Patient Safety, Performance Improvement, Risk Management

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

PATIENT SAFETY PERFORMANCE IMPROVEMENT RISK MANAGEMENT:

PATIENT SAFETY PERFORMANCE IMPROVEMENT RISK MANAGEMENT To be completed by All OMC Employees, Contract Employees and Volunteers

PATIENT SAFETY PERFORMANCE IMPROVEMENT RISK MANAGEMENT:

PATIENT SAFETY PERFORMANCE IMPROVEMENT RISK MANAGEMENT An organizational QUALITY PERFORMANCE program exists to: Evaluate and improve processes that enhance patient safety and result in quality service Educate and involve staff in processes Identify events and other opportunities that allow for process review and improvement

WHAT IS PERFORMANCE IMPROVEMENT?:

WHAT IS PERFORMANCE IMPROVEMENT? Performance Improvement is EVERY staff person’s concern It is the assessing of how things are done or the results of how they turn out and how to make them better No matter what your job, you play an important role in helping OMC provide safe quality patient care Performance Improvement is vital to our organization and your department’s goals! IT IS HOW WE ARE JUDGED!!!

State and Federal Legislation Increasing:

State and Federal Legislation Increasing HIPPA (Health Insurance Portability & Accountability Act) addresses patient confidentiality and impacts the entire healthcare continuum EMTALA (Emergency Medical Treatment & Active Labor Act) addresses medical care, screening, transfer & when billing may be discussed COP (Conditions of Participation) defines Medicare’s expectations for delivery of care to patients

PATIENT SAFETY & QUALITY EXAMPLE ACTIVITIES & SOURCES:

PATIENT SAFETY & QUALITY EXAMPLE ACTIVITIES & SOURCES Application/Credentialing Orientation 90 Day Introductory Evaluation Evaluations/Success Reviews Continuing Education Policies/Procedures Regulatory Compliance Patient/Worker Safety

THE JOINT COMMISSION PATIENT SAFETY GOALS:

THE JOINT COMMISSION PATIENT SAFETY GOALS Focus on previously reported Sentinel Events Can change every year Related to specific programs – hospital, home care, long-term care Evidenced-based and require “culture change”

2013 Patient Safety Goals:

2013 Patient Safety Goals Identify patients correctly Name & Date of Birth Improve staff communication Read back

2013 Patient Safety Goals:

2013 Patient Safety Goals Use medicines safely Label medications Anticoagulant safety Medication reconciliation Prevent Infection Identify patients at risk for suicide non-psychiatric healthcare settings have increasingly become the settings for patient suicide. Patients are accessed on admission to determine if risk factors for suicide are present. Those identified at risk for self harm will be placed on suicide precautions.

2013 Patient Safety Goals:

2013 Patient Safety Goals Prevent mistakes in surgery pre-procedure verification Verify correct surgery, correct patient and correct place on patient's body Mark the surgery site Time Out

Performance Improvement Methodology:

Performance Improvement Methodology “LEAN”/Six Sigma A3 9 Step Process What is our reason for action? What is our current state? What is our target state? What are the gaps b/w current and target state? What are possible solutions? Perform Rapid experiments Develop completion plan Compare actual results to target metrics to confirm state Document insights or lessons learned

Example of Current A3:

Example of Current A3

OMC Specific Activities Addressing Performance Improvement/Patient Safety:

OMC Specific Activities Addressing Performance Improvement/Patient Safety Organization-wide initiatives – MISSION Routine monitoring of outcomes/events Timely reporting and evaluation of events/complaints with process the focus Use of external information as a source for process change Departmental initiatives to enhance processes One-time successes aren’t enough! Performance Improvement is ongoing! Key is TEAMWORK!!

Safety Management and Error Prevention for Oconee Medical Center Employees:

Safety Management and Error Prevention for Oconee Medical Center Employees

3 Behavior Expectations for Employees………..:

3 Behavior Expectations for Employees……….. Communicate Effectively I am personally responsible for effective communication Take “Time-Out” for Detail I will attend carefully to important details Commit to Safety I am accountable for safety

Why Do Events Happen?:

Why Do Events Happen? Slices of Cheese represent checks and balances which could be technology, processes, people, P&P Errors “getting” through Significant events or injuries “Safety is a Dynamic Non-Event” Adapted from Dr. James Reason, Managing the Risks of Organizational Accidents , 1997

Sentinel Events:

Sentinel Events Staff responsibility is to immediately report any significant event to a manager, supervisor, or to the OMC Nursing Supervisor Staff are to complete an appropriate factual report per policy and enter appropriate clinical documentation on the record Participate if asked to serve on a ROOT CAUSE ANALYSIS (RCA) team

After an Event? Why the Analysis?:

After an Event? Why the Analysis? The goal is to identify what, if anything, can be changed and how best to change it Once change is implemented, it provides for monitoring that the change has made a difference. IT IS QUALITY IN ACTION!

How to Prevent Errors:

How to Prevent Errors Expectation #1: Communicate Effectively Techniques for this expectation: Use Repeat-Backs and Read-Backs with Clarification Questions Identify Self, Department & Purpose with patients and with each other Use “SBAR” for Reports and Handoffs Situation, Background, Assessment, Recommendations

How to Prevent Errors:

How to Prevent Errors Expectation #2: Commit to Safety Techniques for this expectation: Adhere to Red Rule, Policies and Procedures Practice Peer Checking and Peer Coaching STOP and ASK when Unsure Raise the “Red Flag”

How to Prevent Errors:

How to Prevent Errors Adhere to the Red Rule, Policies, Procedures Follow the requirements of the RED Rule, Policies, and Procedures Perform the required activities as specified and in the order as specified.

Red Rule:

Red Rule I will confirm patient ID using 2 identifiers prior to any treatment or procedure.

Safety Starts with Me:

Safety Starts with Me The three behavior expectations are: Communicate Effectively and Clearly Take “Time Out” for Detail Commit to Safety

NOTHING WILL CHANGE UNLESS YOU CHANGE IT:

NOTHING WILL CHANGE UNLESS YOU CHANGE IT SAFETY IS AN INDIVIDUAL & COLLECTIVE RESPONSIBILITY

authorStream Live Help