Quality and Regulatory Compliance in Health Care

Nawanan Theera-Ampornpunt, MD, PhDHealth Informatics Division

Faculty of Medicine Ramathibodi HospitalMahidol University, Thailand

Modified from slides of Assoc.Prof. Artit Ungkanont

Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award

Number IU24OC000013 (Health IT Workforce Curriculum v.3.0, Component 12/Units 1-12).

Introduction to Quality Improvement & Health IT Principles of Quality and Safety for HIT The Culture of Safety Learning From Mistakes: Error Reporting and

Analysis and HIT

Introduction to Quality Improvement and Health Information Technology:

Part 1

This material (Comp12_Unit1a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

First, Do No Harm

Primum non nocere

1991

2000-2001

20042009

2011

ONCHIT

HITECH Act“Meaningful Use”

(IOM, 2001)(IOM, 2000) (IOM, 2011)

Humans are not perfect and are bound to make errors

Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality

Recommends reform that would change how health care works and how technology innovations can help improve quality/safety

Health IT plays a role in improving patient safety (but it may also carry risks to safety in certain ways)

“Healthcare reform without attention to the nature and nurture of healthcare as a system is doomed …It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it.” (Berwick, 2009)

“The performance of a system — its achievement of its aims —depends as much on the interactions among elements as on the elements themselves. (Berwick, 2009)

“The improvement of health and healthcare depends on systems thinking and systems redesign… ‘Reform’ without systems thinking isn’t reform at all.” (Berwick, 2009)

8Health IT Workforce Curriculum Version 3.0/Spring 2012

Quality Improvement Introduction to QI and HIT

Lecture a

MEANINGFUL USEProviders show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.

PATIENT-CENTERED MEDICAL HOMEProviders organize care around patients, working in teams,coordinating care, and tracking over time.

ACCOUNTABLE CARE ORGANIZATIONProvider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients.



Lecture a

“Meaningful Use”

of a Pumpkin

Pumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

“Even hospitals with fully functioning EMRs still make extensive use of digitized scans of manually completed forms and textual checklists. With no forms or screens to capture data in a structured way, hospitals fail to report quality measures as a routine byproduct of the practices, relying instead on a retrospective chart abstracting process.” (Holland, 2010)



Lecture a

The American Recovery and Reinvestment Act of 2009“…authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming ‘meaningful users’ of certified electronic health record technology …” (The American Reinvestment and Recovery Act of 2009)

• The HITECH (Health Information Technology for Economic and Clinical Health) Act establishes programs under CMS in coordination with the Office of the National Coordinator to accomplish this charge.



Lecture a

Improve quality, safety, & efficiencyEngage patients & their families Improve care coordination Improve population & public health;

reduce disparitiesEnsure privacy & security protections



Lecture a



Lecture a

The quality of care received needs improvement.

In the current healthcare environment there are a number of initiatives that aim to improve the care in the U.S. context through the use of HIT.• Meaningful Use

• Patient Centered Medical Home

• Accountable Care Organization



Lecture a

References• Affordable Care Act. Available from: www.healthcare.gov/law/index.html• Berwick, D. October 30, 2009, speech, Harvard School of Public Health• Center for Medicaid Services. Shared Services Program. Available from:

https://www.cms.gov/sharedsavingsprogram/• Endorsing national consensus standards for measuring and publicly reporting on performance; California Academy

of Family Physicians Diabetes Initiative Care Model Change Package originally developed by Lumetra• Holland, Marc. In Health Information Exchange: From Meaningful Use to Healthcare Transformation. Available

from: http://www.himss.org/content/files/Carefx%20_HIE_meaningful-use2.pdf• The National Coalition on Health Care (NCHC, 2007). Available from: http://nchc.org/

Patient-Centered Primary Care Collaborative. What We Do (PCMH). Available from: http://www.pcpcc.net/what-we-do

• Patient Protection and Affordable Care Act (PPACA). Available from: http://www.healthcare.gov/law/index.html• President Barack Obama. Barack Obama, speech at George Mason University, January 12, 2009• U.S. Department of Health and Human Services. (June 22, 2011). Up to $500 million in Affordable Care Act funding

will help health providers improve care. Retrieved from: http://www.hhs.gov/news/press/2011pres/06/20110622a.html

ImagesSlide 14: Meaningful Use Stages. Courtesy of Dr. Anna Maria Izquierdo-Porrera



Lecture a


Part 2

This material (Comp12_Unit1b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

Explain healthcare quality and quality improvement (QI).

Describe quality improvement as a goal of meaningful use.



Lecture b

“Quality of care is the degree to which health services for individuals and

populations increase the likelihood of desired outcomes and are consistent with

current professional knowledge.” (IOM, 2001)



Lecture b



Lecture b

National Quality Forum (NQF) www.qualityforum.org National Committee for Quality Assurance (NCQA) www.ncqa.org Provider organizations

• AMA’s Physician Consortium for Performance Improvement (PCPI) www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-consortium-performance-improvement

Joint Commission (JC) www.jointcommission.org Institute for Healthcare Improvement (IHI)



Lecture b

The Healthcare Accreditation Institute (Public Organization) www.ha.or.th Joint Commission (JC) www.jointcommission.org International Organization for Standardization (ISO) www.iso.org Provider & professional organizations

• University Hospital Network (UHOSNET) www.uhosnet.com

• The Medical Council of Thailand www.tmc.or.th

• Thai Medical Informatics Association (TMI) www.tmi.or.th

• Other professional councils and organizations Regulatory organizations

• Ministry of Public Health

• Ministry of Education Thai Qualifications Framework for Higher Education (TQF:HEd)

Payer organizations

• National Health Security Office (NHSO) www.nhso.go.th

• Social Security Office (SSO)

• Comptroller-General Department Other quality frameworks

• Thai Quality Award (TQA) www.tqa.or.th22

Needs to be improved, especially for the uninsured

Patient safety & healthcare-associated infections warrant urgent attention

Quality is improving, but pace is slow, especially in preventive care & chronic disease management

Disparities are common and lack of insurance is a contributor

Many disparities are not decreasing; those that warrant increased attention include care for cancer, heart failure, and pneumonia



Lecture b

National study of physician performance for 30 medical conditions plus preventive care: physicians provided only 55% of recommended care.

(McGlynn et al. NEJM 2003; 348:2635)

66% of people with hypertension are inadequately treated. (JNC 7, JAMA 2003;289: 2560)

63% of people with diabetes have HbA1c levels greater than 7.0%. (Saydah, et al. JAMA 2004;291:335)

62% of people with elevated LDL cholesterol have not reached lipid goals.

(Afonso, Am J Man Care 2006;12:589)

50-70% of healthcare-associated infections are preventable.(Umscheid et al. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.)

24.7% of Medicare patients admitted to the hospital for heart failure are readmitted within 30 days.

(CMS, 2009)



Lecture b

Only 27% of adults with a regular primary care physician (PCP) could easily contact their physician over the telephone, obtain care or medical advice after hours, or experience timely office visits.

Only 57% of adults rate the information they get about their health issues as very good; only 43% find it easy to get an appointment; and only 56% find the physician’s office to be well-organized and feel their time is not wasted.



Lecture b

Given the current sub-optimal quality of care received by patients, the introduction of QI initiatives is imperative.

HIT has an important role to play in QI initiatives.



Lecture b

“Every system is perfectly designed to achieve the results it achieves.”

(Paul Batalden, M.D, 2008)

So, the answer must lay in the system redesign.



Lecture b



Lecture b

Make it specific• Assign it a number if possible

Assign it a timelineMake it measurableMake sure it is challenging but doable



Lecture b

PROCESS MEASURE: Are we doing what we must to get the improvement we seek?

OUTCOME MEASURE: Are we getting what we expect?

BALANCING MEASURE: Are we causing new problems in other parts of the system?



Lecture b

Hospital• AIM: we will reduce the number of

ventilator-associated pneumonias (VAP) in the ICU from the current 23% to under 10% in 4 months

• MEASURES: Process measure: Ventilator days Over-sedation hours Oral care performed

Outcome measure: Number of VAP

Balancing Measure: Cost of care Re-intubation rates

Ambulatory• AIM: we will reduce the amount

of time it takes our patients to get an appointment (request to appointment) from 23 days to 0 days in 6 months

• MEASURES: Process measure: Supply Demand No-show rate

Outcome measure: third next available appointment

Balancing Measure: Patient satisfaction



Lecture b

Concepts and strategies: decide on the overall changes that will lead to the desired improvement.

Specific changes: • Make them small• Make them fast• Make them frequent

You may need to include additional measures specifically to decide if a change you have tested is worth keeping or did not lead to improvement.

Consider using pre-existing change packages.



Lecture b

• One of the most important aspects of QI is to understand how your systems actually perform, under a range of conditions.

• Deming’s theory of profound knowledge is based on the principle that each organization is composed of a system of interrelated processes and people.

• The improvement of the system depends on the capability to organize the balance of each component to enhance the entire system.

• Understanding and learning about your system is essential to improve it.



Lecture b

• PDCA (Deming Cycle)

34

Plan

Do

Check

Act

http://en.wikipedia.org/wiki/Shewhart_cycle

• Continuous Quality Improvement (CQI)http://en.wikipedia.org/wiki/Continual_improvement_process

Quality improvement is an ongoing, continuous effort

• Total Quality Management (TQM)http://en.wikipedia.org/wiki/Total_quality_management

Quality of products and processes is the responsibility of everyone involved in the products or services

• Six Sigmahttp://en.wikipedia.org/wiki/Six_Sigma

Seeks to improve quality by removing causes of defects and minimizing variability in manufacturing and business processes

35

• Leanhttp://en.wikipedia.org/wiki/Lean_manufacturing

Considers expenditure of resources that does not create value a waste -> “Preserving value with less work”

Including tools such as Value Stream Mapping, 5S, Kanban (pull systems), Just in time (JIT), etc.

• Routine to Research (R2R)http://home.kku.ac.th/kitsir/research/html/download/news/r2r.pdf

Improves the routine work processes through research

• Risk Managementhttp://en.wikipedia.org/wiki/Risk_management

Identification, assessment, prioritization , prevention, mitigation, monitoring, and control of risks

36

Image source: Senoo et al. (2007) http://dx.doi.org/10.1108/14601060710776725

Nonaka SECI Model

The quality of care received needs improvement.

Quality improvement is an ongoing process that includes the setting of an aim and a progressive measurement, change test, and understanding of the system.

There are various complementary approaches to quality improvement



Lecture b

References• Agency for Healthcare Research and Quality (AHRQ). Available from: http://www.ahrq.gov/• Batalden, Paul M.D in The Improvement Collaborative: An Approach to Rapidly Improve Health Care and Scale Up

Quality Services. June 2008. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CCQQFjAB&url=http%3A%2F%2Fwww.ovcsupport.net%2Flibsys%2FAdmin%2Fd%2FDocumentHandler.ashx%3Fid%3D790&ei=g2nWTtbdFoHn0QH8uP39AQ&usg=AFQjCNEnga43Tn8Y_Mmf0uUbcRUzhevA0w&sig2=RG7ZXVjV_eKlghcJarz_1A

• Beal et al. Closing the Divide: How Medical Homes Promote Equity in Health Care. Commonwealth Fund, 2007• Centers for Medicare and Medicaid Services. http://www.cms.gov/• IOM—International Institute of Medicine. Available from: http://iom.edu/• Institute for Healthcare Improvement (IHI) Available from: http://www.ihi.org/Pages/default.aspx• Joint Commission. Available from: http://www.jointcommission.org/• National Committee for Quality Assurance. Available from: http://www.ncqa.org/• National Quality Forum (NQF). Available from: http://www.qualityforum.org/Home.aspx• Physician Consortium for Performance Improvement (PCPI)- American Medial Association. Available from:

http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-consortium-performance-improvement.page

• Wasson, J. & Benjamin, R. How is your health: what you can do to make your health and healthcare better, 2009. Available from: http://www.howsyourhealth.org/html/HowsYourHealth_4thEd.pdf



Lecture b

ImagesSlide 20: Quality Health Care: Who Defines It? Courtesy of Dr. Anna Maria Izquierdo-PorreraSlide 23: Cover of the 2009 National Quality Healthcare Report and the 2009 National Healthcare Disparities

Report. Available from: http://www.ahrq.gov/qual/qrdr09.htmSlide 28: Basics of Quality Improvement. Courtesy of Dr. Anna Maria Izquierdo-Porrera



Lecture b


Part 3

This material (Comp12_Unit1c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.



Lecture c

Has the potential to: improve health care qualityprevent medical errors increase health care efficiency & reduce

unnecessary costs increase administrative efficienciesdecrease paperworkexpand access to affordable care improve population health



Lecture c

CPOE Computerized provider order entry Can reduce errors in drug prescribing

and dosingMedical Device Interface

Automated vital sign capture

Can reduce errors in transcription

Knowledge Links Reference information links Can reduce errors due to lack of

knowledgeMonitoring

Quality metric reporting

Can identify opportunities for improvement

e-MAR Computerized medication administration

record Can reduce errors in drug administratione-Allergy List

Computerized allergy list

Can reduce errors in preventable adverse drug events

Reminders Prompts and flags Can reduce errors in omission

Structured Notes

Standardized observations

Can reduce errors related to failure to detect subtle changes in status



Lecture c

System change:

A medical logic module (MLM) was created that

provides the following functionality: When selected

drugs are ordered at a frequency of every 24 hours or

longer, the prescriber is automatically presented with

the last administration time if the drug had been

ordered previously.



Lecture c

Early detection and effective treatment are the

cornerstones of treatment for pneumonia. Adults

aged 65 and older should receive the influenza and

pneumococcal immunization to prevent pneumonia

and its complications.



Lecture c

Knowledge access Patient-friendly websites Can provide medical

information and access to support groups

Tailor to Patient Needs

Clinical decision support

Can tailor information according to patient characteristics and condition

Patient portal Patient access and manage

own health record Can enable self-

managementDisease management

Customized health education and disease management messaging

Can enable self-management



Lecture c

Event:

A standard protocol (document specifying best

practices for care) and electronic prescriber order

sets are used for all adult patients receiving

intravenous blood thinners. There are new changes

to the protocol due to a switch to new laboratory

tests for monitoring drug activity.



Lecture c

System Change:

The current protocol and electronic order

sets were revised to include orders for the

new laboratory tests. The new order sets

include changes to the therapeutic goals of

nurse-managed therapy.



Lecture c

Knowledge access Patient-friendly websites Can provide medical

information and access to support groups

Tailor to Patient Needs


Can tailor information according to patient characteristics and condition

Patient portal Patient access and manage

own health record Can enable self-

managementDisease management

Customized health education and disease management messaging

Can enable self-management



Lecture c

Event:

Mr. Jackson took his mother to a pre-operative evaluation

center in preparation for her impending surgery. He was

asked to help her complete an information form that

included her home medications. Mr. Jackson’s sister

manages these medications and he had forgotten to bring

the list. He was unable to contact her on her cell phone and

became increasingly frustrated since, after all, his mother’s

doctors should know what medicines she is taking!



Lecture c

System Change:

The ambulatory care center implemented a web-

based patient portal that would allow patients or

caregivers to enter much of the history

information in advance, from home. Satisfaction

scores for patients improved with this active role

in their care.



Lecture c

A medical office practice is considering the use of

a web-based secure messaging system to improve

patient-provider communication and enhance

patient satisfaction.



Lecture c

Telemedicine• Internet-based access• Can provide immediate

access to medical information

Time-sensitive PromptsTimed draw alertsCan remind nurses when

to draw blood based on a medication intervention

Clinicians Reminders Task list schedules Can remind nurses when

treatments are duePatient Reminders Appointment schedulingCan remind patients

when they need to return for follow-up visits



Lecture c

Event:

Medication patches are small, flesh-colored, and are usually

placed in discreet locations, e.g. the upper shoulder area or

on the back of the upper arm. Some patches are

appropriately left on for 2-3 days or longer. It is difficult to

track the placement and removal of these patches over time,

leading to errors in which medication patches were not

removed and the patient received too much medicine.



Lecture c

System Change:

A change was made to the electronic medication record

(eMAR). After the nurse documents the application of the

patch in the eMAR, a follow-up task to remove the patch at

the ordered date and time is automatically generated. If the

follow-up task is still active during a transfer in care, the

receiving nurse will see this task on the eMAR.



Lecture c

A healthcare system saw increases in adverse

events in its home care company due to inadequate

transfer of clinical information at hospital

discharge. An electronic hospital discharge

summary with auto-faxing was developed to

increase availability of discharge information at the

time of follow-up care.



Lecture c

Wireless mobile technology

• Vital Sign Capture• Can eliminate need to

write or type vital signsSystem integration

• Pull forward historical information

• Can reduce data collection time

Character expansion• Ability to translate a few

characters into phrases, sentences or paragraphs

• Can decrease typing time


• Prompt for duplicate labs

• Can reduce redundant laboratory testing



Lecture c

Event:

The emergency department (ED) staff at a community hospital

used a large whiteboard mounted on the wall that could be

quickly updated with felt-tip markers to track patients and

treatments. The problem was that staff could not obtain

information from the board unless they were physically standing

in front of it. In addition, information on the board only reflected

what was already known by the ED staff.



Lecture c

System Change:

The hospital implemented an automated ED

patient tracking system that used business

intelligence technology. This technology

enabled more efficient patient flow using real-

time data.



Lecture c

Hope Memorial Hospital implemented an

electronic picture archiving and communication

system (PACS) for requesting radiological

examinations and displaying images. They saw a

reduction in repeat chest X-ray films at outpatient

appointments.



Lecture c

Data capture Monitoring by population

characteristics Can uncover health care

disparitiesTailor to Patient Needs

Competency-based patient education

Can tailor information to educational background and development status

Multi-Modal functionality Various ways for patients to

get health information Can decrease health care

disparityDecision support

Drug cost information

Can assist providers in selecting alternatives for low income patients



Lecture c

All healthcare settings can benefit from the assistance of HIT professionals in identifying electronic solutions to quality concerns.



Lecture c

References• Institute of Medicine. Crossing the quality chasm. Washington DC: National Academy Press, p. 232. 2001.

ImagesSlide 42: What is Health Care Quality? Courtesy Dr.Anna Maria Izquierdo-Porrera



Lecture c


Part 4

This material (Comp12_Unit1d) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

Analyze the ways that HIT can either help or hinder quality improvement.



Lecture d

Work-arounds and artifacts can lead to unintended consequences



Lecture d

Defined Alternative processes

that help workers avoid demands placed on them that they perceive to be unrealistic or harmful

Unanticipated behaviors directly or indirectly caused by the EHR when the system impedes one’s work

Example Nurses taking verbal

orders rather than prescribers entering the order into POE due to workflow timing of event



Lecture d

When a bar-coding medication system interfered with their workflow, nurses devised work-arounds, such as removing the armband from the patient and attaching it to the bed because the barcode reader failed to interpret bar codes when the bracelet curved tightly around a small arm.



Lecture d

Investigators found increased mortality among children admitted to Children’s Hospital in Pittsburgh after CPOE implementation.

Three reasons were cited for this unexpected outcome:• CPOE changed the workflow • Order entry required as many as 10 clicks & took as long as 2 minutes • When the team changed its workflow to accommodate CPOE, face-to-

face contact among team members diminished.



Lecture d

Well-crafted HIT solutions can:• Improve safety, effectiveness, efficiency, equity,

timeliness, and patient-centeredness of care• Work to accomplish the best care for the whole

population at the lowest cost Poorly designed HIT solutions can:

• Lead to work-arounds and unintended consequences that may lead to patient risks or bad outcomes



Lecture d

References• Connolly, C. (2005, March 21). Cedars-Sinai doctors cling to pen and paper. Washington Post, p. A01. Available from:

http://gunston.gmu.edu/.../cedars-sinai%20cpoe%20washpost%203-21-05• Doyle, M. Impact of the Bar Code Medication Administration (BCMA) system on medication administration errors.

Unpublished doctoral dissertation, University of Arizona, Tucson in Nursing Informatics and the Foundation of Knowledge. Jones and Bartlett Publishers Sudbury, Massachusetts. 2005.

• Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 116;1506-1512. 2005

ImagesSlide 69: Patient Armbands. Department of Defense. Available from:

http://www.defense.gov/HomePagePhotos/LeadPhotoImage.aspx?id=74561Slide 70: Children's Hospital, Pittsburgh, PA. Available from: http://www.chp.edu/CHP/Community+Preview+Photo+Gallery



Lecture d

Principles of Quality and Safety for HIT

Part 1



Quality Improvement Principles of Quality and Safety for HIT

Lecture a

In U.S. Healthcare system7% of patients suffer a medication error44,000- 98,000 deaths100,0000 death from hospital-acquired

infectionsPatients receive half of recommend

therapies $50 billion in total costs

Similar results in UK and Australia



Lecture a

How can this happen?

We need to view the delivery of health care as a science



Lecture a

1. Accept we are fallible—assume things will go wrong rather than right.

2. Every system is perfectly designed to achieve the results it gets.

3. Understand principles of safe design. • Standardize• Create checklists• Learn when things go wrong

4. Recognize these principles apply to technical and team work.

5. Teams make wise decision when there is diverse and independent input.

Caregivers are not to blame



Lecture a



Lecture a



Lecture a



Lecture a

References• Boeing. 2001 Statistical Summary of Commercial Jet Airplane Accidents. June 2002• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm• Reason, J. BMJ 2000;320:768-770



Lecture a

ImagesSlide 74: Sponge Left in Stomach. Image courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual

Conference: September 9, 2008 Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm

Slide 78: The Swiss Cheese Model. Adapted by Dr. Peter Pronovost from original in Reason, J. BMJ 2000;320:768-770.Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008

Slide 79: System Factors. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Image courtesy Dr. Peter Pronovost.

Slide 80: A Dosage Error? Creative Commons by MBBradford. Available from: http://en.wikipedia.org/wiki/File:Glucagon_vials_and_syringe.JPG

Principles of Quality and Safety for HIT

Part 2


Standardize. • Eliminate steps if possible.

Create independent checks.Learn when things go wrong.

• What happened?• Why did it happen?• What did you do to reduce risk?• How do you know it worked?



Lecture b



Lecture b



Lecture b



Lecture b



Lecture b

Assume things will go wrong Develop lenses to see systems Work to Mitigate Technical and Teamwork

Hazards• Standardize work• Create independent checks• Learn from mistakes

Make wise decisions by getting input from others

Keep the patient the north star



Lecture b

In this unit we’ve learned about the ways that teams make wise decisions with diverse and independent input. We’ve also explored the importance of communication and especially the place of critical listening.



Lecture b

References• Dayton, E. Joint Commission Journal, Jan. 2007• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm• Reason, J. BMJ 2000;320:768-770



Lecture b

ImagesSlide 85: A Bank of ATMs. Creative Commons: Piotrus. Available from:

http://commons.wikimedia.org/wiki/File:PNC_bank_ATMs.JPGSlide 86. A Three-Point Seat Belt in a Lincoln Town Car. Courtesy Creative Commons Gerdbrendel. Available from:

http://en.wikipedia.org/wiki/File:Seatbelt.jpgSlide 87. Jelly Beans. Creative Commons Brandon D

Available from: http://3.bp.blogspot.com/-oxxwjc9sQp8/TbCxyVKPtWI/AAAAAAAAAcA/NkPtINLsFjw/s1600/jelly-beans.jpg

The Culture of Safety

This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

Video 1


Quality Improvement Reliability, Culture of Safety, & HIT

Pointing the finger at people rather than systems.





Limits learning Increases likelihood of repeat errorsDrives self-reporting underground













Video 2

In this unit we explored the characteristics of high reliability organizations and learned more about establishing an organizational culture of safety.



References• AHRQ Patient Safety Primers. Safety Culture. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=5• Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD. AHRQ

Publication No. 08-0022, 2008 April. Agency for Healthcare Research and Quality. Available from: http://www.ahrq.gov/qual/hroadvice/

• Riley, W., Davis, S.E., Miller, K.K., & McCullough, M. A model for developing high reliability teams. J Nurs Manag. 2010 Jul18(5):556-563.

Charts, Tables, FiguresTable 4_1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn

is a prerequisite for safety. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

ImagesSlide 92: Aircraft Carrier USS Enterprise. Courtesy U.S. Navy, photo by Photographer's Mate Airman Rob Gaston.

Available from: http://www.navy.mil/view_single.asp?id=15089Slide 94: Blame. Created by Dr. Stephanie Poe.Slide 95: Blame Arrows. Created by Dr. Stephanie Poe.Slide 96: How to Promote a Culture of Learning 1. Courtesy: Dr. Anna Maria Izquierdo-PorreraSlide 97: How to Promote a Culture of Learning 2 Courtesy: Dr. Anna Maria Izquierdo-PorreraSlide 98:How to Promote a Culture of Learning 3 Courtesy: Dr. Anna Maria Izquierdo-PorreraSlide 99: Culture of Safety Characteristics. Courtesy: Dr. Anna Maria Izquierdo-PorreraSlide 100: Honey Bee. Creative Commons by William Warby. Available from: http://www.flickr.com/photos/wwarby/



Learning From Mistakes: Error Reporting and

Analysis and HIT: Part 1


“A new delivery system must be built to achieve substantial improvements in patient safety – a system that is capable of preventing errors from occurring in the first place, while at the same time incorporating lessons learned from any errors that do occur.”(IOM,2004)


Quality Improvement Learning From Mistakes: Error Reporting and Analysis

and HIT─Lecture a



and HIT─Lecture a



and HIT─Lecture a

Admit that providing health care is potentially hazardous

Take responsibility for reducing risks Encourage error reporting without blame Learn from mistakes Communicate across traditional hierarchies and

boundaries; encourage open discussion of errors Use a systems (not individual) approach to analyze

errors Advocate for multidisciplinary teamwork Establish structures for accountability to patient safety



and HIT─Lecture a



and HIT─Lecture a

Near Miss Harm



and HIT─Lecture a

Swiss cheese model of errorA culture of safetyThree HIT mechanisms to help control

error• surveillance systems, on-line event reporting,

and predictive analytics/data modelingRisk assessment model (near-miss VS

harm)

References• AHRQ Patient Safety Network. Glossary. Available from: http://psnet.ahrq.gov/glossary.aspx • AHRQ. Glossary: Failure Mode Effects Analysis. Available from:

http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysis• Kilbridge PM, & Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am

Med Inform Assoc. 2008 Jul-Aug;15(4):397-407. Epub 2008 Apr 24.• Reason J. Human error: models and management. BMJ. 320:768-770. 2000.

ImagesSlide 105: Adapted from Reason J. Human Error: Models and Management. BMJ 320:768 2000. by Dr. Peter

Pronovost. Available from: http://www.bmj.com/content/320/7237/768.longSlide 106: Adapted from Reason J. Human Error: Models and Management. BMJ 320:768 2000. by Dr. Peter

Pronovost. Available from: http://www.bmj.com/content/320/7237/768.longSlide 108: Types of Outcomes. Dr. Anna Maria Izquierdo-Porrera



and HIT─Lecture a





Quality Improvement Learning From Mistakes: Error Reporting and Analysis and

HIT─Lecture b



HIT─Lecture b



HIT─Lecture b

Alert fatigue



HIT─Lecture b

Classification of error• AHRQ• James Reason• Slips & mistakes• Latent conditions & active failures• Sharp end & blunt end


http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysis• Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended

consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-423.• Reason J. Human error: models and management. BMJ. 320:768-770. 2000. • Siegler EL, Adelman R. Copy and paste. A remediable hazard of electronic health records. Am J Med. 2009

Jun;122(6):495-6.

ImagesSlide 112: Types of Error –Commission/Ommission. Dr. Anna Maria Izquierdo-PorreraSlide 113: Types of Error. Dr. Anna Maria Izquierdo-PorreraSlide 114: Types of Error II. Dr. Anna Maria Izquierdo-Porrera



HIT─Lecture b



This material (Comp12_Unit12c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.



HIT─Lecture c

Structured problem-solving process

Considers all potential causal or contributing factors Human factors System factors

Detailed chronological list of events surrounding incident

Premise: one can learn from one’s mistakes



HIT─Lecture c



HIT─Lecture c

Healthcare Example: Mrs. A. received blood in the Emergency Department. Within 15 minutes, she experienced a bad reaction. Her nurse realized that she had received blood intended for another patient. She was transferred to the intensive care unit to be stabilized. The ED staff wanted to know how this could have happened so they assembled a team to identify possible causes.



HIT─Lecture c

Briefly describe event Identify affected areas/servicesAssemble a team Diagram the process (flow chart) Identify potential root causes Prioritize root causes Develop action plan Evaluate results!



HIT─Lecture c



HIT─Lecture c

Story: Before I had children, I invited one of my high school friends and her family, including a toddler, to dinner. I was worried that her toddler would somehow manage to hurt himself in my house, which was designed for a childless couple.



HIT─Lecture c

Select a high risk process, one that is

known to have problems, and assemble a

team.



HIT─Lecture c



HIT─Lecture c



HIT─Lecture c

The higher the number, the more urgent the need to prevent a failure.

Event: After reading several articles about laboratory specimen errors that result in lab tests being done on the wrong patients, doctors at a community office practice decide to examine the potential for this problem to happen in their office laboratory.



HIT─Lecture c

Select a high risk process (patient identification):• Affects a large number of patients• Carries a high risk for patients• Has known process problems identified by other

organizations (e.g., Joint Commission Sentinel Event Alert!) Assemble a team

• People closest to issue involved• People critical to implementation of potential changes• Respected, credible team leader• Someone with decision-making authority• People with diverse knowledge bases



HIT─Lecture c



HIT─Lecture c

The higher the number, the more urgent the need to prevent a failure.



HIT─Lecture c



HIT─Lecture c



HIT─Lecture c

Tools• Root Cause Analysis (RCA)• Failure Mode Effect Analysis (FMEA)• Hazard Analysis• Flow Charting


http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysis

Charts, Tables, FiguresTable12.1 Conduct a Hazard Analysis. Dr. Stephanie PoeTable12.2 Conduct a Hazard Analysis II. Dr. Stephanie Poe

ImagesSlide 119: Quality Improvement Tools. Dr. Stephanie PoeSlide 121: Root Cause Analysis. Dr. Stephanie PoeSlide 124: Failure Mode Effects Analysis. Dr. Stephanie PoeSlide 127: FMEA: Steps. Dr. Stephanie PoeSlide 128: FMEA Diagram. Dr. Stephanie PoeSlide 133: Quality Improvement Tools. Dr. Stephanie Poe



HIT─Lecture c

The End

Health & Medicine

Quality and Regulatory Compliance in Health Care