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CRG MEDICAL FOUNDATION FOR PATIENT SAFETYCommunity of CompetenceTM for Patient Safety: A New Paradigm for Safety in Healthcare and the WorkplaceAmerican Society of Safety EngineersDecember 1, 2005 : 

CRG MEDICAL FOUNDATION FOR PATIENT SAFETYCommunity of CompetenceTM for Patient Safety: A New Paradigm for Safety in Healthcare and the WorkplaceAmerican Society of Safety EngineersDecember 1, 2005

Officers : 

Copyright 2005 CRG Medical Foundation for Patient Safety Officers Elizabeth A. Smith, PhD Executive Director Matthew C. Mireles, PhD Vice President & Director of Research Jonathan B. Tucker, MPA Secretary-Treasurer

Advisory Board : 

Copyright 2005 CRG Medical Foundation for Patient Safety Advisory Board University of Texas- Houston Health Science Center, School of Nursing University of Texas - Austin, School of Nursing University of Houston Texas Woman’s University Texas Southern University Private Sector: Pediatrician epidemiologist, hospital administrators, business leaders, researchers, educators, and patient advocates

Mission Statement : 

Copyright 2005 CRG Medical Foundation for Patient Safety Mission Statement “Promote and support patient safety, quality management and other health care areas to reduce medical errors in hospitals, clinics, physician’s offices, nursing homes, and in patients’ homes.”

What are these numbers? : 

Copyright 2005 CRG Medical Foundation for Patient Safety What are these numbers? 116,000 Fatalities during WWI 407,000 Fatalities during WWII 54,000 Fatalities during Korean War 58,000 Fatalities during Vietnam War

What are these numbers? : 

Copyright 2005 CRG Medical Foundation for Patient Safety What are these numbers? 56,000 Annual occupational fatalities 36,000 Daily nonfatal injuries on the job 9,000 Disabling nonfatal injuries $145,000,000,000 Cost of occupational injuries alone

Health Care Should Be… : 

Copyright 2005 CRG Medical Foundation for Patient Safety Health Care Should Be… Safe Timely Effective Efficient Equitable Patient-Centered

Statistics : 

Copyright 2005 CRG Medical Foundation for Patient Safety Statistics Healthcare costs (2004) are approximately $1.6 trillion Cost of medical errors: $80 billion Approximately 48,000 - 98,000 patients die/yearly due to medical errors (IOM 2000) Recent study suggested deaths are higher, up to almost 300,000 annually (Health Grades Inc., 2004)

More Statistics… : 

More Statistics… Only 21% of Medicare patients after a heart attack received effective drug interventions-18,000 deaths! 17 million people reported their pharmacist told them that their Rx could cause an adverse interaction. CDC lists medical errors as the 6th leading cause of death, ahead of diabetes, pneumonia, Alzheimer’s, and renal failure

More Statistics… : 

Copyright 2005 CRG Medical Foundation for Patient Safety More Statistics… Preventable healthcare-related injuries cost our economy $17 to $29 billion annually, half of which are added healthcare costs 10% due to human factors 90% due to healthcare system design 80% of medical errors are preventable!

What is the problem? : 

Copyright 2005 CRG Medical Foundation for Patient Safety What is the problem? Forces, factions & fads in healthcare are hard to describe and place in perspective No common goal in healthcare Few share knowledge or results beyond their own discipline Communication is inadequate and inefficient Many cooperative efforts fail because building successful teams takes years

What is the solution for the Healthcare Industry? : 

Copyright 2005 CRG Medical Foundation for Patient Safety What is the solution for the Healthcare Industry? A New Paradigm Shift: Systems Approach New Organizational Culture Improvement in Learning Empowerment Actualized Changes Community-Building

Communities of Competence™ : 

Communities of Competence™ Not just any group, committee, or coalition...but a true community of individuals based on knowledge, skills, expertise, experience, motivation, and competency

Theory Underlying CoC:Maslow’s Hierarchy of Needs : 

Copyright 2005 CRG Medical Foundation for Patient Safety Theory Underlying CoC:Maslow’s Hierarchy of Needs PHYSIOLOGICAL SAFETY SOCIAL ESTEEM SELF-ACTUALIZATION

Theory Underlying CoC:Evolution of Human Activity : 

Copyright 2005 CRG Medical Foundation for Patient Safety Theory Underlying CoC:Evolution of Human Activity Survival—exist, search for food, shelter, stay away from predators Safety—”in number”, group together to share food, protection, etc. Belonging—be with people who value and need you; trust Socialization—communicate with people, learn, share ideas Motivation—be competent at what you do

Theory Underlying CoC:Systems Theory : 

Copyright 2005 CRG Medical Foundation for Patient Safety Theory Underlying CoC:Systems Theory A system is the merging of parts, or subsystems, interconnections, feedback loops, and purposes (von Bertalanffy, 1968 & Plsek, 2001) A system is a set of components that work together for the objective of the whole (Haines, 1998) All systems have hierarchy consisting of clusters and levels based on processes and products (Scott, 1992)

Theory Underlying CoC:Systems Thinking : 

Copyright 2005 CRG Medical Foundation for Patient Safety Theory Underlying CoC:Systems Thinking Originated in biology and in common laws governing living systems in nature Applied to many fields, beginning in engineering, and used in aviation, nuclear power, and now slowly in healthcare Gradually replacing linear thinking See a unit as whole first & then how separate parts fit together & how they relate to the other Feedback loops connect all parts of the system together (transportation, education, healthcare)

Theory Underlying CoC:Driving Forces for Organizations : 

Copyright 2005 CRG Medical Foundation for Patient Safety Theory Underlying CoC:Driving Forces for Organizations Globalization—cultural diversity, politics, distance, continuous production, communication, etc. Complexity of work itself—numerous disciplines, experience levels, e-work, growing number of products and services Organizations are becoming virtual and boundaryless Turbulent external environment--limited resources Challenges in behaving, learning, adapting, and surviving

Community of CompetenceTMDefinition : 

Copyright 2005 CRG Medical Foundation for Patient Safety Community of CompetenceTMDefinition A new framework to first visualize what type of group exists and what type of group should be created to do a specific task or job A methodology to describe, assess, & combine separate strengths and core competencies of individuals, groups, & organizations into a meaningful, goal-oriented whole A team of highly skilled, specialized people with proven competencies A flexible, learning organization A network of organizations or systems

Community of CompetenceTMResponsibility of Members : 

Copyright 2005 CRG Medical Foundation for Patient Safety Community of CompetenceTMResponsibility of Members Do specific tasks or jobs for which they are qualified or competent Engage in continual learning and improving skills Are intensely focused, problem-driven, and knowledge rich Work together cooperatively and recognize expertise of their members and of other individuals

Community of CompetenceTMResponsibility of Members (cont.) : 

Copyright 2005 CRG Medical Foundation for Patient Safety Community of CompetenceTMResponsibility of Members (cont.) Rotate leadership based on unique competencies Make maximum use of tacit knowledge based on common sense and information sharing Communicate openly and share skills, abilities, knowledge, unique expertise, and evaluation

Community of CompetenceTMAdvantages : 

Copyright 2005 CRG Medical Foundation for Patient Safety Community of CompetenceTMAdvantages Members may volunteer or be selected for their competencies Solve problems quickly as members are focused, goal-driven, & cohesive Members are totally dedicated to the task and motivated by the task itself Members can move on to other communities where their talents are needed Members know the importance of open communication and sharing of lessons learned from both positive & negative experiences

Community of CompetenceTMAdvantages (cont.) : 

Copyright 2005 CRG Medical Foundation for Patient Safety Community of CompetenceTMAdvantages (cont.) Members use their unique tacit knowledge that is often based on common sense and experiences Members desire to be in a community and have their organizations recognize & make better use of time, energy, their overall talents and potential to increase effectiveness and efficiency Build communities based on trust, creativity, and competence

Case Study of Naval Aviation : 

Copyright 2005 CRG Medical Foundation for Patient Safety Case Study of Naval Aviation

First Safety Innovation : 

Copyright 2005 CRG Medical Foundation for Patient Safety First Safety Innovation

Sometimes, mistakes do happen… : 

Copyright 2005 CRG Medical Foundation for Patient Safety Sometimes, mistakes do happen…

CRG Medical FoundationBuilding Communities of Competence : 

Copyright 2005 CRG Medical Foundation for Patient Safety CRG Medical FoundationBuilding Communities of Competence Communities of nurses, educators, partners, etc. Focus on patients as members of CoC Patient Safety Checklist©, My Medical Journal© Patient safety book Patient Safety Registry© (prescription & dispensing errors to safe disposal of meds; medical dx; peer review network, near-miss reporting, etc.) Rural health project with Texas A&M

CRG Medical FoundationBuilding Communities of Competence for Workplace Safety : 

Copyright 2005 CRG Medical Foundation for Patient Safety CRG Medical FoundationBuilding Communities of Competence for Workplace Safety Safety as a way of thinking and acting wherever you are (work, home, leisure) Everyone is responsible for safety Everyone should feel comfortable to report a safety issue Everyone should be encourage to report Safety should be part of organizational culture and investment in human capital

Join our Community! : 

Copyright 2005 CRG Medical Foundation for Patient Safety Join our Community! Get involved with the Foundation (research, educational outreach) Become an individual or corporate member Volunteer with the Communities of Competence Help spread the word about workplace and patient safety Support our mission and projects Make a donation!

Communities of CompetenceReferences : 

Copyright 2005 CRG Medical Foundation for Patient Safety Communities of CompetenceReferences Bandura, A. (1986), Social foundations of thought and action: A social cognitive theory. Prentice-Hall, Englewood Cliffs, NJ. Code of Federal Regulations. (2003), Title 12, Vol. 1, Section 482.21, Dept of Health and Human Services, Centers for Medicare and Medicaid Services. Conditions of Participation for Hospitals, January. Davis, K. (2004), Address to the Commonweath Fund, U.S. Congress. Senate. Committee on Health, Education, Labor, and Pensions. 108th Congress. 2nd Session. Edmonds, M.J., Pradhan, M. & Runciman W.B. (2002), “Setting Priorities for Patient Safety”, 11 Qual Saf Health Care, pp. 224-229. Hackman, J.R. (1992), “Group influences on individuals in organizations”, In M.D. Dunnett & L.M. Hough (Eds.), Handbook of industrial and organizational psychology, Vol. 3 (2nd ed.), pp. 199-267, Consulting Psychologists Press, Palo Alto, CA. Haines, S. (1998), Systems Thinking and Learning, HRD Press, Amherst, MA. Homans, G.C. (1950), The human group, Harcourt, Brace & Co., New York.

Communities of CompetenceReferences (cont.) : 

Copyright 2005 CRG Medical Foundation for Patient Safety Communities of CompetenceReferences (cont.) Institute of Medicine. (2000), To Err is Human: Building a Safer Health System, L.T. Kohn, J.M. Corrigan & M.S. Donaldson (Eds.), National Academy Press, Washington, D.C. Likert, R. (1967), The human organization, McGraw-Hill, New York. Maslow, A.H. (1943), “A dynamic theory of human motivation”, Psychology Review, Vol. 50, pp. 370-396. Scott, W.R. (1992), Organizations: rational, natural, and open systems, 3rd Edition; Prentice Hall, New Jersey. Smith, E.A. (2006), “Communities of competence: A new form of group”, The 2006 Annual: 1 Consulting, Vol. 2, Pfeiffer & Company, San Francisco, CA. von Bertalanffy, L. (1968), General systems theory: Foundations, development, and applications, (Rev. Ed.), New York, George Braziller Publishers. White, R.W. (1959), “Motivation reconsidered: The concept of competence”, Psychological Review, Vol. 66, pp. 297-334. Wilson, E.O. (1971), The insect societies, Harvard University Press, Cambridge, MA.

Thank you! : 

Copyright 2005 CRG Medical Foundation for Patient Safety Thank you! Please visit us www.communityofcompetence.com 6800 West South Loop Suite 190 Bellaire, Texas 77401 832-778-7777 esmith@crgmedical.com matthew@crgmedical.com

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