Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement (original) (raw)
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Case Study Keeping the Commitment : Progress in Patient Safety March 2011
2011
OSF HealthCare, an integrated health care delivery system serving parts of Illinois and Michigan, was an early leader in promoting a collaborative approach to patient safety improvement. OSF has enhanced these efforts during the past five years by continuing to build awareness of safety risks through systemwide error reporting and local risk assessment, by identifying clinicians who can serve as models for their peers, and by engaging staff in intraorganizational learning and competition to spur improvement. It also has raised performance expectations by educating hospitaland system-level board members about patient safety issues and quality improvement techniques. Exemplary facility-level results include: an 80 percent reduction over six years in the rate of ventilator-associated pneumonia among intensive care patients; an increase from 39 percent to 100 percent in compliance with a standardized medication administration process; and a nine-percentage-point increase over one year i...
Committed to Safety: Ten Case Studies on Reducing Harm to Patients
2006
This report presents 10 case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in five areas that hold great promise for improving patient safety nationally: promoting an organizational culture of safety, improving teamwork and communication, enhancing rapid response to prevent heart attacks and other crises in the hospital, preventing health care–associated infections in the intensive care unit, and preventing adverse drug events throughout the hospital. Participating organizations ranged from large integrated delivery systems to small community hospitals. The cases describe the actions taken, results achieved, and lessons learned by these patient safety leaders, with suggestions for those seeking to replicate their successes. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or...
Transforming concepts in patient safety: a progress report
BMJ quality & safety, 2018
In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for H...
A critical appraisal of what organisational approaches are pivotal to improve patient safety
Background: Patient safety remains a priority for healthcare organisations globally. There remains little consensus regarding the extent of this issue and the resultant impact on both individuals and communities. Aim: Our study aims to provide healthcare organisations and decision makers with increased information regarding predictive risk factors to enhance patient safety, and develop an organisational culture of safety. Methods: This paper reviews current literature regarding patient safety and presents predictive risk factors and recommendations for healthcare organisations globally to measure and monitor patient safety. Results: Three categories of organisational factors promoting safety culture were identified-Focusing on system/culture, management support and team work and event reporting. Conclusions: This review strove to identify and discuss the predictive risk factors for patient safety and support the importance of a positive organisational culture and strong leadership in monitoring and reducing patient care errors and improving patient care in healthcare setting.
Organizational and Cultural Changes for Providing Safe Patient Care
Quality Management in Health Care, 2005
established a patient safety committee (PSC) and charged it with reviewing adverse events. (2) Cultural Change-PSC sponsors and participants work to promote a culture of collaboration, study, learning, and prevention versus a culture of blame. (3) Collaboration-The PSC includes chief residents and members from medical informatics, nursing, pharmacy, quality assurance, risk management, and utilization management. (4) Evolution-The duties of the PSC progressed from merely learning from adverse event reports to implementing patient safety and quality improvement projects. (5) Standardization-The PSC uses standard definitions and procedures when reviewing cases of adverse events, and when conducting patient safety and quality improvement projects. Results: (1) Developed an online adverse event reporting system, shortening the average report collection time by 2 days and increasing the number of adverse events reported. (2) Established a model for change using (a) safety rounds with residents, (b) e-mail safety alerts, and, in some cases, (c) decision alerts using electronic order entry. These changes in culture and capability led to improvements in care and improved financial results. Conclusions: Senior management support of a culture of learning and prevention and an organizational structure that promotes collaboration has provided an environment in which patient safety initiatives can flourish by providing not only safer and higher quality patient care but also a positive financial return on investment.
Health Services Research, 2006
Objective. To assess the potential contribution of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) to organizational learning for patient safety improvement. Principal Findings. Patient safety improvement requires organizational learning at the system level, which entails changes in organizational routines that cut across divisions, professions, and levels of hierarchy. This learning depends on data that are varied along a number of dimensions, including structure-process-outcome and from granular to high-level; and it depends on integration of those varied data. PSIs are inexpensive, easy to use, less subject to bias than some other sources of patient safety data, and they provide reliable estimates of rates of preventable adverse events. Conclusions. From an organizational learning perspective, PSIs have both limitations and potential contributions as sources of patient safety data. While they are not detailed or timely enough when used alone, their simplicity and reliability make them valuable as a higher-level safety performance measure. They offer one means for coordination and integration of patient safety data and activity within and across organizations.
Patient safety: a tale of two institutions
Journal of healthcare information management : JHIM, 2006
The Johns Hopkins Medical Institutions and the University of Pittsburgh Medical Center are both working to improve patient safety. Johns Hopkins is focused on creating a culture of safety--frontline interventions at its Children's Center include a focus on the "Culture of Safety" and three programs that use information technology to "fix the broken medication process." Quantitative data indicate these programs are making care safer. At UPMC, efforts launched under the Robert Wood Johnson Foundation and the Institute of Health Care Improvement, a program named Transforming Care at the Bedside, are redesigning care processes to support nurses and focus on patients. Interventions include family-initiated rapid response teams and other changes designed to streamline processes and use information technology to make care patient-centered. Simulation-based training targets critical procedures and performance for physicians and nurses, and a "smart room" is...
Training a Patient Safety Work Force: The Patient Safety Improvement Corps
Health Services Research, 2009
Objective. Evaluate short-term effects of the Patient Safety Improvement Corps (PSIC), an Agency for Healthcare Research and Quality–sponsored program to train state teams in patient safety skills/tools, to assess its contribution to building a national infrastructure supporting effective patient safety practices.Data Source. Self-reported information gathered from (1) group interviews at the end of each year; (2) individual telephone interviews 1 year later; (3) faxed information forms 2 years later.Study Design. Program evaluation of immediate and short-term process and impact (use of skills/tools, information sharing, changes in practice).Data Collection. Semistructured interviews; faxed forms.Principal Findings. One year after training, approximately half of Year 1 and 2 state agency representatives reported they had initiated or modified legislation to strengthen safe practices, and modified adverse event oversight procedures. Approximately three-quarters of hospital representatives said training contributed to modifications to adverse event oversight procedures and promotion of patient safety culture. Two years posttraining, approximately three-quarters of Year 1 trainees said they continued to use many skills/tools.Conclusions. The PSIC contributed to building a national infrastructure supporting effective patient safety practices. Expanded training is needed to reach a larger fraction of the population for which this training is important.
2018
In their editorial, Mannion and Braithwaite contend that the approach to solving the problem of unsafe care, Safety I, is flawed and requires a shift in thinking to what they are calling Safety II. We have reservations as to whether by itself the shift from Safety I to Safety II is sufficient. Perhaps our failure to improve outcomes in the field of patient safety and quality lies less in our approach – Safety I vs. Safety II – and more in the lack of an agreed upon, commonly understood set of core competencies (knowledge, skills, and attitudes) needed in its workforce. The authors explore in this commentary the need to establish core competencies as part of the pathway to professionalism for the discipline of patient safety and quality.