Seguridad y calidad en al atendimiento en UTI-Pediátrica

Transcription

1 Seguridad y calidad en al atendimiento en UTI-Pediátrica - Jornada en commemoración de los 25 años de Terapia Intensiva Pediátrica del Hospital de Clínicas de la Facultad de Medicina de Asunción Paraguay. - Hotel Excelsior en Asunción, Paraguay - 17 de noviembre de a

2 Seguridad y calidad en al atendimiento en UTI-Pediátrica - Eduardo Juan Troster, MD, PhD Director of PICU Hospital Israelita Albert Einstein São Paulo, Brasil Médico Asistente de ITACI ( Instituto de Tratamento de Cancer Infantil) troster@einstein.br & eduardotroster@gmail.com 2

3 Seguridad y calidad en al atendimiento en UTI-Pediátrica Libros: - Derek S. Wheeler, Hector R. Wong & Thomas Shanley: Pediatric Critical Care Medicine. Basic Science and Clinical Evidence - Crossing the Quality Chasm. Institute of Medicine. A New Health System for the 21 st Century 3

4 Seguridad y calidad en al atendimiento en UTI-Pediátrica Sites: p g com seguranca do paciente/ 4

5 Patient Safety in the PICU 1. The 6 aims for improvement 2. Safety 3. Classification of Safety and Medical Errors 4. Modelo do Avedis Donabedian 5. Methods to Improve Patient safety in the PICU 6. Joint Commission International 5

6 Patient Safety in the PICU 7. Six Sigma 8. Leapfrog Group 9. Sistema Einstein de Qualidade e Segurança 10. Institute of Health Care Improvement 6

7 6 aims for improvement 1. Safe: avoiding injuries to patients from the care that is intended to help them 2. Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely l to benefit ( avoiding underuse and overuse respectively) 7

8 6 aims for improvement 3. 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. 4. Timely reducing waits and sometimes harmful delays for both those who receive and those who give care. 8

9 6 aims for improvement 5. Efficient avoiding waste, including waste of equipment, supplies, ideas and energy 6. Equitable providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status. 9

10 Classification of the Commission on Health Care Quality To characterize Health Care Quality this classification uses the realtionship between health care risks and benefits: 1. Underuse 2. Overuse 3. Misuse 10

11 Classification of the Commission on 1. Underuse: Health Care Quality The potential benefits outweigh the potential risks yet the service is not provided 11

12 Classification of the Commission on 2. Overuse: Health Care Quality the potential risks outweigh the potential benefits yet the service is still provided 12

13 Classification of the Commission on 3. Misuse: Health Care Quality Variation in the provision of services as well as the potentially avoilable errors and complications that occur because of the manner in which a service is provided 13

14 Safety Safety is first step in achieving health care quality Safety is defined as the freedom from accidental injury 14

15 Safety Safe care is care that minimizes risks and optimizes benefits It is very important in PICU due to the inherent risks and benefits The challenge for the PICU is to optomize benefits and minimize the ocurrence of risk. 15

16 Safety The patients and their families also have a role in safe care. The consent process is designed to provide information about the potential risks, benefits and alternatives treatments and to allow decisions that align with the family s personal interests 16

17 Safety Together providers, patients and families can improve the safety of care in the PICU 17

18 Classification of Safety and Medical Errors 1. Diagnostic errors 2. Treatment errors 3. Nosocomial infections 4. Procedural errors 5. Prophylactic errors 18

19 Classification of Safety and Medical Errors 1. Examples of diagnostic i errors: a) Wheezing attributed to asthma is really congestive heart failure b) Hypoxia is not recognized as a cause of agitation c) Signs of intracranial hypertension are not appropriately recognized d) Arterial blood gas values are inappropriately interpreted 19

20 Classification of Safety and Medical Errors 2. Examples of treatment errors: a) Treatment of intracranial hypertension without appropriate calibration of the monitor b) Failure to provide antipseudomonal coverage to neutropenic, febrile patients c) Renal failure during aminoglycoside treatment 20

21 Classification of Safety and Medical Errors 3. Examples of nosocomial infections a) Bloodstream infections b) Ventilator-associated pneumonia c) Urinary tract infection 21

22 Classification of Safety and Medical Errors 4. Examples of procedural errors: a) Pneumothorax occuring during central venous catheterization b) Nasogastric feeding tube placed in the lung c) Unplanned extubation 22

23 Classification of Safety and Medical Errors 5. Examples of prophylactic errors: a) Failure to provide appropriate position changes with resulting decubitus ulcer formation b) Failure to provide appropriate stress ulcer prophylaxis c) Failure to provide appropriate deep venous thrombosis prophylaxis 23

24 Ambiente Complexo e Interdependente 24

25 Modelo do Avedis Donabedian Estrutura Recursos Disponíveis para a execução dos serviços propostos Podem ser materiais ( equipamentos, edificações), humanos ( número e qualificações) e financeiros ( investimento e manutenção) Processo `Denota o que é realmente feito para oferecer cuidados Refere-se ao conjunto de procedimentos envolvidos na transformação dos recursos ( estrutura) t em resultados. Resultado Refletem o efeito dos cuidados no estado de saúde do paciente e da população em questão Devem ser avaliada pela satisfação da expectativa do usuário e pelos indicadores de resultados: morbidade e mortalidade 25

26 . Methods to Improve Patient safety in the PICU Processes are the steps by which patients and their care providers interact. A systematic analysis of these processes can highlight the variability occuring within these interactions and lead to opportunities to reduce risk points and improve the delivery of care. 26

27 3 Standart Approaches that are being used currently in Health care Performance Improvement Methods Root Cause Analysis Failure Mode and Effects Analysis 27

28 Performance Improvement Methods TQM ( Total Quality Management) and CQI ( Continuous Quality Improvement) these techniques aim to continually improve health care processes by reducing variability and streamlining care. 28

29 Performance Improvement Methods: PDSA Plan Do Act Study 29

30 Root Cause Analysis RCA is a standardized process analysis technique that is used by hospitals to understand the circunstances of a bad event. The technique is used to investigate and analyze serious and sentinel events after their. ocorrence 30

31 Root Cause Analysis RCA it is a process that is required by the Joint Commission for Accreditation of Helathcare organizations to maintain accreditation. In a stepwise process, a multidisciplinary team sequentially asks, what happened and why it happened to determine the fundamental reasons or root causes for the event s ocurrence. 31

32 Root Cause Analysis The root causes generally fall into multiple themes, incluing human factors ( fatigue), organizational factors ( workplace policies and procedures) and technical factors ( missing or inappropriate equipment) 32

33 Failure Mode and Effects Analysis Methodology: prospective process of identification may be more appropriate p applications for promoting safety in high risk healthcare settings as is a PICU. 33

34 Failure Mode and Effects Analysis It consists of defining i what can fail and the way it can fail ( failure modes), determining the effect of each failure mode on the system, classifying each potential failure mode according to its severity, and determining the response to the failure. Steps can then be taken to change the design or process to eliminate the failure, reduce its impact, or compensate for the failure 34

35 Root Cause Analysis in Health Care: Tools and Techniques, Fourth Edition If something goes seriously wrong with a patient in your organization's care, you want to know what happened and why so that it won't happen again to anyone else. A fully updated version of a Joint Commission Resources best-seller, Root Cause Analysis, Fourth Edition is designed to help health care organizations around the world prevent system failures by using the technique of root cause analysis to identify causes of sentinel events, implement risk reduction strategies, and develop effective and efficient ways to improve processes. This book offers a straightforward, 21-step framework for conducting a root cause analysis. The fourth edition also includes a Web resource containing root cause analysis tools such as worksheets, a slide presentation, sample case studies, and relevant articles compiled from Joint Commission Resources periodicals. 35

36 Joint Comission International The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation services. 36

37 Section I: Patient-Centered Standards International Patient Safety Goals (IPSG) Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patients (AOP) Care of Patients (COP) Anesthesia and Surgical Care (ASC) Medication Management and Use (MMU) Patient and Family Education (PFE) 37

38 Section II: Health Care Organization Management Standards Quality Improvement and Patient Safety (QPS) Prevention and Control of Infections (PCI) Governance, Leadership, and Direction i (GLD) Facility Management and Safety (FMS) Staff Qualifications and Education (SQE) Management of Communication and Information (MCI) 38

39 Six Sigma What does it mean to be "Six Sigma"? Six Sigma at many organizations simply means a measure of quality that strives for near perfection. But the statistical implications of a Six Sigma program go well beyond the qualitative eradication of customerperceptible defects. It's a methodology that is well rooted in mathematics and statistics. 39

40 Six Sigma Six Sigma is a process analysis technique that is being increasingly used in many health care organizations. It can usedin the PICU to improve events such as unintended extubations, bloodstream infections or even the timeless of transfers from the PICU to the ward. 40

41 The Leapfrog Group Mission Statement To trigger giant leaps forward in the safety, quality and affordability of health care by: Supporting informed healthcare decisions by those who use and pay for health care; and, Promoting high-value health care through incentives and rewards. 41

42 The Leapfrog Group The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information as well as rewards for hospitals that have a proven record of high quality care. 42

43 Qualidade e Segurança do Paciente A liderança da instituição estabeleceu o Decálogo da Segurança, firmando o compromisso de todos com a segurança do paciente, dos profissionais i i e do ambiente: 1. Decisão e interesse do nível mais estratégico 2. Responsabilidade da supervisão 43

44 Qualidade e Segurança do Paciente 3. Refletida como prioridade - no cotidiano, nas reuniões e discussões; nas políticas e procedimentos, que refletem padrões de qualidade d e excelência 4. Metas e resultados mensurados 5. Eventos adversos notificados, analisados e recomendações retro - alimentadas 44

45 Qualidade e Segurança do Paciente 3. Refletida como prioridade - no cotidiano, nas reuniões e discussões; nas políticas e procedimentos, que refletem padrões de qualidade d e excelência 4. Metas e resultados mensurados 5. Eventos adversos notificados, analisados e recomendações retro - alimentadas 45

46 Qualidade e Segurança do Paciente O Einstein participa de importantes iniciativas internacionais para a melhoria da assistência e da segurança do paciente, lideradas por instituições i como: - Joint Commission International, - Institute of Healthcare Improvement - Organização Mundial da Saúde. 46

47 The Institute for healthcare Improvement The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world 47

48 The Institute for healthcare Improvement Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. 48

49 Critical Care Intensive Care How to Improve Measures Changes Improvement Stories Tools Resources Literature FAQs Sepsis How to Improve Measures Changes Improvement Stories Tools Resources Literature The Institute for healthcare Improvement 49

50 Muchas Gracias por la Atención 50