# Presentation: 534973

## Module H: Patient Safety Homework

- Anne Tomolo, M.D., M.P.H.
- Louis Stokes Cleveland DVAMC

**Notes:**
Additions and edits by J Gosbee  (e.g., objectives added)

## Objectives

- Provide concrete tactic for adult learning model for learning about safety
- Something in-between full-fledged project and in-class exercise
- Early anecdotal success...soon to be more concrete/quantitative

## IOM Report (2001): Crossing the Quality Chasm
Safety is a key dimension of quality

Systems approach to safety improvement
Simply trying harder will not work 
Stepwise correction of problems in the system is the key to success
Overcome the culture of blame and shame:
...Human error is to be expected!

- Safety is a key dimension of quality
- Systems approach to safety improvement
- Simply trying harder will not work* *
- Stepwise correction of problems in the system is the key to success
- Overcome the culture of blame and shame:
**...****Human error is to be expected!**

**Background**

- Source:  Institute of Medicine * *2001.

**Notes:**
The IOM issued its second report on quality of care, Crossing the Quality Chasm, in 2001. This report expanded on the concepts presented in the first IOM report by looking at the full spectrum of factors that define quality in health care. Everyone deserves quality health care, and safety is certainly a key dimension of quality.
However, patients do not necessarily think of safety as a key dimension of quality. They take it for granted. Many assume that health care is always safe, just as they assume that every airplane they board will take off, fly, and land safely. This erroneous assumption has far-reaching implications for physicians. It leads some patients to have unrealistic expectations of the health care system in general, and of physicians in particular. Unrealistic expectations can also set physicians up to feel ashamed if an error occurs in practice that has adverse effects on the patient’s well-being. Just as our “culture of blame” fuels litigation, and needs to be remedied, a “culture of shame” based on unrealistic expectations fuels the tendency for practitioners to disregard or hide errors. The fact is we all are human, and we all err at times. 
But if we consider what it really takes to assure safety — looking at other complex enterprises, such as aviation, as models of what it takes — we see that a systems approach to safety improvement is the way to go. Trying harder will not work. Even if we all do the best we can as individuals, the systems in which we work have to be engineered for safety, so to speak, to assure that we can deliver health care that does no harm.
What can improve patient safety? Stepwise correction of problems in health care systems is the key to success.  A preoccupation with safety by everyone involved in the delivery of health care is needed.  

## Quality health care is...

**SAFE**
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable

- Source:  Institute of Medicine 2001.

**Notes:**
Here are the six dimensions of quality as described in the second IOM report. Quality health care is the following:
Safe: This is what’s embodied in the oath we’ve all taken to do no harm.
Effective: We achieve the desired clinical outcomes by using proven methods and applying our clinical expertise.
Patient-centered: This encompasses qualities — such as compassion, empathy, and responsiveness — to patients’ expressed needs and cultural diversity.	
Timely: This dimension touches on the need to reduce delays in the office and the hospital, in responding to inquiries from patients or colleagues, and in doing what we can to avoid delays in diagnosis and treatment.
Efficient: This, quite simply, is a mandate to reduce waste. Overuse of certain services is one factor that drives up the costs of health care, and errors are another. After all, errors drain resources and productivity when they result in an increased length of stay, hospitalization that would otherwise be unnecessary, or preventable morbidity or mortality.
Equitable: The aim here is to assure that health care is accessible to everyone, and delivered with sensitivity to patients’ needs and cultural diversity.

## A Call to Action...

**ACGME Competencies (2003)**
_**Systems-Based Practice**_: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
- Residents are evaluated on their use of systematic approaches to reduce errors and improve patient care and their assistance in the development of system improvements

## AN OPPORTUNITY EXISTSBECAUSERESIDENTS are an underutilized frontline resource to understanding OUR health care systems and its failures

## Safety Curriculum – Basic Goals

- Develop an understanding of the scope and importance of patient safety
- Become familiar with basic terminology & theories used in safety and human factors engineering
- Understand the current culture of “blame and train” in health care & YOUR INSTITUTION
- Relate curriculum efforts to clinical practice
- Identify local “realities” of event reporting
- SPECIFIC EFFORTS vary with the CONTEXT of the educational initiative

## Some Examples for Homework

- What is a system and how does it relate to health care?
- Structured approach to hazard identification

## Homework Ideas

- Issues and problems at
- Level of resident on a rotation (outcomes card)
- Level of all residents (hand-offs)
- Level of institution (RCA or HFMEA action plan)
- Should be...
- Easy enough to do with minimal mentoring
- Bounded with clear beginning and end
- Integrated with reality so as not to breed cynicism

## Donabedian’s Model of Quality Health Care

- © 1996 Dartmouth Medical School and Lahey Hitchcock Clinic

**Quality of Life**

**Social**

**Mental**

**Physical**

**Biological**

**Donabedian’s Model of Quality Health Care**

_**STRUCTURE**_

- Input Resources...

- •

-   Human-Professional

- •

-   Buildings

- •

-   Equipment

- •

-   Supplies

_**PROCESS**_

- Performance...

- •

-   Appropriateness

- •

-   Availability

- •

-   Continuity

- •

-   Effectiveness

- •

-   Efficacy

- •

-   Respect & Caring

- •

-   Safety

- •

-   Timeliness

_**OUTCOMES**_

- Health Results...

- •

-   Biological Function

- •

-   Physical Function

- •

-   Mental Health

- •

-   Social Function

- •

-   Quality of Life

- Satisfaction...

- •

-   With Care Delivery

- •

-   Perceived Health Benefit

_**PATIENT FACTORS**_

-  Demographics
-  Family History

## Potential Causes of Hazards

_**Organizational**_**:**
- Workplace design, planning/policies, administration/finance, incentives/leadership, supply mgmt, hand-off/transfers, supervision/feedback, unfamiliarity with tasks, and mismatch of personnel
_**Technical**_**:**
- Poor automation & equipment, lack of equipment, no decision support, complexity, lack of integration, no forcing function, irreversible error, info. overload, and no checklist
_**Human**_**:**
- Fatigue, lack of training, poor communication, power/control, hostility, distraction/time shortage, poor judgment, and logic error

## Factors Influencing Clinical Practice & Contributing to Adverse Events

**Factors Influencing Clinical Practice & Contributing to Adverse Events**

| Institutional | Regulatory context
Medicolegal environment | Priority of safety issues
Legal pressure agst discussion |
| --- | --- | --- |
| Organizational & Mgmt | Financial resources/constraints; policy std; safety cx & priorities | Lack of safety awareness
Policies  inadequate staff |
| Work Environment | Staffing levels & skill mix; equipment; workload patterns | Heavy workloads; limited access to equipment; lack of admin. support |
| Team | Verbal & written communication; supervision | Poor supervision & leadership; poor communication (cut/paste) |
| Individual staff member | Knowledge & skills; motivation & attitude; personal health | Lack of knowledge  see one, do one...; stress & fatigue |
| Task | Availability & use of protocols; availability & accuracy of tests | Lack of timely & accurate tests; lack of clear protocols |
| Patient | Complex condition; communication; social factors | Distress; language barriers |

- Vincent, Charles.  Understanding and Responding to Adverse Events. NEJM 348;11:1051-1056.

## Safety Curriculum - Assessment

- Opportunity exists
- Based upon competency in Systems-Based Practice
- Discussion of problem cases with structured feedback or rating of pre-defined goals
- Apply case to Reason’s *Swiss* Cheese Model
- Link hazard identification to improvement efforts
- Assess improvement plan
- Current forums – morning report, teaching rounds, M&M conference, and ambulatory rotation