What is Patient Safety?

Transcription

“The names of the patients whose lives we save can
never be known.
Our contribution will be what did not happen to them.
And, though they are unknown, we will know that
mothers and fathers are at graduations and weddings
they would have missed, and that grandchildren will
know grandparents they might never have known, and
holidays will be taken, and work completed and books
read, and symphonies heard, and gardens tended that,
without our work, would never have been.”
Donald M. Berwick, MD, MPP
President and CEO
Institute for Healthcare Improvement
Creating a Culture of Safety
Kaiser Permanente Southern California
6th Nursing Quality & Innovation Conference – 10/1/10
1
Beyond Blame
As you watch this video
Please think about how this story
Made you feel and
Whether or not the
Situations were handled
Correctly
Objectives
Upon completion of this presentation, you
will be able to:
• Define a culture of safety
• Define a Just Culture
• Describe our current safety culture and
the need for change
• Describe what KP SCAL is doing to spread
a Just Culture across all Medical Centers
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Reporting Errors
• How many of you think it is important to
report errors?
• Why is it important to report errors?
• Do you report errors?
• Why do you think some staff/physicians
don’t report errors?
What should be reported?
•Errors that cause
harm
•Errors that do not
cause harm
Errors
Reported
Errors
Actually
Occurring
•Near misses
3
Near Misses
Sometimes the only thing
separating an error that
causes no injury from one
that causes major harm is
pure luck or the robust
nature of human
physiology.
Death
1
Severe
10s
Minor – Moderate
100s
Prevented/No harm incidents
1,000s
What is a Just Culture?
• A key component of a safety culture
• A culture of trust where people are encouraged
and recognized for providing essential safetyrelated information
• A culture which clearly defines where the line
must be drawn between acceptable and
unacceptable behavior
Ref: James Reason
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Working in a Just Culture
• Errors and mistakes are inevitable
• Learn from your mistakes
• Encourage reporting

Causes are looked for
Things get fixed
Reporters are valued, not harassed
Management supports reporting and fixing
LMP National Agreement
2005
Patient Safety
Improving the quality of care delivered to members and
patients requires significantly increasing the reporting
of actual errors and “near misses.” It is recognized
that the reporting of such errors can only improve if
employees are assured that punitive discipline is not
seen as the appropriate choice to handle most errors.
We must jointly create a learning environment which
views errors as an opportunity to continued, systematic
improvement. This environment must encourage all
employees to openly report errors or “near misses” and
participate in analyzing the reason for the error and the
determination to the resolution and corrective action
needed to prevent reoccurrence.
5
Reporting System
The Reporting System will include the following
components:
• Reporting of errors, with systematic, standardized analysis
of errors and near misses;
• Communication of learning to help make needed policy and
procedure changes;
• Confidentiality of involved employees unless prohibited by
statute or law;
• Involvement of staff in error analysis and/or resolution;
• Positive reinforcement for reporting;
• Training and education programs that enhance skills and
competency to help prevent future errors;
• Maintenance of the integrity of privileged information; and
• Ability to collect and trend data across the organization.
Authorizing Sponsors
• Benjamin Chu, MD – President Southern
California Region KP
• Patty Harvey, RN – Vice President Regional
Quality and Risk Management
• John Brookey, MD – SCPMG Assistant Medical
Director, Quality and Risk Management
• Kathy J. Sackman, RN – President UNAC/UHCP
• Arlene Peasnall – Vice President Human
Resources, KP Southern California
• Al Carver – Vice President Pharmacy Strategy
and Operations
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Steering Committee
Members
•Susan Al-Sabih, NP – SCPMG Nursing
•Libra Baker, RN BSN – Director Home Care Patient
Services Kaiser Riverside
•Barbara Blake, RN – State Secretary UNAC/UHCP
•Terry Bream, RN – Nursing Manager SCPMG
Administration
•Dottie Carmichael, RN – Director Adult Primary
Care
•Denise Duncan, RN – Staff Representative
UNAC/UHCP
•Linda Fahey, NP – Regional Manager, Quality &
Patient Safety
•Suzanne Graham, RN, PhD – Director Patient
Safety California Regions
•Kristine Hilary, RN – Regional Director Home Care
Services
•Janna Hoff, RN – Regional Manager, Clinical
Practice Med/Surg
•Helen Horn - Union Representative, UHW
•Judy Husted, RN – Executive Director Patient Care
Services
•Carol Jones, RN – Staff Representative
UNAC/UHCP
•Cindy Klein, RN – Out Patient, Kaiser Riverside
•Rich Levy – Pharmacy Quality KP/SCPMG
•Janice MacDonald, RN – Patient Safety Officer,
LAMC
•Barbara Macon, RN – Staff Representative,
UNAC/UHCP
•Paul Martin – HR LAMC
•Nancy Miner – OE Consultant
•Therese Morley, RN, EdD – Practice Leader Patient
Safety
•Regina Okura – Pharmacy Technician
•Richard Rosas – Labor Relations
•Pamela Pressney, RN – In-Patient Kaiser San
Diego
•Jodi Santiago, RN – AMGA Kaiser Fontana
•Peter Sidhu, RN – In-Patient, Kaiser Woodland
Hills
•Heddy Steinman – UFCW Representative, OutPatient Pharmacy Technician
•Cathy Turner, RN – Patient Safety Officer Kaiser
West LA
•Pamela Wald, MD – Pediatrician Kaiser Downey
•Kara Yoneshige – Management Consultant
Steering Committee
Desired Outcomes
• Employees report errors that could or did cause harm
to patients
• Employees report systems and processes are improved
based on errors and near misses reported
• Employees are treated fairly when an error occurs and
there is appropriate use of corrective action
• Staff report leadership (labor and management)
support and foster a just culture through organization
• Employees feel comfortable identifying and escalating
patient safety risks and concerns
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Hopes
• Promote patient safety; front-line staff feel comfortable in
reporting
• Educate our DA’s – give it substance
• Decrease variation – implement consistent practices
• Becomes our way of doing business for everyone – Union,
Physicians, etc.
• Implement Just Culture in pharmacy setting
• Stay enthusiastic after kickoff
• We can take algorithm and make it practical in fact-finding
• Address more than just medical errors
• Clarify that it is a culture of accountability at Medical Center level
• More than just nursing and pharmacy
Concerns
• Political climate not one of just culture;
instead, there is a need to punish
• Regulations and rules not easy to change
• Making sure there is follow-up
• Resources – not just another initiative
• Medical Center leadership needs to be
able to prioritize for their area
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Policy Statement
It is the policy of Kaiser Permanente, Southern
California, that leadership and management are
responsible for creating and sustaining an
environment in which employees are
encouraged to report errors and “near misses”
without fear of retaliation. When an error or
potential error is discovered, leaders and
managers will use the Managing Error in a Just
Culture Algorithm (adopted from the work of
James Reason) when investigating the event
and determining next steps for the resolution of
the identified risk.
Just Culture
Pilot Site
Downey Medical Center
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Informed
Patient Safety University
May 20-21, 2010
Presenters included:
Program Office and SCAL
Doug Bonacum,
Suzanne Graham,
Jeff Convissar MD,
Therese Morley
Locally:
Lisa Owyang, MD Chief of Ophthalmology
Aaron Lim, MD Assistant Chief OB-GYN
170 attendees:

21 physician leaders,
91 managers,
46 Labor leads,
10 community affiliates,
2 members from Pt. Safety Council
Informed
Downey Pilot Briefing
Topics
Escalation – March 15, 2010
Just Culture – June 21, 2010
Responsible Reporting – May 10, 2010
Great Communication Stories – March 22, 2010
Patient Safety/Just Culture Reading/Video List –
September 20, 2010
DMC Near Miss – March 22, 2010
Patient Identification – April 26, 2010
The Anatomy of Escalation – August 10, 2010

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Informed
Face-to Face
Labor Leads:

Rounding
Coalition
One-on-Ones
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Management Leads:

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DA Meeting
Chiefs Meeting
AMCA Meeting
Med Exec Meeting
MCAT Meeting
One-on-Ones
In Partnership
Department
Training
Informed
Training
• Training model developed by Site Steering
Committee using preliminary work done at
Regional level.
• Training designed to convey the Just Culture
model without overwhelming line level staff.
• Training method utilizes strength of Partnership
by using Labor Partners and Managers of each
unit to train their own units.
• Training method requires Managers to take
ownership of Just Culture in front of their staff
and helped to give credibility to the process.
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Reporting
Just Culture Rollout Physicians
Focus on awareness and acceptable behavior
Department chiefs educated at Chiefs Meetings and
Patient Safety University
General physician staff memo distributed explaining
the Just Culture initiative and rollout
Direct presentation to physicians at departmental
meetings and upcoming physician offsite with Dr.
Karm, Dr. Magallanes
Just & Flexible
New Approach
Looking at balance between individual
accountability and system failure on case-bycase basis.
New Approach for:
• Human Resources
• Labor
• Management
Our greatest hurdle is gaining the trust of Labor.
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Just Culture Rollout
Where are we now?
As of September 22:
Train the trainer is 99% complete-each department is
responsible for training its own members-accountability and
ownership.
About 1500 employees and managers have been trained.
4 departments are fully implemented.
Many DAs are using the algorithm and the substitution test,
even before staff is trained.
Learning
Our Journey
• Celebrating our success
• Learning from our missteps
Culture change is a journey
NOT a light bulb!
You can’t just flip the switch!
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Adopted from James Reason
“Managing the Roles of
Organization Accidents” and work
of David Marx
Managing Error in a Just Culture
STEP 1
STEP 2
no
Were the
actions as
intended?
yes
Updated 4/26/10
Just
Managing Error in a Just Culture
Substance Use
Or Abuse?
yes
no
STEP 3
no
STEP 4
Knowingly violated
safe operating
procedures?
no
STEP 5
yes
Pass
substitution
test?
History of
unsafe
acts?
no
yes
no
yes
Were the
consequences as
intended?
yes
Medical
Conditions?
Were procedures
available, workable,
Intelligible and correct?
yes
no
no
Deficiencies in
training and
selection, or
inexperienced?
no
yes
yes
System
induced
Behavior
Substance
Abuse
Possible
Reckless
Behavior
Pass
substitution test
yes
Malevolent,
Sabotage,
Damage, fraud, etc.
yes
Outside scope of “Just
Culture” Refer to: Human
Resources, Compliance
Policies, EAP, etc
Reckless Behavior
Corrective Action
Does the series of
errors reside within
system
System
induced
human error
System Induced
Error
Manager Action:
Coaching and /or
Corrective Action
Manager
Action: Refer
to Primary
Care Provider
yes
System
induced
human error
in need of
investigation
Human Error
Manager
Action
Management
Action
Console
At Risk Behavior
Coach
no
Although
not
culpable
for this
error
coach/
counseling
action
may be
needed
Human Error
Console
“The names of the patients whose lives we save can
never be known.
Our contribution will be what did not happen to them.
And, though they are unknown, we will know that
mothers and fathers are at graduations and weddings
they would have missed, and that grandchildren will
know grandparents they might never have known, and
holidays will be taken, and work completed and books
read, and symphonies heard, and gardens tended that,
without our work, would never have been.”
Donald M. Berwick, MD, MPP
President and CEO
Institute for Healthcare Improvement
14