The Global Challenge for Patient Safety

1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs

November 3, 2013

Sao Paulo, Brazil

Derek Feeley

Executive Vice

President

Our Vision

Everyone has the best care and health possible.

Who We Are

IHI is a leading innovator in health and health care

improvement worldwide, joining forces with the IHI community

to spark bold, inventive ways to improve the health of

individuals and populations.

Our Mission

To improve health and health care worldwide.

IHI’s Work: Five Key Areas3

Patient Safety

“The magnitude of medical error is enormous. The fault lies with poorly conceived systems

rather than irresponsible people.”

- Dr. Lucian Leape

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The Situation in Health Care

“What has eluded us thus far…is maintaining a consistently high level of safety and quality over time and across all health care services settings.

….Along with some progress, we are experiencing an epidemic of serious and preventable adverse events.

The concept that I believe can and should change this is: “High Reliability.”

Dr. Mark Chassin, President, JACHO, Health Affairs, April 2011

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To Err is Human6

Although no single activity can offer a total solution for dealing with medical errors, the combination of activities proposed in To Err is Human offers a roadmap toward a safer health system. With adequate leadership, attention, and resources, improvements can be made. It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead.

Crossing the Quality Chasm7

“Between the health care we have and the care we could have lies not just a gap, but a chasm.”

Health care does not yet reliably transfer best-known science into action, and processes frequently fail, despite the best intentions of a dedicated and highly skilled workforce. Our system, which intends to heal, too often does just the opposite – leading to unintended harm and unnecessary deaths at alarming rates.

No Shortage of Analysis

Level of Harm9

United States:3.7% of admissions44,000 – 98,000 deaths

United States:3.7% of admissions44,000 – 98,000 deaths

Australia:16% of admissions 50,000 permanent disability250,000 adverse events 10,000 deaths

Australia:16% of admissions 50,000 permanent disability250,000 adverse events 10,000 deaths

Denmark:9% of admissionsDenmark:9% of admissions

New Zealand:10% of admissionsNew Zealand:10% of admissions

United Kingdom:11% of admissions850,000 adverse events

United Kingdom:11% of admissions850,000 adverse events

DoH ECRI 2002 Knox K et all

Global Trigger Tool Reviews10

3 Exemplar Hospitals (900 notes)

40 Bed rural Hospital (300 notes)

10 Hospital Research Project (240 notes)

7 Hospital System (3000 notes)

Multi-state Tertiary System (2000 notes)

Events/1000 Days

83 90 NA 119 86

Events/100 admissions

45 40 37 41 38

Admissions with adverse events

32% 30% 30% 29% 30%

Taking ActionThe 100,000 Lives Campaign was a nation-wide initiative launched by the Institute for Healthcare Improvement to significantly reduce morbidity and mortality in American health care.

Building on the successful work of health care providers all over the world, we are introducing proven best practices across the country to help participating hospitals extend or save as many as 100,000 lives.

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International Reach12

Implementing at scale….

can it be done?

Execution

Ideas

Will

Our change theory

A clear and stretch goalA clear and stretch goalA clear and stretch goalA clear and stretch goal

A methodA methodA methodA method

Predictive, iterative testingPredictive, iterative testingPredictive, iterative testingPredictive, iterative testing

0,8

0,9

1,0

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Oct-Dec2006

Apr-Jun2007

Oct-Dec2007

Apr-Jun2008

Oct-Dec2008

Apr-Jun2009

Oct-Dec2009

Apr-Jun2010

Oct-Dec2010

Apr-Jun2011

Oct-Dec2011

Apr-Jun2012

Sta

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dise

d M

orta

lity

Rat

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HSMR up to September 2012

8497 less than expected deaths

12.4% reduction

60

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Baseline NHS South West median

98.05

90.90

HSMR NHS South West

A New Culture of Safety

Institute of Medicine Report:• Health care organizations must develop a “culture of

safety” such that their workforce and processes are focused on improving the reliability and safety of care for patients.

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Culture: A Definition

A culture is made of shared values and beliefs that interact within an organization in order to produce behavioral norms , or:

“How we do things around here.”

It is determined by how individuals and teams learn together and work together.

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Lessons Learned

1. Establish and Oversee Specific System-Level Aims at the Highest Governance Level

2. Develop an Executable Strategy to achieve these Aims3. Channel Leadership Attention to System-Level

Improvement4. Put Patients and Families on the Improvement Team5. Make the Chief Financial Officer a Quality Champion6. Engage Physicians7. Build Improvement Capability

IHI Seven Leadership Leverage Points

Summary

Safety is a global challenge – harm exists in every system.You will have great care in your hospitals but not for every patient, every time.Improvement is possible – lives can be saved and harm avoided.New systems are necessary to make care safer and more reliable.It takes building will, generating ideas and a method for implementation.Cultural issues are important – leaders set the tone.

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