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Keeping Patients and Staff Safe Dr. Arati Verma Sr VP-Medical Quality

Keeping Patients and Staff Safe Dr. Arati Verma Sr VP-Medical Quality Co Chair, NABH Technical Committee. “Healthy Gujarat -Setting an Agenda for Actions” Gandhinagar, 3 rd Dec, 2013. The Vision. The Challenge. The Roadmap for improvement. The Vision. The Challenge.

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Keeping Patients and Staff Safe Dr. Arati Verma Sr VP-Medical Quality

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  1. Keeping Patients and Staff Safe Dr. Arati Verma Sr VP-Medical Quality Co Chair, NABH Technical Committee “Healthy Gujarat -Setting an Agenda for Actions” Gandhinagar, 3rd Dec, 2013

  2. The Vision The Challenge The Roadmap for improvement

  3. The Vision The Challenge The Roadmap for improvement

  4. “Quality Healthcare for all” Healthcare Infrastructure

  5. Gujarat leading the way…..Congratulations! • A Success Story : Quality Improvement Programme- Gujarat, India • I • ndia’s 1st NABH / NABL Accredited Govt. Facilities:- • Dist. General Hospital Gandhinagar • Primary Health Centre Gadboriad, • Dist: Vadodara • Medical College Hospital Labs Bhavanagar • Blood Bank (BJMC Ahmadabad) • Food & Drug laboratory Badodara • Mental Hospital Badodara • Community Health Center, Bardoli-Surat And we applaud the ongoing initiatives!

  6. Quality Benefits all Stakeholders • Deliver the Highest Quality of Care to all our Patients • Service Delight: Timeliness, efficient, clean • No harm/complications • Cure/control of disease • Ethical & Trustworthy • Feel safe • Staff Satisfaction and Health • Meet Financial Objectives • Affordable • Low operating costs • Value for money • Realization of the Vision

  7. Patient Centered Care Coordination and integration of care (Team Medicine) Optimum Health Outcome Information, communication and education No harm Shared Decision making Transition and continuity Value for money Safety Involvement of family and friends Respect for patient’s values, preferences and needs. Physical comfort Emotional support

  8. Improve at all Levels Outcome What is achieved Patient & staff satisfaction, Low infection rates, good clinical outcomes Protocols, Procedures, Treatments, Policies, Training, Efficiency, low waste, Appropriate use Process What is done Structure Availability of Beds, OPDs, Staff, Building, Space Equipment, Supplies, Resources, Basic Monitoring of patients What is needed

  9. Floor to Ceiling Outcomes Aim for “HUNDRED” Disease or Procedure Based Outcomes Benchmarked with Evidence Based Practices Eg: Outcomes of Acute MI Stroke Management etc Patient Reported Outcome Measures (PROM) Mobility, Health Outcomes, Pain, Longevity, Functionality, Experience etc Ceiling Safety and Complications Patient falls, Hospital Acquired Infections, Pressure Sores, Adverse Drug Events, Other Adverse Events Floor Aim for “ZERO”

  10. The Vision The Challenge The Roadmap for improvement

  11. Why is patient safety important? • 1 in 10 patients admitted to hospitals will experience some form of unintended harm (limited data from low-income countries) • An estimated 50% are preventable • Global problem – no country has solved it Source: World Health Organization

  12. How Hazardous Is Health Care? 1999 Institute of Medicine Report $9 billion in annual costs Lucian Leape, 2/2001

  13. Why is Staff Safety Important? The health care industry is one of the worldwidelargest segments of the global workforce World health statistics 2011 World Health Organization estimates: 9.2 million physicians 19.4 million nurses and midwives 1.9 million dentists and other dentistry personnel 2.6 million pharmacists and other 1.3 million community health workers 13

  14. Healthcare Workers are exposed to many Hazards Common to all Clinical areas Bloodborne pathogens Airborne pathogens Ergonomic Slips, trips, falls Sharps Latex Fire/Electrical Stress • Lab Workers • Infectious diseases • • Chemical agents • (formaldehyde, • toluene, xylene) • CSSD • Compressed • gases • • Anesthetic • gases • • Chemical • agents • (sterilizers, • cleaners) • • Burns, cuts • OT • Anesthetic gases • • Compressed • gases • • Lasers Radiology • Radiation • Pharmacy • Drug absorption • Laundry • Contaminated laundry • • Noise • • Heat • • Lifting • • Fire hazard • Kitchen Staff • Food borne diseases • • Heat • • Moving machinery • • Slips, trips, falls

  15. What makes Healthcare Hazardous Low Control, high uncertainty, less than ideal work flows, Low “culture of Safety” Low threshold: small breakdowns may lead to catastrophic harm

  16. Example: Frequency and Distribution of Hospital Acquired Infections • A prevalence survey in 55 hospitals of 14 countries representing (Europe, Eastern Mediterranean, South-East Asia and Western Pacific): • Average of 8.7% of hospital • patients had nosocomial infections • At any time, over 1.4 million people • worldwide suffer from infectious • complications acquired in hospital Increase in hospitalization: 8 days Increase in Cost, Length of stay, morbidity, mortality Source; World Health Organization

  17. Negative Impact: • Families: • Want justice: punishment of the guilty • Loss of trust • Sudden Bereavement • Earning Member • Agony, Violence and aggression • Cannot deal with loss • Want compensation • Patients/Staff: • Annoyance / Disappointment: did not • deliver on perceived promise • Harm • Permanent - Disability • Death • Additional Costs hospitalization/medicines • Discomfort: prolonged stay/distress • Loss of ability to work/earn • Clinicians: • Shattering Experience • Low morale • Loss of organizational/peer respect • Loss of reputation • Loss Of Career • Criminal Charges • Life Long Distress • Organization: • Media Scandals • Lose Trust of Community / Society • Loss of reputation • Service Disruption: reduced patient flows • Discounts • Litigation and costs

  18. Adverse Events versus Errors • Not all Adverse events are due to errors • Not all adverse events are preventable • Not all medical errors lead to harm Adverse events Errors Mortality

  19. Leadership The “Swiss Cheese” Model of Accident Causation (Reason, 1990) • Excessive cost cutting – staffing reduction • Equipment shortages • Communication • Staff Motivation • Divided or confused accountability “Latent Errors” • Poor compliance to policies • Poor Coordination & Communication Policies/ Procedures Available Resources • Deficient training program • Inexperienced X-Ray Tech Barriers to Accidents Communication • Failed to review allergies • Wrong X-ray marker used • Wrong procedure performed • Accident & Injury • Wrong Site Surgery • Medication Error • Fall • Sharps injury Failures in the System

  20. The Vision The Challenge The Roadmap for improvement

  21. Culture: The way we do things around here 21

  22. The ultimate goal is to manage quality, but you cannot manage it until you have a way to measure it, and you cannot measure it until you can monitor it. Florence Nightingale 22

  23. INCIDENT REPORTING Do not identify more than 10 % of adverse events • Aim is to have active surveillance to learn and improve: • Root Cause Analysis • Corrective Action • Preventive Action • Disclosure Risks: • Blame and Punitive Threat • Legal Immunity • Peer Pressure : Reputation, Teamwork • Thin line between Accident, Error, Negligence • Family Disclosure • Media scandals HARM

  24. Incident Reporting: Learning from the Animal Kingdom What is Instinctive Behavior? 24

  25. Protect • Watch out • Sense • Report • Guide • Learn • Share • Team Behavior Instinctive behavior is a process whereby animals "know“ (without having to think about it) when to search for food, drink water, seek safety, and seek shelter when there is inclement weather. Culture of Safety 25

  26. Critical success factors • Active Participation of Doctors and Nurses • Transparency • Mutual trust within clinicians and staff • Unbiased • Culture of safety and of continuous improvement • Openness to change • No Blame games • Must show improvement over time

  27. The Future Beckons • Learning’s from Complaints • Adverse Event Reports Analysis • Clinical Specialty Specific Outcomes Powerful Drivers of Change

  28. Mission, vision, values, safety goals • High Visibility to Safety Committee: Open support • Accountability down the line : rules and obligations : who is meant to do what • Allocate Resources • Safety Culture: No Blame, report • Action Plans: SOPs, Train, Monitor, Improve Leadership Commitment Involve Workers Communicate Reduce Risks • Active participation in Committees, empower • Training • Policies, rules, • Obligations: Speak up, raise concerns, report, to listen, to be aware, • mindfulness, to work as a team player • Articulate at every possible forum • Candid and open feedback on incidents, data, survey results • Memos, newsletters, Brochures, posters, conferences • Reporting of Incidents and Near Misses • Perform observational rounds, surveys • Root Cause Analysis of Incidents and improvements • Safe Infrastructure, equipment, medicines

  29. The cycle of continuous improvement 29

  30. Let us aim to make each new day safer than yesterday

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