perioperative patient safety changing safety culture one step at a time n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Perioperative Patient Safety Changing Safety Culture One Step at a Time PowerPoint Presentation
Download Presentation
Perioperative Patient Safety Changing Safety Culture One Step at a Time

Loading in 2 Seconds...

play fullscreen
1 / 70

Perioperative Patient Safety Changing Safety Culture One Step at a Time - PowerPoint PPT Presentation


  • 96 Views
  • Uploaded on

Perioperative Patient Safety Changing Safety Culture One Step at a Time. Satya Krishna Ramachandran MD FRCA Department of Anesthesiology University of Michigan. Disclosures. Paid scientific advisory consultant Galleon Pharmaceuticals Merck, Sharp & Dohme Funding PSA with MSD for 2014

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Perioperative Patient Safety Changing Safety Culture One Step at a Time' - keran


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
perioperative patient safety changing safety culture one step at a time

Perioperative Patient SafetyChanging Safety CultureOne Step at a Time

Satya Krishna Ramachandran MD FRCA

Department of Anesthesiology

University of Michigan

disclosures
Disclosures
  • Paid scientific advisory consultant
    • Galleon Pharmaceuticals
    • Merck, Sharp & Dohme
  • Funding
    • PSA with MSD for 2014
    • MiCHR CTSA PGP UL1TR000433 for 2014

The material of this talk is independent of these disclosures

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

slide8
We can't solve problems by

using the same kind of thinking

we used when we created them

Albert Einstein

where healthcare was
Where Healthcare Was
  • Cottage Industry Mentality
  • Virtually Total Reliance on:
    • Professional/Individual Responsibility
    • Individual Perfection
    • Train and Blame
  • Little Understanding of Systems Relative to People and Processes
    • Ignorance vs. Arrogance

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

where healthcare is
Where Healthcare Is
  • Cottage Industry Mentality
  • Virtually Total Reliance on:
    • Professional/Individual Responsibility
    • Individual Perfection
    • Train and Blame
  • Little Understanding of Systems Relative to People and Processes
    • Ignorance vs. Arrogance

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

patient safety culture
Patient Safety Culture

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

A culture of safety can be defined as an

integrated pattern of individual and organizational behaviour

based upon shared beliefs and values that

continuously seeks to minimize patient harm

that may result from the processes of care delivery

(Kizer, 1999)

importance of culture
Importance of Culture

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  • “Health care organizations must develop a culture of safety such that an organization's care processes and workforce are focused on improving the reliability and safety of care for patients.” (p. 14; IOM, 1999)
  • “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.” (p. 79; Crossing the Quality Chasm, 2001)
culture and patient safety
Culture and Patient Safety

PatientSafety

Patient

Safety Culture

Norms and

Behaviour

Enabler/

Barrier

Patient Safety Interventions

typical approach
Typical Approach
  • New Policies, Regulations, Reporting Systems, Training
  • Good First Step But…..
    • Lack of Systems Insight
    • Superficial Solutions (?Answers)
    • Inadequate Follow-Up
    • Lost Opportunity

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

typical missing features
Typical Missing Features
  • Clear Understanding of Goal
  • Preventive Approach
  • Field Understanding & Buy-In
  • Systems Approach
  • Sustainability
  • Trust/Culture of Safety

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

patient safety culture elements
Patient Safety Culture Elements

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  • Leadership commitment to safety
  • Organizational resources for patient safety
  • Priority of safety versus production
  • Effectiveness and openness of communication
  • Openness about problems and errors
    • Near misses
  • Organizational learning

(Singer et al. 2003)

iom strategy for improvement
IOM Strategy For Improvement
  • Education: Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety
  • Reporting: Identifying and learning from errors by developing a nationwide public mandatoryreporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

iom strategy for improvement1
IOM Strategy For Improvement
  • Implementing safety systems in health care organizations to ensure safe practices at the delivery level
  • Professionalism: Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

key points
Key points
  • Patient Safety, Professionalism and Quality Improvement skills are extremely valuable for all career paths
  • These attributes have renewed emphasis in the NAS
    • Anesthesiologists are uniquely positioned to lead
    • We can leverage existing resources to improve teaching/learning of these attributes
    • The goal is to create physicians who are in tune with growing public demand for accountability and transparency, while upholding the highest standards of clinical care

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

why change the system
Why change the system?

The ACGME’s public stakeholders have heightened expectations of physicians

  • team-oriented care
  • information-technology literacy
  • sensitivity to cost-effectiveness
  • the ability to involve patients in their own care, and
  • the use of health information technology to improve care for individuals and populations

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

slide24
CLER

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

cler qa areas of focus
CLER - QA Areas of Focus
  • Patient Safety – opportunities for residents to:
    • report errors, unsafe conditions & near misses
    • participate in inter-professional teams to promote & enhance safe care.
  • Quality Improvement – engage residents in using data to:
    • improve systems of care,
    • reduce health care disparities &
    • improve patient outcomes.
  • Professionalism -
    • educate for professionalism,
    • monitor behavior on the part of residents and faculty &
    • respond to issues concerning: (i) accurate reporting of program information; (ii) integrity in fulfilling educational and professional responsibilities; & (iii) veracity in scholarly pursuits.
so how can you make a difference
So How Can You Make a Difference?
  • Problem:

No Problem

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

non punitive systems approach
Non-Punitive Systems Approach
  • TIVA for acoustic neuroma
  • Patient coughs = surgeon very upset
    • In a punitive system – event would go unreported
  • Root cause contributing factors:
    • Carrier fluid ran out (without alerting resident)
    • Antibiotics hung on carrier line
    • Teaching session ongoing distracting clinical care
    • Depth of anesthesia unknown
    • Isoflurane could be used (AEP)

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

patient safety
Patient Safety
  • How to report a clinical event?
    • hint: search for “QA” in Centricity

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

patient safety1
Patient Safety
  • How to report a confidential QA concern?
    • hint: search for “QA” in Centricity

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

patient safety2
Patient Safety
  • What happens when you report an event?

An anesthesia reviewer (usually faculty member) from the QA Committee conducts a comprehensive incident review…

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

slide33

Standard Review Process

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

patient safety3
Patient Safety
  • How to identify system issues from adverse event reports?

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

slide35

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

the postoperative patient care handover uh pacu

The Postoperative Patient Care HandoverUH PACU

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

Department of Anesthesiology, University of Michigan Health System

the postoperative patient care handover a plan for improvement
The Postoperative Patient Care Handovera plan for improvement
  • UMHS Proposal:
    • Clearly establish & communicate patient care handover expectations to all involved care givers.
    • Standardize handoff communication by:
      • developing a comprehensive, succinct conversation guideline for all handovers
      • leveraging the EHR to provide easily accessible and retrievable electronic documentation
    • Establish expectations for the required
      • Timing of and Participants in the care handover
    • Provide a clearly communicated path for care escalation

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

implementation
Implementation

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  • New EHR tool
  • Video handover simulation
  • Multiple presentations at departmental M&M’s
  • One-on-one PACU RN training
  • Signage in PACU
  • Continuous implementation feedback
participation and distraction rates
Participation and Distraction Rates

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  • Both Surgery and PACU anesthesia attendance rates increased ~ 30%,
  • surgery distraction rates at the bedside also increased:
    • Attending/resident conversations - Non-handover conversations
    • Texting - Responding to pages
quality of handover communication teamwork
Quality of Handover – communication & teamwork

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

handover time distribution
Handover Time Distribution

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  • Observed handovers differ greatly from re-structured goals.
    • Brief assessment allowance
    • Coordinated communication
    • OR Anesthesia time
barriers
Barriers

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

Observed barriers included:

  • Time pressures,
  • Non-standard work,
  • System support issues &
  • Institutional culture
barriers t ime p ressures
Barriers - time pressures

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

  • OR Turnover
    • Periods of high workload and competing tasks, such as future cases, negatively impact communication and coordination between care providers.
  • Initial Post-Operative Assessment
    • The need for the PACU RN to assess patients immediately upon arrival to the recovery unit establishes a built-in delay to communication efforts. This delay reduces participation in the established communication structure.
rn assessment time
RN Assessment Time

Median nurse assessment time = 3:43

25% = 2:41

75% = 4:56

Mean = 4:11

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement
Perioperative Quality Improvement
  • Medical Team Training:
    • Provides for a shared mental model of care by enabling clear, concise communication between providers
    • For better patient care &
    • Timely identification and resolution of problems
  • The Debrief Process:
    • The gateway for improvement of intraopSystems failures

WHY IS THIS IMPORTANT???

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement1
Perioperative Quality Improvement
  • Problems Addressed:
  • Even with limited feedback to providers, there has been an >100% increase in participation just since last October:

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement2
Perioperative Quality Improvement
  • Problems Addressed:
  • Cases with documented issues with instrumentation have declined by >30%

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement3
Perioperative Quality Improvement
  • Problems Addressed:
  • Cases with documented issues with instrumentation have declined by >30%

Is this decline actual improvement,

…. or “reporting fatigue”?

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement4
Perioperative Quality Improvement
  • Coming Updates:
  • Preview of changes coming to the OR quality
  • system in the new year:
      • the Perioperative Quality Improvement Committee will exercise oversight of OR QI efforts
      • the OR Debrief form will be improved
      • the Debrief form will be displayed on the OR whiteboards before submittal
      • (continued…)

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement5
Perioperative Quality Improvement
  • Coming Updates:
  • Preview of changes coming to the OR quality
  • system in the new year:
      • Every Debrief ‘issue’ will be triaged at the next OR daily huddle
        • What needs to be done
        • Who is responsible
        • Deadline for completion
      • New feedback and online reporting will enable all providers to monitor the progress of Debrief ‘issues’

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement6
Perioperative Quality Improvement
  • OR Debrief:
  • OR Debrief Keys:
    • Professional
    • Non-personal
    • Facts-only
    • Use the Whiteboard as a script

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement7
Perioperative Quality Improvement
  • Daily Huddle Overview:
  • The “Daily Problem-Solving Huddle”
  • Each day, all OR Debrief forms with ‘issues’ noted will be discussed by OR leaders to:
    • Review new problems
    • Triage to the appropriate owners
    • Document countermeasures
    • Assign completion deadlines

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

perioperative quality improvement8
Perioperative Quality Improvement

Daily Huddle Overview:

The “Daily Problem-Solving Huddle”

This “huddle” will take place every day at 12:30 outside of UH OR 24.

  • Daily Attendees:
  • RN Pod Managers
  • RN Service Leads
  • Available Periop Techs
  • Available RN staff
  • Instrument Room rep
  • Pre-op/PACU RN rep
  • Anesthesia Faculty
  • Surgical Faculty

? Residents/CRNAs

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

leveraging ehr for patient safety
Leveraging EHR for Patient Safety
  • Patient Safety
    • Advanced Computing / Decision Support
      • Algorithms
      • Alerting
      • Bar Coding
    • Equipment analysis
    • Infection Control

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

opportunities patient safety
Opportunities- patient safety
  • Patient Safety
    • Advanced Computing / Decision Support
      • Algorithms
      • Alerting
      • Bar Coding
    • Equipment analysis
    • Infection Control

“BP gaps of ≥10 minutes were common in electronic anesthesia records, and their incidence was reduced … by real-time feedback to providers” [9]

“Of 7,422 patients …There were no episodes of sudden-onset postoperative acute respiratory compromise after institution of the OSA alert system.”

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

opportunities lma failures
Opportunities- LMA failures

Problem:

Local increase in laryngospasm rate

  • Equipment analysis

Solution:

Trial new LM

Measure impact on patient care and cost

  • Preliminary Findings:
  • Instituting New LM resulted in
  • decrease in adverse events ,
  • 50% reduction in equipment waste,
  • Overall cost savings

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

opportunities patient safety1
Opportunities- patient safety
  • Infection Control

Problem:

Inability to tie contaminated scopes to patient-use

Solution:

Document scope use & sterilization in the AIMS – tied to the patient’s case

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

changing culture professionalism
Changing cultureprofessionalism

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

professionalism
Professionalism
  • Acceptance of peer critique is probably the fundamental pre-requisite for professionalism
  • How to implement a system that protects both provider confidentiality while upholding accountability?
  • How to create a just culture?
    • AKA when do we breach QA confidentiality with personnel concerns?

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

just culture david marx
Just Culture – David Marx

Human

Error

At-Risk

Behavior

Reckless

Behavior

Product of our current

system design

Unintentional Risk-Taking

Intentional Risk-Taking

  • Manage through changes in:
  • Processes
  • Procedures
  • Training
  • Design
  • Environment
  • Manage through:
    • Removing incentives for at-risk behaviors
    • Creating incentives for healthy behaviors
    • Increasing situational awareness
  • Manage through:
  • Remedial action
  • Disciplinary action

Support

Coach

Punish

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

slide65

“QA Concern” Review Process

QA Concern

Review Closed & Secured

Confidential Discussion:

Provider & Division Head

QA Committee Discussion

Senior Review Subcommittee

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable

qa concern letter
“QA Concern Letter”
  • Weighted towards system issues
    • ¼ individual concern around management
    • ¾ system issues that contributed to event
  • Forces responsibility and accountability from leadership
  • Permits a confidential educational opportunity to providers
    • Significant peer concern over management
    • May signify need for more training

This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers. Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable