STOP the KILLING Peter Pronovost, MD, PhD. Please answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average . How smart am I How hard do I work How kind am I How tall am I How good is the quality of care we provide.
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STOP the KILLINGPeter Pronovost, MD, PhD
NCHS, 2009 Tsan, AJIC, 2008 Klevens, Semin Dialysis, 2008
Thompson, Ann Intern Med 2009 MMWR May 16, 2008; 57:19 Kallen, 19th Annual SHEA Meeting, San Diego, 2009
Umschied, C. University of Pennsylvania. Presentation at HICPAC, March 2009
Arch Surg 2005 MMWR 2002:51(RR16);1-44 Leapfrog Group 2007
Data for Action State Initiatives: Public Reporting of HAIs, 2009
Disclosures of HAI rates required
Comprehensive Unit based Safety program
Translating Evidence Into Practice
Have We Created a Safe Culture?
How Do We know We Learn
How Often Do we Harm?
Are Patient Outcomes
Educate staff on science of safety
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
Summarize the evidence in a checklist
Identify local barriers to implementation
Ensure all patients get the evidence
Pronovost J, Patient Safety, 2005
Pronovost 2005 JCJQI
Pronovost JCC, JCJQI
* “Needs Improvement” - Safety Climate Score <60%
Heifetz: Leadership Without Easy Answers