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The Global Challenge
for Patient Safety
1st Symposium IHI-Einstein: Implementation and
Scale Up of Patient Safety Programs...
Our Vision
Everyone has the best care and health possible.
Who We Are
IHI is a leading innovator in health and health care...
IHI’s Work: Five Key Areas
3
Patient Safety
“The magnitude of medical error is enormous.
The fault lies with poorly conceived systems
rather than irres...
The Situation in Health Care
“What has eluded us thus far…is maintaining a
consistently high level of safety and quality o...
To Err is Human
6
Although no single activity can
offer a total solution for dealing
with medical errors, the
combination ...
Crossing the Quality Chasm
7
“Between the health care we
have and the care we could have
lies not just a gap, but a chasm....
No Shortage of Analysis
Level of Harm
9
United States:
3.7% of admissions
44,000 – 98,000 deaths
United States:
3.7% of admissions
44,000 – 98,000...
Global Trigger Tool Reviews
10
3 Exemplar
Hospitals
(900 notes)
40 Bed rural
Hospital (300
notes)
10 Hospital
Research
Pro...
Taking Action
The 100,000 Lives Campaign was a nation-wide initiative launched by
the Institute for Healthcare Improvement...
International Reach
12
Implementing at scale….
can it be done?
Execution
Ideas
Will
Our change theory
A clear and stretch goalA clear and stretch goalA clear and stretch goalA clear and stretch goal
A metho...
0,8
0,9
1,0
1,1
Oct-Dec
2006
Apr-Jun
2007
Oct-Dec
2007
Apr-Jun
2008
Oct-Dec
2008
Apr-Jun
2009
Oct-Dec
2009
Apr-Jun
2010
Oc...
60
65
70
75
80
85
90
95
100
105
110
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
Ma...
A New Culture of Safety
Institute of Medicine Report:
• Health care organizations must develop a “culture of
safety” such ...
Culture: A Definition
A culture is made of shared values and beliefs that
interact within an organization in order to prod...
Lessons Learned
1. Establish and Oversee Specific System-Level Aims at
the Highest Governance Level
2. Develop an Executab...
Summary
Safety is a global challenge – harm exists in every
system.
You will have great care in your hospitals but not for...
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The global challenge of patient safety

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Apresentação de Derek Freeley durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
Derek Freeley é Vice Presidente Executivo do Institute for Healthcare Improvement (IHI), tem responsabilidades executivas por conduzir estratégias do IHI em cinco áreas de atuação: desenvolvimento de habilidade; cuidado centrado no paciente e família; segurança do paciente; qualidade; custo e valor; e grande foco em populações. Antes de integrar a equipe do IHI em 2013, foi diretor geral de saúde e assistência social e diretor executivo do National Health Service (NHS) na Escócia.

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Transcript of "The global challenge of patient safety"

  1. 1. The Global Challenge for Patient Safety 1st Symposium IHI-Einstein: Implementation and Scale Up of Patient Safety Programs November 3, 2013 Sao Paulo, Brazil Derek Feeley Executive Vice President
  2. 2. Our Vision Everyone has the best care and health possible. Who We Are IHI is a leading innovator in health and health care improvement worldwide, joining forces with the IHI community to spark bold, inventive ways to improve the health of individuals and populations. Our Mission To improve health and health care worldwide.
  3. 3. IHI’s Work: Five Key Areas 3
  4. 4. Patient Safety “The magnitude of medical error is enormous. The fault lies with poorly conceived systems rather than irresponsible people.” - Dr. Lucian Leape 4
  5. 5. The Situation in Health Care “What has eluded us thus far…is maintaining a consistently high level of safety and quality over time and across all health care services settings. ….Along with some progress, we are experiencing an epidemic of serious and preventable adverse events. The concept that I believe can and should change this is: “High Reliability.” Dr. Mark Chassin, President, JACHO, Health Affairs, April 2011 5
  6. 6. To Err is Human 6 Although no single activity can offer a total solution for dealing with medical errors, the combination of activities proposed in To Err is Human offers a roadmap toward a safer health system. With adequate leadership, attention, and resources, improvements can be made. It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead.
  7. 7. Crossing the Quality Chasm 7 “Between the health care we have and the care we could have lies not just a gap, but a chasm.” Health care does not yet reliably transfer best-known science into action, and processes frequently fail, despite the best intentions of a dedicated and highly skilled workforce. Our system, which intends to heal, too often does just the opposite – leading to unintended harm and unnecessary deaths at alarming rates.
  8. 8. No Shortage of Analysis
  9. 9. Level of Harm 9 United States: 3.7% of admissions 44,000 – 98,000 deaths United States: 3.7% of admissions 44,000 – 98,000 deaths Australia: 16% of admissions 50,000 permanent disability 250,000 adverse events 10,000 deaths Australia: 16% of admissions 50,000 permanent disability 250,000 adverse events 10,000 deaths Denmark: 9% of admissions Denmark: 9% of admissions New Zealand: 10% of admissions New Zealand: 10% of admissions United Kingdom: 11% of admissions 850,000 adverse events United Kingdom: 11% of admissions 850,000 adverse events DoH ECRI 2002 Knox K et all
  10. 10. Global Trigger Tool Reviews 10 3 Exemplar Hospitals (900 notes) 40 Bed rural Hospital (300 notes) 10 Hospital Research Project (240 notes) 7 Hospital System (3000 notes) Multi-state Tertiary System (2000 notes) Events/1000 Days 83 90 NA 119 86 Events/100 admissions 45 40 37 41 38 Admissions with adverse events 32% 30% 30% 29% 30%
  11. 11. Taking Action The 100,000 Lives Campaign was a nation-wide initiative launched by the Institute for Healthcare Improvement to significantly reduce morbidity and mortality in American health care. Building on the successful work of health care providers all over the world, we are introducing proven best practices across the country to help participating hospitals extend or save as many as 100,000 lives. 11
  12. 12. International Reach 12
  13. 13. Implementing at scale…. can it be done? Execution Ideas Will
  14. 14. Our change theory A clear and stretch goalA clear and stretch goalA clear and stretch goalA clear and stretch goal A methodA methodA methodA method Predictive, iterative testingPredictive, iterative testingPredictive, iterative testingPredictive, iterative testing
  15. 15. 0,8 0,9 1,0 1,1 Oct-Dec 2006 Apr-Jun 2007 Oct-Dec 2007 Apr-Jun 2008 Oct-Dec 2008 Apr-Jun 2009 Oct-Dec 2009 Apr-Jun 2010 Oct-Dec 2010 Apr-Jun 2011 Oct-Dec 2011 Apr-Jun 2012 StandardisedMortalityRatio HSMR up to September 2012 8497 less than expected deaths 12.4% reduction
  16. 16. 60 65 70 75 80 85 90 95 100 105 110 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Baseline NHS South West median 98.05 90.90 HSMR NHS South West
  17. 17. A New Culture of Safety Institute of Medicine Report: • Health care organizations must develop a “culture of safety” such that their workforce and processes are focused on improving the reliability and safety of care for patients. 17
  18. 18. Culture: A Definition A culture is made of shared values and beliefs that interact within an organization in order to produce behavioral norms, or: “How we do things around here.” It is determined by how individuals and teams learn together and work together. 18
  19. 19. Lessons Learned 1. Establish and Oversee Specific System-Level Aims at the Highest Governance Level 2. Develop an Executable Strategy to achieve these Aims 3. Channel Leadership Attention to System-Level Improvement 4. Put Patients and Families on the Improvement Team 5. Make the Chief Financial Officer a Quality Champion 6. Engage Physicians 7. Build Improvement Capability IHI Seven Leadership Leverage Points
  20. 20. Summary Safety is a global challenge – harm exists in every system. You will have great care in your hospitals but not for every patient, every time. Improvement is possible – lives can be saved and harm avoided. New systems are necessary to make care safer and more reliable. It takes building will, generating ideas and a method for implementation. Cultural issues are important – leaders set the tone. 20
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