Quality Improvement

Principles of Quality and Safety for HIT

Lecture a

This material (Comp12_Unit2a) 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.

Principles of Quality and Safety for HIT

Learning Objectives─Lecture a

• Investigate the fallibility of people and systems.

• Describe the ways that every system is designed to achieve the results it gets.

• Apply the basic principles of safe design.

• Explain the ways that teams make wise decisions with diverse and independent input.

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Quality Improvement Principles of Quality and

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Bilateral Cued Finger Movements

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X-Ray Reveals Sponge

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Josie King (18 months old) died from medical error

A Fatal Mistake

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The Problem Is Large

In U.S. Healthcare system

• 7% of patients suffer a medication error

• 44,000- 98,000 deaths

• 100,0000 death from HAI

• Patients receive half of recommend therapies

• $50 billion in total costsSimilar results in UK and Australia

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A Question…

• How can this happen?

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

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How Can We Improve?Understand the Science of Safety

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

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The Swiss-Cheese Analogy

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System Factors

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A Dosage Error?

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Aviation AccidentsPer Million Departures

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Image: Boeing, 2001 Statistical Summary of Commercial Jet Airplane Accidents, June 2002

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Principles of Quality and Safety for HIT

Summary─Lecture a

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Quality Improvement Principles of Quality and

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Principles of Quality and Safety for HIT

References─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

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Images

Slide 3: Bilateral Cued Finger Movements . Image courtesy Dr. Peter Pronovost. Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm

Slide 4: 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 5: Josie King. 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 9: 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 10: System Factors. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Image courtesy Dr. Peter Pronovost.

Slide 11: A Dosage Error? Creative Commons by MBBradford. Available from: http://en.wikipedia.org/wiki/File:Glucagon_vials_and_syringe.JPG

Slide 12: Adapted from : Boeing. 2001 Statistical Summary of Commercial Jet Airplane Accidents. June 2002 . http://www.fearofflying.com/Boeingaccidentstatsum59-01.pdf

Slide 13: Josie King. 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