Creating a Culture of Patient Safety

1. Creating a Culture of Patient Safety WVU Department of Family Medicine RCB HSC- Eastern Division Konrad C. Nau, MD

2. We work in a complex environment

3. We know that error happens

4. We know that patient safety is the bedrock of quality care Institute of Medicine: Quality Care

5. IOM elements of “Quality” • Safe: avoiding injuries to patients from the care that is intended to help them • Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care • Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse) • Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and energy • Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status • Patient-Centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions “STEEEP” Framework outlined by the Institute of Medicine (“IOM”)

6. We preach “quality” but can we say we have a true “culture of safety” • Culture • “The way we do things around here” • Safety • Avoiding injuries from care intended to help patients

7. Can everyone in our clinic name five ways to improve patient safety ?

8. AHRQ Five Steps to Safer Health Care • 1. Ask questions if you have doubts or concerns. • 2. Keep and bring a list of ALL the medicines you take. • 3. Get the results of any test or procedure. • 4. Talk to your doctor about which hospital is best for your health needs.. • 5. Make sure you understand what will happen if you need surgery.

9. Delivering on our Promise of Quality Medical Care Quality Care Patient Safety

10. Patient Safety &Quality Medical Care Two fundamental questions guide us, as a world-class academic family medicine center, and in this order: 1.How can we help the patient? 2.In doing so, what can we learn?

11. Patient Safety CampaignWVU Dept Family Medicine-East Div • Patient Safety Kickoff • System of Reporting and Analyzing Error • Regular Patient Safety Grand Rounds • Create a Culture of Safety

12. Patient Safety Kickoff • Entire office assembled off-site for lunch meeting January 2005 • Present : Epidemiology of Medical Error • Present : Creating a Culture of Patient Safety

13. System to Report and Analyze Error • Electronic Occurrence Reporting System • Quantros/Dr Quality/ORM • Web based • We encourage ALL staff to file reports online • Patient injury • Adverse drug reactions • Near-misses • Non-putative, can be filed anonymously

14. https://qxpert.quantros.com/orm/jsp/JeffersonLogin.jsp Click here to report an occurrence (a.k.a. variance or incident) anonymously. You do not need a User ID or Password to do this. Please assist us in creating a safer healthcare environment for the customers we serve

15. Resident PhysiciansReporting and Analyzing Error • All residents are REQUIRED to self report their own “medical errors”. • Electronic format is confidential and Peer Review protected. • Encourages reflection and honesty expected in physicians • Non-putative focus on systems-based analysis • Will formulate basis of Patient Safety Grand Rounds topics

16. Patient Safety Grand Rounds • Bimonthly – residents, faculty, students, invited clinic staff • Based on resident’s self reported medical error or near miss • Clinical case presented • Systems-based analysis of the error • Present patient safety literature that supports recommendations • Case Report and analysis is written up and reviewed with Chair prior to required submission to AHRQ M&M

17. Create a Culture of Patient Safety • Enhance clinic library with Patient Safety materials • Journal of Patient Safety • Patient Safety & Quality Healthcare Journal • Seminal textbooks • Crossing the Quality Chasm • To Err is Human • Enhance clinic technology for Patient Safety • Clinic wide Lexicomp/Drug Interaction software on all computers and handhelds • Redesign Clinic Web Page • Medication Charts • Office Visit preparation/safety tips

18. Create a Culture of Patient Safety • AHRQ Patient Safety Culture Survey http://www.ahrq.gov/qual/hospculture/ • Outpatient format available in PDF or Word • Results display template on PowerPoint • Involve entire clinic in patient safety culture survey • Patient focus groups to inform clinic about patient stakeholder perspectives • Clinic leadership makes “Patient Safety Rounds”

19. Patient Safety Culture Survey

20. Sample culture Survey result slide: Overall Perceptions of Safety % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree Survey Items • 1. Patient safety is never sacrificed to get more • work done. (A15) • 2. Our procedures and systems are good at • preventing errors from happening. (A18) • R3. It is just by chance that more serious • mistakes don’t happen around here. (A10) • R4. We have patient safety problems in this • unit. (A17) RIndicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Page

21. Quality Primary Care for the 21st Century • Safe Patient Care • Consistent Best Practices • Great Patient Service

22. Ambulatory Patient Safety Culture • Create a Culture of Safety • Culture = the way we do things around here • Culture of Safety Requirements • Visualize a safe system • Non-punitive environment • Leadership support Quality Care Patient Safety

23. Ambulatory Patient Safety • Capture errors that occur • Analyze errors • Follow-up on analysis • Safety projects will emerge • Medication • EMR • Communications • Team work • Test results • Pt education about safety Quality Care Patient Safety

24. We need creativity

25. We need enthusiasm We need you.