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
– 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
How Hazardous Is HealthCare?
PATIENT SAFETY AND HUMAN
FACTORS
TO ERR IS HUMAN
We can't solve problems by
using the same kind of thinking
we used when we created them
Albert Einstein
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
• 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
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)
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
Importance of Culture
• “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)
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
Culture and Patient Safety
Patient
Safety Culture
Norms and
Behaviour
Enabler/
Barrier
Patient
Safety
Patient Safety
Interventions
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
•
•
•
•
•
•
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
•
•
•
•
•
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)
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 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
mandatory reporting 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 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
CHANGING CULTURE
RESIDENT EDUCATION
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?
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
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
1. Patient Safety – opportunities for residents to:
– report errors, unsafe conditions & near misses
– participate in inter-professional teams to promote & enhance safe
care.
2. Quality Improvement – engage residents in using data to:
– improve systems of care,
– reduce health care disparities &
– improve patient outcomes.
3. 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?
• 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
• 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
CHANGING CULTURE
REPORTING ADVERSE EVENTS
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 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 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
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 Safety
• How to identify system
issues from adverse
event reports?
SYSTEM FACTORS
Equipment failure
Technical accident
Communication error
Limitation of therapeutic
standards
Limitation of diagnostic
standards
Limitation of available
resources
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 of
thesupervision
provisions of MCL 333.20175;
Limitation
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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
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;
of Anesthesiology,
University
Michigan
Health
System
MCL Department
333.21515; MCL
331.531; MCL 331.533
or suchofother
statutes
that may
be applicable
The Postoperative Patient Care Handover
a plan for improvement
UMHS Proposal:
1. Clearly establish & communicate patient care
handover expectations to all involved care givers.
2. Standardize handoff communication by:
 developing a comprehensive, succinct
conversation guideline for all handovers
 leveraging the EHR to provide easily accessible
and retrievable electronic documentation
3. Establish expectations for the required
 Timing of and Participants in the care handover
4. Provide a clearly communicated path for care
This is a confidential Qualityescalation
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;
37
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
Implementation
1. New EHR tool
2. Video handover simulation
3. Multiple presentations at
departmental M&M’s
4. One-on-one PACU RN
training
5. Signage in PACU
6. Continuous implementation
feedback
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
Participation and Distraction Rates
• Both Surgery and PACU anesthesia attendance rates increased ~ 30%,
• surgery distraction rates at the bedside also increased:
This is a confidential
Quality Improvement and conversations
Assurance/peer review-document
of the University
of Michigan Hospitals and Health Centers.
– Attending/resident
Non-handover
conversations
Unauthorized disclosure or duplication is absolutely prohibited. This document is protected from disclosure pursuant to the provisions of MCL 333.20175;
– Texting
Responding
pages
MCL 333.21515; MCL 331.531; MCL 331.533 -or such
other statutesto
that
may be applicable
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
• Observed handovers differ greatly from re-structured goals.
– Brief assessment allowance
– Coordinated communication
– OR Anesthesia time
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
Barriers
Observed barriers included:
1. Time pressures,
2. Non-standard work,
3. System support issues &
4. Institutional 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
Barriers - time pressures
• 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.
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
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
CHANGING CULTURE
ENGAGE SURGEONS AND NURSES
Perioperative Quality Improvement
WHY IS THIS IMPORTANT???
 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 intraop Systems
failures
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;
46
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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;
48
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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;
49
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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;
50
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
Perioperative Quality Improvement
Coming Updates:
Preview of changes coming to the OR quality
system in the new year:
1. the Perioperative Quality Improvement Committee
will exercise oversight of OR QI efforts
2. the OR Debrief form will be improved
3. 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;
51
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
Perioperative Quality Improvement
Coming Updates:
Preview of changes coming to the OR quality
system in the new year:
4. Every Debrief ‘issue’ will be triaged at the next OR
daily huddle
• What needs to be done
• Who is responsible
• Deadline for completion
5. 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;
52
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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;
53
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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:
1. Review new problems
2. Triage to the appropriate owners
3. Document countermeasures
4. 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;
54
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
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;
55
MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable
CHANGING CULTURE
LEVERAGE ELECTRONIC HEALTH
RECORDS
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
• Patient Safety
– Advanced Computing / Decision Support
• Algorithms
• Alerting
• Bar Coding
– Equipment analysis
– Infection Control
“BP
“Of 7,422
gaps of
patients
≥10 minutes
…There
were
were no
common
episodes in
of electronic
sudden-onset
anesthesia
records,
postoperative
and their
acute
incidence
respiratory
was
reduced
compromise
… byafter
real-time
institution
feedback
of the
to
[9]
providers”
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
• Equipment analysis
Problem:
Local increase in laryngospasm
rate
Solution:
1. Trial new LM
2. Measure impact on patient care and cost
Ratio QTY purchased to QTY
Documented
May '10 - Feb '13 Oct '12 May '13
2.517
1.453
diff
1.064
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 safety
• Infection Control
Problem:
Solution:
1. Inability
toscope
tie contaminated
scopesinto
Document
use & sterilization
patient-use
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
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
• 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
Human
Error
At-Risk
Behavior
Product of our current
system design
Unintentional Risk-Taking
Manage through changes in:
•
•
•
•
•
Processes
Procedures
Training
Design
Environment
Support
Manage through:
• Removing incentives for
at-risk behaviors
• Creating incentives for
healthy behaviors
• Increasing situational
awareness
Coach
Reckless
Behavior
Intentional Risk-Taking
Manage through:
• Remedial action
• Disciplinary action
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
“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”
• 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
Thank you
Although the road is long …
There’s always an opportunity …
How Hazardous Will HealthCare Be?