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Grand RoundsThursday, February 28,
2013
Grand RoundsThursday, February 28,
2013
Patient Safety – No Patient Safety – No Problem HereProblem Here
http://www.youtube.com/watch?http://www.youtube.com/watch?v=hJbYwL2vfJEv=hJbYwL2vfJE Silent Killer , Josie King StorySilent Killer , Josie King Story
Answer = ZeroAnswer = Zero
The correct question is:The correct question is: Mizzou’s trips to the Final Four?Mizzou’s trips to the Final Four? The number of children harmed in our The number of children harmed in our
MRI?MRI? CMH’s strategic plan harm goal?CMH’s strategic plan harm goal? The chance that nobody in the Auditorium The chance that nobody in the Auditorium
or off site spots isn’t currently on their or off site spots isn’t currently on their smart phone or tablet?smart phone or tablet?
2017 Goals and Strategies2017 Goals and StrategiesDemonstrate Quality
OutcomesDemonstrate Quality
OutcomesDemonstrate Quality
Outcomes
Go
als
Str
ateg
ies
A1. Eliminate harmA1. Eliminate harm
A2. Improve the A2. Improve the outcomes of the care outcomes of the care providedprovided
B1. Effectively allocate B1. Effectively allocate staffing and other staffing and other resources to meet needsresources to meet needs
B2. Increase transparency B2. Increase transparency and accountabilityand accountability
B3. Build upon a culture B3. Build upon a culture which is agile/nimble and which is agile/nimble and engaged in innovation at engaged in innovation at all levelsall levels
B4. Enhance team B4. Enhance team behaviors to promote behaviors to promote service excellence for service excellence for internal & external internal & external customerscustomers
C1. Assertively act to C1. Assertively act to retain current regional retain current regional position and take position and take proactive steps to secure proactive steps to secure and grow complex and grow complex patient referrals in patient referrals in Southwest Missouri and Southwest Missouri and Eastern Kansas Eastern Kansas
C2. Grow inpatient and C2. Grow inpatient and specialty outpatient specialty outpatient services at CM-Southservices at CM-South
C3. Improve the C3. Improve the relationship with and relationship with and connection to primary connection to primary care physicianscare physicians
C4. Enhance access across C4. Enhance access across our systemour system
D1. Enhance and grow D1. Enhance and grow the Pediatric Care the Pediatric Care Network (PCN)Network (PCN)
D2. Work with D2. Work with commercial payers commercial payers and/or adult Accountable and/or adult Accountable Care Organizations to be Care Organizations to be their pediatric networktheir pediatric network
D3. Leverage system D3. Leverage system expertise to build expertise to build business opportunities business opportunities outside of traditional outside of traditional market areas (e.g., market areas (e.g., international)international)
E1. Enhance the research E1. Enhance the research enterprise with cohesive enterprise with cohesive oversight/ guidance, oversight/ guidance, broad-based funding, broad-based funding, and a focused research and a focused research portfolioportfolio
E2. Increase the caliber E2. Increase the caliber of CMH’s educational of CMH’s educational programs ensuring programs ensuring leading-edge teaching leading-edge teaching approachesapproaches
Answer = TenAnswer = Ten
What is the best question:What is the best question: Years since I completed my residency?Years since I completed my residency? Number of HACs being tracked by the Number of HACs being tracked by the
Children’s Hospitals Solution for Patient Children’s Hospitals Solution for Patient Safety Consortium?Safety Consortium?
Number of central line infections (CLA-Number of central line infections (CLA-BSIs) at CMH last year?BSIs) at CMH last year?
Mike Artman’s golf handicap?Mike Artman’s golf handicap?
Safety Event ClassificationSafety Event Classification
Near Miss Safety Event Precursor Safety Event
Near Miss Safety EventNear Miss Safety Event
Does not reach the patient.Does not reach the patient.
Error found by detection barrier Error found by detection barrier or luck.or luck.
http://www.youtube.com/watch?http://www.youtube.com/watch?v=KNqWPswYYaAv=KNqWPswYYaA Amazing near miss car crashAmazing near miss car crash
Precursor Safety EventPrecursor Safety Event
Reaches the patient.Reaches the patient.
Minimal or no detectable harm.Minimal or no detectable harm.
http://www.youtube.com/watch?http://www.youtube.com/watch?v=CKkXQxQyYpUv=CKkXQxQyYpU 4 yr old Turkish Boy's Amazing 4 yr old Turkish Boy's Amazing
EscapeEscape
Serious Safety EventSerious Safety Event
Reaches the patient.Reaches the patient.
Causes moderate or severe Causes moderate or severe harm,harm,
Or causes death.Or causes death.
http://www.youtube.com/watch?http://www.youtube.com/watch?v=RPBlEE3xIE0v=RPBlEE3xIE0 A closer look at a medication errorA closer look at a medication error
Answer = Too numerous to countAnswer = Too numerous to count
What is the best question:What is the best question: Days since Burry retired?Days since Burry retired? Near miss safety events in our MRI?Near miss safety events in our MRI? Surgical site infections in the past Surgical site infections in the past
academic year?academic year? Losses by the KU football team in past Losses by the KU football team in past
10 years?10 years?
http://www.youtube.com/watch?http://www.youtube.com/watch?v=plvIEf7JsKov=plvIEf7JsKo Dangers of MRIDangers of MRI
Answer = FourAnswer = Four
What is the best question:What is the best question: Number of times Jason Newland has Number of times Jason Newland has
competed in the Hawaii Ironman?competed in the Hawaii Ironman? Number of people who have given Number of people who have given
Jason a hard time this week?Jason a hard time this week? Number of near miss wrong site Number of near miss wrong site
surgery events since Jason has been surgery events since Jason has been the Medical Director of Safety?the Medical Director of Safety?
http://www.youtube.com/watch?http://www.youtube.com/watch?v=SxDx2DlL0UYv=SxDx2DlL0UY Tom Shillue's Wrong Side SurgeryTom Shillue's Wrong Side Surgery
http://www.youtube.com/watch?http://www.youtube.com/watch?v=t6mr3gxXx64v=t6mr3gxXx64 Jess’s storyJess’s story
Jess’s StoryJess’s Story
““The Holter monitor test was The Holter monitor test was never looked at until after I died, never looked at until after I died, more than a year after I had the more than a year after I had the test.”test.”
““Zero” Zero”
2012 PICU Quality Improvement Report
2012 PICU Quality Improvement Report
Chris Hubble, MDChris Hubble, MD
Kathy Baharaeen, RNKathy Baharaeen, RN
2012 PICU Quality Improvement Report
2012 PICU Quality Improvement Report
2012 PICU Quality Improvement Report
2012 PICU Quality Improvement Report
Unplanned ExtubationsUnplanned Extubations
20122012 20112011
TotalsTotals 12 12 38 38
2012 PICU Quality Improvement Report
2012 PICU Quality Improvement Report
PICU – Catheter Associated UTIs (CA-UTI) PICU – Catheter Associated UTIs (CA-UTI)
Nurse driven removal algorithmNurse driven removal algorithm
Rate before algorithm (July – Dec 2011) = 5.83Rate before algorithm (July – Dec 2011) = 5.83 Rate after algorithm (July – Dec 2012) = 2.24Rate after algorithm (July – Dec 2012) = 2.24
60% reduction60% reduction
2012 PICU Quality Improvement Report
2012 PICU Quality Improvement Report
http://www.youtube.com/watch?http://www.youtube.com/watch?feature=player_embedded&v=Gfeature=player_embedded&v=GPOQ8pzY0kYPOQ8pzY0kY Labels OutLabels Out