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Quality in Healthcare Organizations

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  • 1. Nawanan Theera-Ampornpunt, MD, PhD Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University, Thailand January 9, 2013 TMHG 541: Fundamentals of Health Care and Medical Terminology Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of theNational Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award Number IU24OC000013 (Health IT Workforce Curriculum v.3.0, Component 12/Units 1-12).
  • 2.  Introduction to Quality Improvement Principles of Quality and Safety The Culture of Safety Learning From Mistakes: Error Reporting and Analysis and HIT
  • 3. Introduction to Quality Improvement This material (Comp12_Unit1a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 4. First, Do No HarmPrimum non nocere
  • 5. (IOM, 2000) (IOM, 2001) (IOM, 2011)
  • 6.  To Err is Human (Institute of Medicine, 1999) Reported that: • 44,000 to 98,000 people die in hospitals each year as a result of preventable medical mistakes • Mistakes cost hospitals $17 billion to $29 billion yearly • Individual errors are not the main problem • Faulty systems, processes, and other conditions lead to preventable errorsHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 6 Lecture d
  • 7.  Affected 1 in 3 hospital patients in one study In 2008, harms to patients from medical errors cost $17.1 billion Errors can result in medical malpractice lawsuits • 42% of doctors are sued at some point • Hospital malpractice suits alone could top $8.6 billion in 2011 Sufferingfrom medical errors: not measurable Introduction to Healthcare and Public Health in the US 7Health IT Workforce Curriculum Version 3.0/Spring 2012 Regulating Healthcare Lecture d
  • 8.  Humans are not perfect and are bound to make errors Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality Recommends reform that would change how health care works and how technology innovations can help improve quality/safety Health IT plays a role in improving patient safety (but it may also carry risks to safety in certain ways)
  • 9. “Healthcare reform without attention to the nature and nurture of healthcare as a system is doomed …It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it.” (Berwick, 2009)“The performance of a system — its achievement of its aims — depends as much on the interactions among elements as on the elements themselves. (Berwick, 2009)“The improvement of health and healthcare depends on systems thinking and systems redesign… ‘Reform’ without systems thinking isn’t reform at all.” (Berwick, 2009)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 9 Lecture a
  • 10. MEANINGFUL USE Providers show theyre using certified EHR technology in ways that can be measured significantly in quality and in quantity. PATIENT-CENTERED MEDICAL HOME Providers organize care around patients, working in teams, coordinating care, and tracking over time. ACCOUNTABLE CARE ORGANIZATION Provider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 10 Lecture a
  • 11.  The American Recovery and Reinvestment Act of 2009 “…authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming ‘meaningful users’ of certified electronic health record technology …” (The American Reinvestment and Recovery Act of 2009)• The HITECH (Health Information Technology for Economic and Clinical Health) Act establishes programs under CMS in coordination with the Office of the National Coordinator to accomplish this charge.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 11 Lecture a
  • 12.  Improve quality, safety, & efficiency Engage patients & their families Improve care coordination Improve population & public health; reduce disparities Ensure privacy & security protectionsHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 12 Lecture a
  • 13. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 13 Lecture a
  • 14.  The quality of care received needs improvement. In the current healthcare environment there are a number of initiatives that aim to improve the care in the U.S. context through the use of HIT. • Meaningful Use • Patient Centered Medical Home • Accountable Care OrganizationHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 14 Lecture a
  • 15. “Quality”
  • 16. “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.” (IOM, 2001)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 16 Lecture b
  • 17.  Better patient outcomes (patient health) Better system performance (patient care) Better professional development (clinician learning) Scientific evidence + particular context = measured performance improvementHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 The Evolution and Reform of Healthcare in the US 17 Lecture c
  • 18. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 18 Lecture b
  • 19.  National Quality Forum (NQF) www.qualityforum.org National Committee for Quality Assurance (NCQA) www.ncqa.org Provider organizations • AMA’s Physician Consortium for Performance Improvement (PCPI) www.ama-assn.org/ama/pub/physician- resources/clinical-practice-improvement/clinical- quality/physician-consortium-performance-improvement Joint Commission (JC) www.jointcommission.org Institute for Healthcare Improvement (IHI)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 19 Lecture b
  • 20.  Joint Commission certifies medical care facilities • Oldest and largest healthcare accrediting body • Independent nonprofit organization • Evaluates more than 18,000 US healthcare organizations and programs of all types Goal is to improve effectiveness, safety, and value of healthcare Organizations must undergo periodic site visits to identify and resolve problemsHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Delivering Healthcare (part 1) 20 Lecture c
  • 21.  1910: The forerunner of JC is called the “end- result” system 1951: Joint Commission on Accreditation of Hospitals (JCAH) is created and starts accrediting and certifying healthcare organizations 1987: Name changed to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007: Name simplified to Joint Commission (JC); currently accredits and certifies more than 18,000 organizations and programs in the USHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 21 Lecture a
  • 22. “To continuously improve healthcare forthe public, in collaboration with otherstakeholders, by evaluating healthcareorganizations and inspiring them to excelin providing safe and effective care of thehighest quality and value.”(The Joint Commission, 2011)Health IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 22 Lecture a
  • 23.  Earned by an entire healthcare organization (hospital, nursing home, office-based surgery practice, etc.) Tools the JC uses to measure performance • Integrated Survey Process (ISP): Evaluates performance across organization • ORYX: System for healthcare organizations to report to the JC about patients with certain conditions (core measure sets)  The core measure sets reported depend on the type and size of the organizationHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 23 Lecture a
  • 24.  Examples • Heart attack • Pneumonia • Inpatient psychiatric care • Children’s asthma • Stroke Each core set has performance measures • For example, the JC looks at whether children with asthma received certain drugs in the hospital and were sent home with a management planHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 24 Lecture a
  • 25.  JC-accredited organizations and providers of healthcare staffing services can also earn certification for specific programs or services • For chronic diseases and conditions  Examples: asthma, diabetes, heart failure programs • Programs can be within the medical center or in the communityHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 25 Lecture a
  • 26.  National Patient Safety Goals Universal Protocol Office of Quality Monitoring Speak Up™ program Sentinel Event PolicyHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 26 Lecture a
  • 27.  Sentinel Event Policy • Unexpected death, unexpected serious physical or psychological injury, or the risk of such an event Patient Safety Advisory Group • Panel of experts who recommend National Patient Safety Goals • Also address newly developing safety issuesHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 27 Lecture d
  • 28. • Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery – Pre-surgery verification – Site marking – “Time out” before an incision is made• The Speak Up Initiative – Encourages patients to participate in their care – Free patient education materialsHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 Regulating Healthcare 28 Lecture d
  • 29.  Part of Department of Health and Human Services Mission: “to improve quality, safety, efficiency, and effectiveness of healthcare for all Americans” • Safety and quality: Reduce risk of harm • Effectiveness: Improve healthcare outcomes • Efficiency: Transform research into practiceHealth IT Workforce Curriculum Introduction to Healthcare and Public Health in the USVersion 3.0/Spring 2012 The Evolution and Reform of Healthcare in the US 29 Lecture c
  • 30.  The Healthcare Accreditation Institute (Public Organization) www.ha.or.th Joint Commission (JC) www.jointcommission.org International Organization for Standardization (ISO) www.iso.org Provider & professional organizations • University Hospital Network (UHOSNET) www.uhosnet.com • The Medical Council of Thailand www.tmc.or.th • Thai Medical Informatics Association (TMI) www.tmi.or.th • Other professional councils and organizations Regulatory organizations • Ministry of Public Health • Ministry of Education  Thai Qualifications Framework for Higher Education (TQF:HEd) Payer organizations • National Health Security Office (NHSO) www.nhso.go.th • Social Security Office (SSO) • Comptroller-General Department Other quality frameworks • Thai Quality Award (TQA) www.tqa.or.th 30
  • 31.  Needs to be improved, especially for the uninsured  Patient safety & healthcare-associated infections warrant urgent attention  Quality is improving, but pace is slow, especially in preventive care & chronic disease management  Disparities are common and lack of insurance is a contributor  Many disparities are not decreasing; those that warrant increased attention include care for cancer, heart failure, and pneumoniaHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 31 Lecture b
  • 32.  National study of physician performance for 30 medical conditions plus preventive care: physicians provided only 55% of recommended care. (McGlynn et al. NEJM 2003; 348:2635) 66% of people with hypertension are inadequately treated. (JNC 7, JAMA 2003;289: 2560) 63% of people with diabetes have HbA1c levels greater than 7.0%. (Saydah, et al. JAMA 2004;291:335) 62% of people with elevated LDL cholesterol have not reached lipid goals. (Afonso, Am J Man Care 2006;12:589) 50-70% of healthcare-associated infections are preventable. (Umscheid et al. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.) 24.7% of Medicare patients admitted to the hospital for heart failure are readmitted within 30 days. (CMS, 2009)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 32 Lecture b
  • 33.  Only 27% of adults with a regular primary care physician (PCP) could easily contact their physician over the telephone, obtain care or medical advice after hours, or experience timely office visits. Only 57% of adults rate the information they get about their health issues as very good; only 43% find it easy to get an appointment; and only 56% find the physician’s office to be well-organized and feel their time is not wasted.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 33 Lecture b
  • 34.  Given the current sub-optimal quality of care received by patients, the introduction of QI initiatives is imperative. HIT has an important role to play in QI initiatives.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 34 Lecture b
  • 35. “Every system is perfectly designed to achieve the results it achieves.” (Paul Batalden, M.D, 2008)So, the answer must lay in the system redesign.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 35 Lecture b
  • 36. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 36 Lecture b
  • 37.  Make it specific • Assign it a number if possible Assign it a timeline Make it measurable Make sure it is challenging but doableHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 37 Lecture b
  • 38.  PROCESS MEASURE: Are we doing what we must to get the improvement we seek?  OUTCOME MEASURE: Are we getting what we expect?  BALANCING MEASURE: Are we causing new problems in other parts of the system?Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 38 Lecture b
  • 39. Hospital Ambulatory • AIM: we will reduce the number of • AIM: we will reduce the amount ventilator-associated pneumonias of time it takes our patients to get (VAP) in the ICU from the current an appointment (request to 23% to under 10% in 4 months appointment) from 23 days to 0 • MEASURES: days in 6 months  Process measure: • MEASURES:  Ventilator days  Process measure:  Over-sedation hours  Supply  Oral care performed  Demand  Outcome measure: Number of VAP  No-show rate  Balancing Measure:  Outcome measure: third next available appointment  Cost of care  Re-intubation rates  Balancing Measure: Patient satisfactionHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 39 Lecture b
  • 40.  Concepts and strategies: decide on the overall changes that will lead to the desired improvement. Specific changes: • Make them small • Make them fast • Make them frequent You may need to include additional measures specifically to decide if a change you have tested is worth keeping or did not lead to improvement. Consider using pre-existing change packages.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 40 Lecture b
  • 41. • One of the most important aspects of QI is to understand how your systems actually perform, under a range of conditions.• Deming’s theory of profound knowledge is based on the principle that each organization is composed of a system of interrelated processes and people.• The improvement of the system depends on the capability to organize the balance of each component to enhance the entire system.• Understanding and learning about your system is essential to improve it.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 41 Lecture b
  • 42. • PDCA (Deming Cycle) Plan Act Do Checkhttp://en.wikipedia.org/wiki/Shewhart_cycle 42
  • 43. • Continuous Quality Improvement (CQI)http://en.wikipedia.org/wiki/Continual_improvement_process Quality improvement is an ongoing, continuous effort• Total Quality Management (TQM)http://en.wikipedia.org/wiki/Total_quality_management Quality of products and processes is the responsibility ofeveryone involved in the products or services• Six Sigmahttp://en.wikipedia.org/wiki/Six_Sigma Seeks to improve quality by removing causes of defects and minimizing variability in manufacturing and business processes 43
  • 44. • Leanhttp://en.wikipedia.org/wiki/Lean_manufacturing Considers expenditure of resources that does not create value awaste -> “Preserving value with less work” Including tools such as Value Stream Mapping, 5S, Kanban (pullsystems), Just in time (JIT), etc.• Routine to Research (R2R)http://home.kku.ac.th/kitsir/research/html/download/news/r2r.pdf Improves the routine work processes through research• Risk Managementhttp://en.wikipedia.org/wiki/Risk_management Identification, assessment, prioritization , prevention, mitigation,monitoring, and control of risks 44
  • 45. Nonaka SECI ModelImage source: Senoo et al. (2007) http://dx.doi.org/10.1108/14601060710776725
  • 46.  The quality of care received needs improvement. Quality improvement is an ongoing process that includes the setting of an aim and a progressive measurement, change test, and understanding of the system. There are various complementary approaches to quality improvementHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 46 Lecture b
  • 47. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 47 Lecture c
  • 48. Principles of Quality and Safety for HITThis material (Comp12_Unit2a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 49. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 49 Lecture a
  • 50. In U.S. Healthcare system 7% of patients suffer a medication error 44,000- 98,000 deaths 100,0000 death from hospital-acquired infections Patients receive half of recommend therapies $50 billion in total costs Similar results in UK and AustraliaHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 50 Lecture a
  • 51.  How can this happen?  We need to view the delivery of health care as a scienceHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 51 Lecture a
  • 52. 1. Accept we are fallible—assume things will go wrong rather than right.2. Every system is perfectly designed to achieve the results it gets.3. Understand principles of safe design. • Standardize • Create checklists • Learn when things go wrong4. Recognize these principles apply to technical and team work.5. Teams make wise decision when there is diverse and independent input. Caregivers are not to blameHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 52 Lecture a
  • 53. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 53 Lecture a
  • 54. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 54 Lecture a
  • 55.  Standardize. • Eliminate steps if possible. Create independent checks. Learn when things go wrong. • What happened? • Why did it happen? • What did you do to reduce risk? • How do you know it worked?Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 55 Lecture b
  • 56. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 56 Lecture b
  • 57. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 57 Lecture b
  • 58. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 58 Lecture b
  • 59.  Assume things will go wrong Develop lenses to see systems Work to Mitigate Technical and Teamwork Hazards • Standardize work • Create independent checks • Learn from mistakes Make wise decisions by getting input from others Keep the patient the north starHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 59 Lecture b
  • 60. In this unit we’ve learned about the ways that teams make wise decisions with diverse and independent input. We’ve also explored the importance of communication and especially the place of critical listening.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 60 Lecture b
  • 61. The Culture of SafetyThis material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 62. Video 1Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 62
  • 63. Pointing the finger at people rather than systems.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 63
  • 64. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 64
  • 65.  Limitslearning Increases likelihood of repeat errors Drives self-reporting undergroundHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 65
  • 66. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 66
  • 67. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 67
  • 68. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 68
  • 69. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 69
  • 70. In this unit we explored the characteristics of high reliability organizations and learned more about establishing an organizational culture of safety.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 70
  • 71. Learning From Mistakes: Error Reporting and Analysis and HIT: Part 1This material (Comp12_Unit12a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 72. “A new delivery system must be built to achieve substantial improvements in patient safety – a system that is capable of preventing errors from occurring in the first place, while at the same time incorporating lessons learned from any errors that do occur.” (IOM,2004)Health IT Workforce Curriculum Quality Improvement 72Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 73. Health IT Workforce Curriculum Quality Improvement 73Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 74. Health IT Workforce Curriculum Quality Improvement 74Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 75.  Admit that providing health care is potentially hazardous  Take responsibility for reducing risks  Encourage error reporting without blame  Learn from mistakes  Communicate across traditional hierarchies and boundaries; encourage open discussion of errors  Use a systems (not individual) approach to analyze errors  Advocate for multidisciplinary teamwork  Establish structures for accountability to patient safetyHealth IT Workforce Curriculum Quality Improvement 75Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 76.  Near Miss  HarmHealth IT Workforce Curriculum Quality Improvement 76Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 77.  Swiss cheese model of error  A culture of safety  Three HIT mechanisms to help control error • surveillance systems, on-line event reporting, and predictive analytics/data modeling  Risk assessment model (near-miss VS harm)Health IT Workforce Curriculum Quality Improvement 77Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 78. Learning From Mistakes: Error Reporting and Analysis and HIT: Part 2This material (Comp12_Unit12b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 79. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 79 HIT─Lecture b
  • 80. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 80 HIT─Lecture b
  • 81. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 81 HIT─Lecture b
  • 82. Learning From Mistakes: Error Reporting and Analysis and HIT: Part 3This material (Comp12_Unit12c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 83. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 83 HIT─Lecture c
  • 84.  Structured problem-solving process Considers all potential causal or contributing factors  Human factors  System factors Detailed chronological list of events surrounding incident Premise: one can learn from one’s mistakesHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 84 HIT─Lecture c
  • 85. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 85 HIT─Lecture c
  • 86. Healthcare Example: Mrs. A. received blood inthe Emergency Department. Within 15 minutes,she experienced a bad reaction. Her nurserealized that she had received blood intended foranother patient. She was transferred to theintensive care unit to be stabilized. The ED staffwanted to know how this could have happenedso they assembled a team to identify possiblecauses.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 86 HIT─Lecture c
  • 87.  Briefly describe event Identify affected areas/services Assemble a team Diagram the process (flow chart) Identify potential root causes Prioritize root causes Develop action plan Evaluate results!Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 87 HIT─Lecture c
  • 88. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 88 HIT─Lecture c
  • 89. Story: Before I had children, I invited one of myhigh school friends and her family, including atoddler, to dinner. I was worried that her toddlerwould somehow manage to hurt himself in myhouse, which was designed for a childlesscouple.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 89 HIT─Lecture c
  • 90. Select a high risk process, one that isknown to have problems, and assemble ateam.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 90 HIT─Lecture c
  • 91. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 91 HIT─Lecture c
  • 92. The higher the number, the more urgent the need to prevent a failure.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 92 HIT─Lecture c
  • 93. Event: After reading several articles aboutlaboratory specimen errors that result in lab testsbeing done on the wrong patients, doctors at acommunity office practice decide to examine thepotential for this problem to happen in theiroffice laboratory.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 93 HIT─Lecture c
  • 94.  Select a high risk process (patient identification): • Affects a large number of patients • Carries a high risk for patients • Has known process problems identified by other organizations (e.g., Joint Commission Sentinel Event Alert!) Assemble a team • People closest to issue involved • People critical to implementation of potential changes • Respected, credible team leader • Someone with decision-making authority • People with diverse knowledge basesHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 94 HIT─Lecture c
  • 95. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 95 HIT─Lecture c
  • 96. The higher the number, the more urgent the need to prevent a failure.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 96 HIT─Lecture c
  • 97. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 97 HIT─Lecture c
  • 98.  Tools • Root Cause Analysis (RCA) • Failure Mode Effect Analysis (FMEA) • Hazard Analysis • Flow ChartingHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 98 HIT─Lecture c