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Newer Trends in Quality and Safety

David Mayer, MDCorporate Vice-President

Quality and SafetyMedStar Health

MedStar Health• Largest Healthcare System in Mid-Atlantic Region• Ten hospitals• 150 Outpatient sites of care• 30,000 MSH Associates• National Center for Human Factors Engineering• MedStar Research Institute• Nationally Recognized Simulation Center (SiTEL)• MedStar Institute for Innovation (MI2)• Over 1000 Residents• 162,000 Inpatient Admissions• 762,000 Inpatient Days• 1,492,000 Outpatient Visits• 215,000 Home Health Visits

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Emerging Trends in Quality and Safety

• Transformation in Healthcare• Human Factors Engineering• Transparency• Patient Engagement and Partnership• High Reliability• Respect and Caring for Fellow Workers• “Educate the Young”

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Quality and Safety

“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous.”

Sir Cyril Chantler, Dean of London’s Guy’s Hospital

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Emerging Trends in Safety and Quality

• Transparency

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Emerging Trends in Safety and Quality

• Transparency (Honesty and Trust)– Transparency in Reporting– Transparency in Outcomes– Transparency in Communications

• Informed consent/Shared decision-making• Open and Honest communication after harm

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Transparency in Outcomes

“There is a ‘Magic’ that occurs when we are transparent and share our outcomes”

Paul Levy

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High Reliability Culture

High-reliability organizations (HROs):“Subset of hazardous organizations that Have operated nearly error-free for very long periods of time”.

Karlene Roberts (1990)

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High Reliability Culture in Healthcare?

Healthcare, in contrast is an industry that has grown to expect and accept errors and patient harm as “normal”. It is considered an inherent risk that comes with the wonderful new advances that healthcare can offer its patients.

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Human Factors Engineering and Safety

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Restoring Joy and Meaning at Work

Every worker’s experience, every day:

• I am treated with respect by everyone else, regardless of position, education or pay.

• I have the education and training, the tools, and the support to develop to my full potential.

• My work is noticed and appreciated

Paul O’Neill14

Patient Partnership

• Engaging and partnering with patients and families in our quality and safety mission

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The Power of Stories and Narratives

The Faces of Medical Error…from tears to transparency:The Story of Lewis Blackmanwww.transparentlearning.com

Telluride Patient Safety Roundtable

Ninth Annual Roundtable:“The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency”June 9th – June 18th, 2013Telluride, CO

Supported by TDCF and MedStar Health 18

Telluride Patient Safety Roundtable

Ninth Annual Roundtable:“The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency”August 1st – August 4th, 2013Washington, DCSponsored by TDCF, MedStar Health, CIR

Telluride Roundtable Vision

“Teaching Open, Honest and Professional Communication Skills to Overcome the

Multiple Barriers to Transparency"

Telluride Patient Safety Summer Camp

Telluride Patient Safety Summer Camp

Telluride Patient Safety Summer Camp

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