Patient Safety
Culture:
FREE WEBINAR | MAY 17, 2016 | 2-3pm ET
A Foundation for a
QAPI Program
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement
Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers
for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views
presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-051716A
Objectives
After this presentation, the learner will:
 Understand the basic foundation of patient safety
and recommendations for moving forward
 Identify two (2) dimensions within an
organization that SOPS (Survey on Patient Safety)
can measure
 Recognize how safety culture aligns with QAPI
Program Standards
 Identify two (2) approaches to safety culture
Today’s Guest Expert
Tina Hilmas, RN, BSN
Project Manager
CENTER FOR PATIENT SAFETY
CULTURE AS A FOUNDATION
FOR A QAPI PROGRAM
Tina Hilmas RN BSN
May 17, 2016
http://www.centerforpatientsafety.org
CENTER FOR PATIENT SAFETY
WELCOME
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•
•
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The Center for Patient Safety
Safety Culture
QAPI and Safety Culture
Approaches to Safety Culture
CENTER FOR PATIENT SAFETY
PATIENT SAFETY
Josie King
CENTER FOR PATIENT SAFETY
WHAT ARE PATIENT SAFETY
ORGANIZATIONS
• Developed under the Patient Safety and Quality
Improvement Act (PSQIA) of 2005
• Mission and primary activity of Patient Safety Organizations
(PSOs) is to conduct activities to improve patient safety and
the quality of healthcare
• PSOs provide a secure environment for the sharing of
information
CENTER FOR PATIENT SAFETY
WHY PSO’s?
• Most organizations truly
don’t know how many
adverse events, near
misses or unsafe
conditions occur.
• There is little education or
training about patient
safety.
• Safety data is fragmented.
CENTER FOR PATIENT SAFETY
WHO IS THE CENTER
FOR PATIENT SAFETY
Independent not-for-profit
organization, established in
2005
Patient safety and quality
resources and services for
hospitals, health systems,
ambulance services, home
health, physician offices and
nursing homes
CENTER FOR PATIENT SAFETY
WHERE WE SERVE
CENTER FOR PATIENT SAFETY
HOW WE DO IT
PREVENTING.
Prevent adverse
events and patient
harm through
supportive cultures.
PROTECTING.
Protect patient
safety and
quality work.
LEARNING.
Learn best practices
and improvement
opportunities.
CENTER FOR PATIENT SAFETY
SAFETY CULTURE - BEGINNING
44,000 TO 98,000 PEOPLE DIE ANNUALLY FROM ERRORS
(1999 IOM REPORT: TO ERR IS HUMAN)
MAY, 2016: MEDICAL ERRORS 3RD LEADING
CAUSE OF DEATH IN THE UNITED STATES
“Quality Problems occur typically not because of a
failure of goodwill, knowledge, effort or resources
devoted to healthcare, but because of fundamental
shortcomings in how healthcare is organized.”
“Trying harder will NOT work.
Changing systems of care will!”
CENTER FOR PATIENT SAFETY
FREE FROM HARM
• Patient harm remains
unacceptably frequent
• Quality improvement
initiatives can advance only
with an emphasis on
culture, teamwork and
patient engagement
• Improving patient safety
and quality of care requires
a Total Systems Approach
NPSF Presentation January 26, 2016
CENTER FOR PATIENT SAFETY
SAFETY CULTURE
CENTER FOR PATIENT SAFETY
MEASURING SAFETY CULTURE - SOPS
CENTER FOR PATIENT SAFETY
SURVEY OF PATIENT SAFETY
11 Dimensions
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•
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•
•
•
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Overall Perceptions of Patient Safety
Communication Openness
Staffing, Work Pressure and Pace
Teamwork
Response to Mistakes
Staff Training
Handoffs
Feedback and Communication about
Mistakes
• Organizational Learning
• Communication During a Response
• Leadership Support for Patient
Safety
CENTER FOR PATIENT SAFETY
MEASURING SAFETY CULTURE - SOPS
“First, identify one or two
areas that need
improvement and drive
change, as opposed to trying
to improve everything at
once. Second, use quality
improvement techniques to
achieve incremental
improvement and set stretch
goals to achieve results.”
Debby Vossenkemper
System Director/Patient
Safety Officer
SSM Health
CENTER FOR PATIENT SAFETY
MEASURING SAFETY CULTURE - SOPS
“The survey is used as a tool. It helps
open the door for us to guide patient
care departments and can assist them in
focusing their priorities.”
Rachel Wells
Office of Patient Safety
CoxHealth
“Safety Surveys tend to turn the invisible
into the visible. Once we saw where we
are at, we came together to make the
needed improvements.”
Jeff Robinson
Radiation Oncology Director
CoxHealth
CENTER FOR PATIENT SAFETY
SAFETY CULTURE AND HOME HEALTH
Strong Safety Culture
Organizational
Learning
Open
Communication
Teamwork
CENTER FOR PATIENT SAFETY
SAFETY CULTURE AND HOME HEALTH
Barriers
Lack of
Leadership
Failure to
Update
Policies/
Processes
Lack of
Knowledge/
Education
CENTER FOR PATIENT SAFETY
Synergy
CENTER FOR PATIENT SAFETY
HOME HEALTH CHANGES
Conditions of Participation
• Infection Control
– Reflect current healthcare
practices
– Prevent/Control Infections
• QAPI
– Quality Assessment and
Performance Improvement
– Develop, Implement &
Maintain
CENTER FOR PATIENT SAFETY
HOME HEALTH CHANGES
• Effectiveness
• Efficiency
• Equity
• Patient Centeredness
• Safety
• Timeliness
CENTER FOR PATIENT SAFETY
QAPI PROGRAM STANDARDS
• Executive Responsibility
• Program Scope
• Program Data
• Program Activities
• Performance
Improvement Projects
CENTER FOR PATIENT SAFETY
SAFETY CULTURE FOUNDATION
CENTER FOR PATIENT SAFETY
QAPI/SAFETY CULTURE
EXECUTIVE RESPONSIBILITY
– Ensure that leaders establish and sustain a safety culture
– Open communication and respect
PROGRAM ACTIVITIES
– Create a common set of safety metrics that reflect
meaningful outcomes
– Root Cause Analysis
CENTER FOR PATIENT SAFETY
THE CULTURE PROBLEM
• Healthcare historically has
been punitive.
• Employees are afraid to
speak up if they make a
mistake or have a near miss
or there is an unsafe
condition.
• But…how can you fix what
you don’t know about?
CENTER FOR PATIENT SAFETY
APPROACHES TO SAFETY CULTURE
CENTER FOR PATIENT SAFETY
TeamSTEPPS
Team Strategies & Tools to Enhance Performance & Patient Safety
• Knowledge
– Shared Mental Model
• Attitudes
– Mutual Trust
– Team Orientation
• Performance
– Adaptability
– Accuracy
– Productivity
– Efficiency
– Safety
CENTER FOR PATIENT SAFETY
JUST CULTURE: BALANCED
ACCOUNTABILITY
Optimal Support for a
System of Safety
No Accountability
Transparency is
Impossible
Adapted from Outcome Engenuity
CENTER FOR PATIENT SAFETY
Comprehensive Unit-based Safety Program
CENTER FOR PATIENT SAFETY
SECOND VICTIMS
“Second victims are healthcare
providers who are involved in an
unanticipated adverse patient event,
medical error and/or a patient
related injury and become victimized
in the sense that the provider is
traumatized by the event.”
CENTER FOR PATIENT SAFETY
SIDE BY SIDE
TeamSTEPPS
•
Provides an
acceptable structure
and skills to voice
concerns about a
safety issue
Focus on a balance of
individual
accountability and
non‐punitive response
to error
•
Promotes team
understanding and
efficiency
Provides a consistent
framework for
evaluating events and
other personnel issues
•
•
Emphasis on the
culture of teamwork
and communication
•
•
Just Culture
Philosophical
approach at the
organizational level
CUSP
•
The unit/clinic takes
ownership of its own
identified safety
problems and
proposes solutions
to correct them
•
Teaches analysis
skills to evaluate
safety events and
put measures in
place to prevent
them from
happening again.
CENTER FOR PATIENT SAFETY
SUMMARY
• So how can safety culture be a foundation for your QAPI
program?
• A culture which emphasizes safety also sets itself up for:
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–
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Positive patient experience
Collaboration between all health care members
Improved Coordination of care
Improved communication
Identification of potential errors before they cause harm
Standardized processes, less handling each event as a separate
event
CENTER FOR PATIENT SAFETY
CONCLUSION
“The single greatest impediment to error prevention
in the medical industry is that we punish people for
making mistakes.”
Dr. Lucian Leape
Professor, Harvard School of Public Health
Testimony before Congress on
Health Care Quality Improvement
CENTER FOR PATIENT SAFETY
QUESTIONS
CENTER FOR PATIENT SAFETY
SAFETY TEAM
NOT PICTURED
KATHY
WIRE
ALEX
CHRISTGEN
JD, MBA, CPHRM
Project Manager
BS-BA
Project Manager
EUNICE
HALVERSON
TINA
HILMAS
MA
Patient Safety
Specialist
LEE
VARNER
RN, BSN
Project Manager
MSEMS, EMT-P
Project Manager
AMY
VOGELSMEIER
PhD, RN, FAAN
Patient Safety
Researcher/Analyst
For more than 10 years, the Center for Patient Safety has been
committed to improving safety for both patients and providers.
CENTER FOR PATIENT SAFETY
CONTACT US
Tel: 888.935.8272
www.centerforpatientsafety.org
[email protected]
Tina Hilmas RN BSN
Project Manager
[email protected]
QAPI Resources
 Home Health QAPI Fact Sheet
 HHQI’s topic-specific Performance Improvement
Project (PIP) tools
– Cardiovascular Health: PIP Tool & PIP Example
– Hospitalizations: PIP Tool & PIP Example
– Medication Management: PIP Tool & PIP Example
 QAPI Canvas
 HHQI University supplemental courses on the
above topics
 CMS’s Final Conditions of Participation (01/13/17)
Continuing Education Steps
Follow these steps to get your CE certificate:
1. Register/log in to HHQI University. You will be automatically
redirected to this website when you exit this webinar.
Continuing Education Steps
2. Click on the Patient Safety Culture: A Foundation
for a QAPI Program course in the Quality
Improvement course catalog.
3. Click on Enroll under the
icon.
4. Click on My Account
to launch the course.
5. Click on the
icon next to the course in the
View column.
Continuing Education Steps
6. Click on the
to Lesson 1.
icon in the Action column next
• Review the e-Learn content. (10 minutes)
• Watch the Patient Safety Culture webinar. (1 hour)
• Take the post-test. (20 minutes)
7. After completing the e-Learn, click on the
the Action column next to Lesson 2.
icon in
• Complete the course evaluation.
8. After completing the evaluation, you can print your
certificate from the My Account area in HHQI
University.
Thank You!
www.HHQIUniversity.org
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health
Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-051716A