medical office survey on patient safety culture initiatives · ahrq 2016 medical office survey on...

MedicalOfficeSurveyonPatientSafetyCultureInitiativesMARIAHRAMIREZMENTOR: KATHY DONOHUEBSN ,MBA ,CHCQM,CPPS D IRECTORAMBULATORY QUAL ITY CEQI

AgendaI.TheRealityofMedicalErrorsII.Definition:PatientSafetyCultureIII.OverviewofAHRQ2016MedicalOfficeSurveyonPatientSafetyCultureIV:DescriptionofSummerProject◦ Methods◦ Initiatives◦ EvaluationTool

V:MyRole/LearningExperience

TheRealityofMedicalErrorsinHealthcareSetting

1jet/day

44,000-98,000/year

Source:ToErrisHuman:BuildingaSaferHealthSystem,1999

Whatis“PatientSafetyCulture”?

“…theproductofindividualandgroupvalues,attitudes,perceptionsandpatternsofbehaviorthatdeterminethecommitmentto,andthestyleandproficiencyof,anorganization’shealthandsafetymanagement.”

AHRQ2016MedicalOfficeSurveyonPatientSafetyCulture

Administeredtostaffandfacultyofambulatorycarecentersincludes:nurses,physicians,front-deskstaff,medicalassistants,nursepractitioners,etc.

PurposeofAHRQSurvey:◦ Canassessthebaselinestatusofthepatientsafetycultureinamedicaloffice

◦ Canactasaninterventiontoraisestaffawarenessaboutpatientsafetyissues

◦ Canbeamechanismtoevaluatetheimpactofpatientsafetyimprovementinitiatives

◦ Isawaytotrackchangesinpatientsafetycultureovertime

10DomainsMeasuredStaffTraining

OfficeProcessandStandardization

CommunicationaboutError

CommunicationOpenness

WorkPressureandPace

PatientCareTrackingandFollow-Up

OverallPerceptionsofPatientSafetyandQuality

Teamwork

LeadershipSupportforPatientSafety

OrganizationalLearning

CharacteristicsofSurveyRespondentsComparativeAHRQDatabase ClinicalPracticesoftheUniversityof

Pennsylvania(CPUP)

25,127medicalofficerespondentsClinicalStaffAdministrativeStaffRegisteredNurses

1,952medicalofficerespondentsPhysiciansAdministrativeorClericalStaffAdvancedpracticenurse

AreasofStrengthTeamworkPatientCareTracking/Follow-Up

AreasofStrengthTeamworkPatientCareTracking/Follow-UpOverallPerceptionsofPatientSafety

AreasofOpportunityWorkPressureandPaceCommunicationaboutError

AreasofOpportunityWorkPressureandPaceCommunication aboutErrorOfficeProcessesandStandardization

AimofSummerProjectGoal:

ImprovePatientSafetyCultureacrosstheClinicalPracticesofUniversityofPennsylvania

Objectives:

RaiseawarenessaboutcurrentstateofsafetycultureacrossCPUP

Designandimplementinterventionstonarrowgapsinsafetyculture

Maintainimprovementsachievedinpatientsafetyculture

PerceivedCultureofSafetyPatientSafety

InitiativesImplementedtoAchievetheAim

1– Signage

2- LanguageofSafety

3 – Department-LevelDataPresentations

4 - Penn-SpecificPatientSafetyCultureToolkit

RaisingStaffAwareness:DataPresentationMeetings

RaisingStaffAwareness:CultureofSafetyToolkitConstruction

2AreasofFocus

- OfficeProcessandStandardization◦ WorkPressureandPace

- Communication◦ CommunicationOpenness◦ CommunicationaboutError

PatientCareTrackingandFollow-Up

StaffTraining

OverallPerceptionsofPatientSafetyandQuality

OfficeProcessandStandardization

Teamwork

CommunicationaboutError

LeadershipSupportforPatientSafety

CommunicationOpenness

OrganizationalLearning

WorkPressureandPace

SafetyInitiativesbyDepartment

EvaluationTool:PennMedicineSafetyNet

- Flexible,web-basedeventreportingtool

- TracksmedicalerrorsthroughreportingofincidentsbyallPennMedicineemployees

- SubmissionExamples:- Labelingerrorsontests- Patientfall- “Near-miss”events- Equipmentunavailableorbroken

EvaluatingtheImpact

Difficultyinmeasuringculture:- CurrentMeasure:

- SafetyNetSubmissionsasaproxyvariable

- FutureMeasure:- Resultsof2018MedicalOfficePatientSafetyCultureSurvey

MyRoleEvaluatetheimpactofpatientsafetyinitiativesbydepartment◦ DataPresentationMeetingsAttendee◦ Collectedsafetyinitiativesofall19departmentsofCPUP

◦ CreatedanddisseminatedCultureofPatientSafetyToolkitthroughoutCPUP◦ PresentedworkperiodicallytoQualityViceChairsMeetingandDataPresentationMeetingsforfeedback

MyLearningExperiencePresentationSkills

Interactionwithmedicalstaff

Theimportanceoftakinginitiative

Beingreceptivetoconstructivecriticismandfeedback

PatientSafetyCultureknowledge

Understandingofessentialcomponentswithinahealthsystemthatarecrucialforsuccess

AcknowledgementsKathyDonohue– Mymentor

DavidHorowitz,MDCPUPChiefMedicalOfficer

BarbaraPriorMSN– CPUPAssociateExecutiveDirector

LaquishaReed– CEQIAdministrativeCoordinator

CEQIOffice

SUMR2017Cohort

JoanneLevy

SafaBrowne

LeonardDavisInstituteforHealthEconomics

Questions?