State of the Science of Safety and Quality: Call to Action

Transcription

1 State of the Science of Safety and Quality: Call to Action Jean Johnson, PhD, RN, FAAN Dean and Professor George Washington University This program generously funded by the Robert Wood Johnson Foundation

2 Learner Objectives At the completion of the session participants will be able to: Demonstrate awareness of the devastating effects of adverse outcomes on patients/families and healthcare professionals. Describe the history of the patient safety movement and the effect on health policy and regulatory standards. Discuss the Quality and Safety Education in Nursing (QSEN) competencies and the benefits of creating an education culture of Quality and Safety.

3 Why are we concerned about quality of health care? Don t we have the best in the world?

4 Institute Of Medicine s (IOM) Quality Chasm Series American Association of Colleges of Nursing All Rights Reserved.

5 US Health System US health system is the most expensive US Scored last on dimensions of access, patient safety, coordination, efficiency, and equity Compared to Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom (Commonwealth Foundation, 2010) US ranks 49 th world wide in life expectancy at year (Monaco is 89.78) (CIA report) Access to timely health care remains a challenge

6 Medicare Study One out of every seven hospital patients with Medicare experienced an adverse event in 2008 (about 134,000 Medicare recipients a month) At least 44% of the mistakes were preventable One month of those adverse events cost the federal government around $324 million dollars Office of the Inspector General, DHHS, 2010

7 Colorado Study At least 1 million patient safety incidents occurred in Medicare patients from Costing $8.9 billion 1 in 10 patients experiencing a patient safety incident died Of 15 monitored events, 8 were worse than previous years decubitus ulcer (bed sores) iatrogenic pneumothorax (collapsed lung) Postoperative hip fracture post-operative physiologic and metabolic derangements, postoperative pulmonary embolism (potentially fatal blood clots forming in the lungs) or deep vein thrombosis (blood clots in the legs) post-operative sepsis transfusion reaction HealthGrades, 2010

8 Colorado Study Most common patient safety incidents (rate per 1000 patients) Failure to rescue (92.71) Decubitus ulcer (36.05) Post-operative respiratory failure (17.52) Post-operative sepsis (16.53)

9 North Carolina Study 25.1 harms per 100 admissions Types of harms Consequence of procedures (186) Medications (162) Nosocomial infections (87) Other therapies (59) Diagnostic evaluations (7) Falls (5) 63% of harms were preventable Landrigan, Gareth, Bones, Hackbarth, Goldmann, and Sharek, 2010

10 Deaths from Medical Error in Perspective (CDC, 2009) Heart disease: 616,067 Cancer: 562,875 Stroke (cerebrovascular diseases): 135,952 Chronic lower respiratory diseases: 127,924 Accidents (unintentional injuries): 123,706 MEDICAL ERROR: 98,000 Alzheimer's disease: 74,632 Diabetes: 71,382 Influenza and Pneumonia: 52,717 Nephritis, nephrotic syndrome, and nephrosis: 46,448 Septicemia: 34,828 American Association of Colleges of Nursing All Rights Reserved.

11 Overall, how would you rate...the quality of health care in this country--as excellent, good, only fair, or poor? Gallup Poll, [Nov, 2011]

12 In the past year USA Today - lax safety practices in 5000 ambulatory surgical centers NYT some hospital infection rates rise USA Today only 20% of USA hospitals using WHO surgery checklist Wall Street Journal Near misses creeping up NYT look- alike tubes kill patients

13 National Quality Strategy Better Care: Improve the overall quality, by making health care more patient- centered, reliable, accessible, and safe. Healthy People and Communities: Improve the health of the United States population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

14 What is quality care? S afe T imely E fficient E quitable E ffective P atient-centered

15 Concern about Quality in All Health Sectors Hospital Ambulatory/outpatient Nursing home Home care and hospice

16 Patients Nurses at the Sharp End Health Care Organizations Health Systems Complex Needs Nurses Working Conditions Organizational Culture Organizational Climate Physicians Quality Improvement External Drivers Human Factors Perceptions Critical Thinking Teamwork Communication Cost Containment Benchmarks

17 Technical van der Schaaf- modified for healthcare Return to Normal Close Call Organizational Dangerous Situation Adequate defenses Human Factors Patient Factors Developing Errors ERROR (Inadequate Defenses)

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19 Normal Error Product of our current system design Manage through changes in: Processes Procedures Training Design Environment Managing Healthcare Risk The Three Behaviors At-Risk Behavior Unintentional Risk-Taking Manage through: Understanding our at-risk behaviors Removing incentives for at-risk behaviors Creating incentives for healthy behavior Increasing situational awareness Reckless Behavior Intentional Risk- Taking Manage through: Disciplinary action Normal Error Negligence? Recklessness *David Marx Just Culture

20 Reporting Errors and Near Misses What happens after an error or near miss? Reporting systems in place, RCA? How are patients and families informed of an unanticipated outcome? Who is accountable for patient safety? What is the process in your school of nursing?

21 Quality and Safety Education in Nursing (QSEN) We can t hope to make lasting changes in the ability of health care systems to improve without changes in the ways we develop future health professionals. Those changes require faculty and schools to change. Paul Batalden Dartmouth College QSEN Advisory Board

22 Patient/Family Centered Care Teamwork and Collaboration Safety Evidence-based Practice Quality Improvement Informatics QSEN Competencies

23 BSN Compared to Graduate Competencies BSN Competencies Describe Identify Recognize Demonstrate Explain Discuss Compare Graduate Competencies Analyze Formulate Explore Lead Interpret Propose Synthesize

24 Patient/Family Centered Care New - Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient s preferences, values and needs Old Listen to patient and demonstrate compassion and respect.

25 Collaboration and Teamwork Old Work side by side with other HC professionals while performing nursing skills. New - Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

26 Quality Improvement Old Routinely updating nursing policies and procedures New - Use data to monitor outcomes of care processes and improvement methods to design and test changes to continuously improve quality and safety of health care systems

27 Evidence-Based Practice Old Adhere to internal policies to standardize skills execution. New - Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

28 Safety Old focus on individual performance to keep patients safe. New - Minimize risk of harm to patients and providers through both system effectiveness and individual performance

29 Health Informatics Old timely and accurate documentation New - Use information and technology to communicate, manage knowledge, mitigate error, and support decisionmaking

30 Defining Change What do you want to accomplish? Substantial change Creating substantive content in quality and patient safety Tinkering at the margins Small changes to curriculum Transformation Create a culture of quality

31 Change (Fatigue?) Health care system Technologic advances Types of organizing units for health care HMO, Preferred Provider Organization, Accountable Care Organization Philosophic shift: paternalistic to patient centered Education Clinical nurse leader DNP APRN regulatory model Content in gero, genomics, end of life care, informatics

32 Passion for Culture Change Share your passion Be clear about how strong of a passion you have to change the culture Is this something I am willing to do everyday? Am I committed to doing this for 5 years? Is this my top professional priority? I want to do this because.. Do I believe lives depend on me to do this?

33 The Lewis Blackman story as told by his mother

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35 CHANGE THE WORLD OF HEALTH CARE Start where you are Use what you have Do what you can» A. Ashe