Keeping Patients and Staff SafeDr. Arati VermaSr VP-Medical Quality

Co Chair, NABH Technical Committee

“Healthy Gujarat -Setting an Agenda for Actions” Gandhinagar, 3rd Dec, 2013

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The Vision The Vision

The ChallengeThe Challenge

The Roadmap for improvement The Roadmap for improvement

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The Vision The Vision

The ChallengeThe Challenge

The Roadmap for improvement The Roadmap for improvement

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“Quality Healthcare for all”

Quality AssuranceSafety

Reduction ofDisease Burden

Intelligenceinformation

Health Expenditure & Affordability

Quality Healthcare for all

HealthcareInfrastructure

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Gujarat leading the way…..Congratulations!

And we applaud the ongoing initiatives!

A Success Story : Quality Improvement Programme- Gujarat, IndiaIndia’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

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

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Physical comfort

Shared Decision making

Information, communication and education

Coordination and integration of care (Team Medicine)

Respect for patient’s values, preferences and

needs.

Involvement of family and friends

Optimum Health Outcome

Patient Centered Care

Safety

Emotional support

No harm

Transition and continuity

Value for money

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Improve at all Levels

Availability of Beds, OPDs, Staff, Building, SpaceEquipment, Supplies, Resources, Basic Monitoring of patients

Protocols, Procedures, Treatments, Policies, Training,

Efficiency, low waste, Appropriate use

Patient & staff satisfaction, Low infection rates, good clinical outcomes

Structure

Process

Outcome

What is needed

What is done

What is achieved

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Disease or Procedure Based Outcomes

Benchmarked with Evidence Based PracticesEg: Outcomes of Acute MI Stroke Management etc

Patient Reported Outcome Measures (PROM) Mobility, Health Outcomes, Pain, Longevity, Functionality, Experience etc

Disease or Procedure Based Outcomes

Benchmarked with Evidence Based PracticesEg: Outcomes of Acute MI Stroke Management etc

Patient Reported Outcome Measures (PROM) Mobility, Health Outcomes, Pain, Longevity, Functionality, Experience etc

Safety and Complications

Patient falls, Hospital Acquired Infections, Pressure Sores, Adverse Drug Events, Other Adverse Events

Safety and Complications

Patient falls, Hospital Acquired Infections, Pressure Sores, Adverse Drug Events, Other Adverse Events

Ceiling Ceiling

Floor Floor

Floor to Ceiling Outcomes

Aim for “ZERO”

Aim for “HUNDRED”

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The Vision The Vision

The ChallengeThe Challenge

The Roadmap for improvement The Roadmap for improvement

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

Error/Event

Surgical problems

Medication Errors

Medical Errors

Patient Falls

Hospital Acquired Infections

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1999 Institute of Medicine Report

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Deat

hs/ye

ar

Medical error Traffic Breast cancer AIDS

$9 billion in annual costs

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10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

Tota

l liv

es lo

st/y

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REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Lucian Leape, 2/2001

How Hazardous Is Health Care?

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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

The health care industry is one of the worldwide

largest segments of the global workforce

World health statistics 2011

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Why is Staff Safety Important?

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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

OT• Anesthetic gases• Compressed gases• Lasers

Lab Workers• Infectious diseases• Chemical agents (formaldehyde, toluene, xylene)

Radiology

• Radiation

Pharmacy

•Drug absorption

CSSD •Compressed gases• Anesthetic gases• Chemical agents (sterilizers, cleaners)• Burns, cuts

Laundry •Contaminated laundry• Noise• Heat• Lifting• Fire hazard

Kitchen Staff• Food borne diseases• Heat• Moving machinery• Slips, trips, falls

What makes Healthcare Hazardous

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Low Control, high uncertainty, less than ideal work flows,Low “culture of Safety”

Low threshold: small breakdowns may lead to catastrophic harm

Low Control, high uncertainty, less than ideal work flows,Low “culture of Safety”

Low threshold: small breakdowns may lead to catastrophic harm

Example: Frequency and Distribution of Hospital Acquired Infections

Source; World Health Organization

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

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Families: oWant justice: punishment of the guilty oLoss of trust oSudden BereavementoEarning MemberoAgony, Violence and aggression oCannot deal with lossoWant compensation

Patients/Staff:oAnnoyance / Disappointment: did not deliver on perceived promise oHarmoPermanent - Disability oDeathoAdditional Costs hospitalization/medicinesoDiscomfort: prolonged stay/distressoLoss of ability to work/earn

Clinicians:oShattering ExperienceoLow moraleoLoss of organizational/peer respectoLoss of reputationoLoss Of Career oCriminal ChargesoLife Long Distress

Organization:oMedia ScandalsoLose Trust of Community / SocietyoLoss of reputationoService Disruption: reduced patient flowsoDiscountsoLitigation and costs

Negative Impact:

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

ErrorsErrors

Adverse Adverse eventsevents

MortalityMortality

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The The “Swiss Cheese”“Swiss Cheese” Model of Accident Causation (Reason, 1990) Model of Accident Causation (Reason, 1990)Excessive cost cutting – staffing reduction

Equipment shortages

Communication

Staff Motivation

Divided or confused accountability

Deficient training program

Inexperienced X-Ray Tech

Poor compliance to policies

Poor Coordination & Communication

Failed to review allergies

Wrong X-ray marker used

Wrong procedure performed

Failures in theSystem

Leadership

Policies/Procedures

Available Resources

Accident & InjuryWrong Site Surgery Medication Error Fall Sharps injury

“Latent Errors”

Barriers to

AccidentsCommunication

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The Vision The Vision

The ChallengeThe Challenge

The Roadmap for improvement The Roadmap for improvement

Culture: The way we do things around here

Safety Culture Definition

The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management.

Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human

Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

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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

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INCIDENT REPORTING Do not identify more than 10 % of adverse events

HARM

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 23

What is Instinctive Behavior?

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Incident Reporting: Learning from the Animal Kingdom

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• 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.

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Culture of Safety

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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

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The Future Beckons

• Learning’s from Complaints

• Adverse Event Reports Analysis

• Clinical Specialty Specific Outcomes

Powerful Drivers of Change

• Reporting of Incidents and Near Misses• Perform observational rounds, surveys • Root Cause Analysis of Incidents and improvements• Safe Infrastructure, equipment, medicines

• Reporting of Incidents and Near Misses• Perform observational rounds, surveys • Root Cause Analysis of Incidents and improvements• Safe Infrastructure, equipment, medicines

• 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

• 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

• 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

• 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

• Articulate at every possible forum • Candid and open feedback on incidents, data, survey results • Memos, newsletters, Brochures, posters, conferences

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The cycle of continuous improvement

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Let us aim to make each new day safer than yesterday