Improvement • Kristen VanderElzen, Infection Control • Maria Wallag, Quality Improvement • Heather Wurster, Office of Clinical Affairs

3. Patient Safety Toolkit Chapters • Safety culture • Safety plan • Safety curriculum • Adverse events • Medication safety • Infection prevention and control • Disclosure

4. Toolkit Organization • Brief introduction • Key issues • Challenges • Primer articles • Tools and templates

5. Adverse Events Chapter • Key issues • External requirements • Understanding error causation • Proactive approaches to error • Reactive approaches to error

6. Adverse Events Chapter • Challenges • Systems issue or performance issue? • When outcomes can’t be adequately measured • QA protection under the law

7. Adverse Events – Reactive Mode Event or near miss occurs Initial meeting for chronology Root cause analysis Action plan Wrap up meeting, implementation and monitoring

8. Facilitated Sessions Willing to try an unproven process… • Botsford General • Chelsea Community • Oakwood - Dearborn • Alpena General Thank you!

9. Facilitated Sessions Process • Needs assessment • Three RCA sessions • One session with presentations and panel discussion • “Hospital Quality and Patient Safety: Existing and Emerging Reporting Requirements” - Dr. Darrell Campbell • “Clinical Practice Strategies to Enhance Patient Safety” – Dr. Sanjay Saint • CEU’s provided

10. RCA Sessions • Patient Safety Orientation presentation • Real adverse events utilized • UMHHC or volunteer hospital event used

11. Adverse Event Processing Challenges and Solutions At All Levels Event or near miss occurs Initial meeting for chronology Root cause analysis Action plan Wrap up meeting, implementation and monitoring

12. Evaluation • Highly rated • “It was a good example for the leadership and physicians here to see that the strength and the success of the outcome, is really the strength and commitment of the team.” • “Would like to continue this dialogue/relationship” • “Proven to be a valuable resource to our sentinel event investigation team”

13. Lessons Learned • We have much in common! • There is significant power in sharing vulnerabilities • We need to take time to do experiential learning with peers at the “detail” level