opening keynote monday 100 - ascls · 2018-07-28 · 7/28/2018 3 13 chassin mr, loeb jm....
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7/28/2018
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July 30, 2018
Heather HurleyExecutive Director, Laboratory AccreditationThe Joint Commission
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All people always experience the safest, highest quality, best‐
value health care across all settings
One Shared Vision
© 2018 The Joint Commission. All Rights Reserved.
The Joint Commission Enterprise
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Largest accrediting
body in health care& crosses
continuum of care
Performance improvement
experts; quality and
safety resource
Creates solutions for high
reliability health care
© 2018 The Joint Commission. All Rights Reserved.
Software Education Publications
High Reliability TrainingTools & Resources
Accreditation CertificationEducation
AccreditationCertification
Exclusive Cross-continuum Capabilities
© 2018 The Joint Commission. All Rights Reserved.
Enterprise Comprehensive OfferingsDesigned to Support a System’s Quality / Safety Journey
High Reliability
Services
Certification
Accreditation
System
Supporting Services Education, software & publications from JCR
High Reliability Services Includes online tools, programs & training from the Center for Transforming Healthcare
Supplemented by a wide range of complimentary tools & services unique to The Joint Commission
© 2018 The Joint Commission. All Rights Reserved.
AT THE FOREFRONT
Programs500
Surveys/Year13,000+
Organizations21,000+
Countries100+
PursuingHigh Reliability
1,000+LARGEST
Hospital Accreditor
Accreditation & Certification
Source: The Joint Commission
7/28/2018
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© 2018 The Joint Commission. All Rights Reserved.
Accreditation & CertificationAcross the Continuum of Care
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The Joint CommissionOur New Guiding Principle
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Zero Patient Harm is Achievable
https://vimeo.com/211533916
“The idea means to me that we will absolutely cause no harm to any patient at any time. Zero harm means identifying every patient, every specimen, collecting it appropriately from the very beginning, and then maintaining that specimen’s integrity and the quality throughout testing process. It’s what we do every day.”
“Zero harm means all of our results, whoever turns them out, would be accurate, so it would be something where we’re not turning out a falsely increased glucose, for example, where we’d have to make the patient have to come in and have a bunch of other tests done to check on it, when really it was just a bad result. So, they want everyone to be able to turn out very accurate results so that the patient can be treated correctly the first time, and not need follow up care, or something like that. It’s already what we’re striving for.”
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We Set Global Standards In
Quality & Safety
We Help Strengthen & Integrate Care Across The Continuum
We Are Uniquely Positioned To
Accelerate Progress Through
Collaboration
We Advance Patient Quality & Safety Beyond Accreditation
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Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. Milb Q 2013;91(3):459-90
LeadershipSafety
Culture
Robust Process Improvement®
Commitment to zero harm
Empowering staff to speak
up
Systematic, data-driven approach to complex problem
solving
High Reliability Model for
Health Care
14© 2018, Joint Commission Center for Transforming Healthcare
High reliability in healthcare is “maintaining consistently high levels of safety and quality over time and across all health care
services and settings” Chassin & Loeb (2013)
70%
35,000
7 to 10 Billion
Medical decisions based off of laboratory tests
Laboratories in the US performing laboratory testing
Lab tests performed in the US each year
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“We're not librarians where a book gets put in a wrong row, every sample is a life.” – Medical Technologist
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“While not all testing mistakes will injure or kill, the precise nature of the work means labs must follow regulations and treat every potential risk as an ‘avoidable risk’.”
‐Paul Epner, past president of the Clinical Laboratories Management Association.
20© 2018, The Joint Commission
What could go wrong in the laboratory? − Expired products are used and could lead to erroneous result
− Blood that is supposed to be kept cold before a transfusion isn't
− Samples are incorrectly labeled or swapped between patients
The FDA concluded that lab test errors are harming patients, and they listed many serious health consequences:
− Unnecessary medical treatment
− Diagnosis of actual condition is delayed
− Expensive treatments
− Surgery to remove healthy organs (ovaries, for example)
− Appropriate treatment is delayed
− Healthy pregnancy is aborted, or a child is born with birth defects
− Cancer treatment is inappropriate, harmful, or ineffective
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Laboratory results that can harm a patient…
For Mary Smith, the lab results seemed like good news. A routine blood screen from her 10‐week pregnancy appointment came back clear in 2006. Seven months later, her son was born critically ill with a blood disorder that could have been treated during pregnancy. The baby died three weeks later at a Louisiana hospital.
The Smiths never found out why Mary's routine blood test didn't identify the condition that killed their son. Antibodies in her blood had been attacking the baby because their blood types were incompatible. Had the condition been identified by the lab test as it should have been, it could have been treated before the baby was born.
22© 2018, Joint Commission Center for Transforming Healthcare
What 99.9% in a Community
Hospital looks like:Blood Bank
− 10,906 units Blood Components Transfused
− 11 Transfusion Reactions
Pharmacy
− 3,416,600 medication doses dispensed
− 3,417 would be Improperly Dispensed
Pathology
− 43,900 Specimens processed
− 44 Wrong Diagnoses
Obstetrics
− 4,300 Babies Delivered
− 4 babies going home with the wrong parents!
Zero Harm IS Achievable
In order for the laboratory to have a positive impact on diagnostic errors, it is necessary to become part of the interdisciplinary patient-centered care team. Laboratory professionals need to view their services as contributing to patient outcomes, not just generating results.
Research on diagnostic errors and the laboratory’s role has found that failure to order appropriate diagnostic tests, including lab tests, makes up 55% of missed and delayed diagnoses in the ambulatory setting and 58% of errors in emergency departments. 5
Plebani M. Diagnostic errors and laboratory medicine – causes and strategies. EJIFCC. 2015 Jan; 26(1): 7–14
7/28/2018
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25© 2018, Joint Commission Center for Transforming Healthcare
How Safe is Healthcare?
1
1
10 100 1000 10,000 100K 1M 10M
Number of Encounters for Each Fatality
Total Lives Lost per Year
10
100
1,000
10,000
100,000
Dangerous(>1/1,000
HealthCare
(1 of ~600)
Mountaineering
BungeeJumping
Driving in US
CharteredFlights
ChemicalManufacturing
ScheduledCommercialAirlines
EuropeanRailroads
NuclearPower
Theme Parks
Ultra Safe(<1/1M)
Amalberti, et al. Ann Intern Med.2005;142:756‐764 26
Transform health care into a high-reliability
industry
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
High Reliability Industries
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Current State: Quality
Routine safety processes fail routinely:
− Hand hygiene
− Medication administration
− Patient identification
− Communication in transitions of care
Uncommon, preventable adverse events:
− Wrong surgery, retained foreign objects
− Fires in ORs
− Infant abductions, inpatient suicides 28© 2018, Joint Commission Center for Transforming Healthcare
⎻We have made some progress− Project to project work “project fatigue”
− Satisfied with modest improvement
⎻Current approach is not good enough− Improvement difficult to sustain/spread
− Getting to zero harm, staying there is very rare
High Reliability offers a different approach
Current State of Improvement
29© 2018, Joint Commission Center for Transforming Healthcare
To transform health care into a high-reliability industry by developing highly effective, durable solutions to health care’s most critical safety and quality problems in collaboration with health care organizations, by disseminating the solutions widely, and by facilitating their adoption
Joint Commission Center
for Transforming Healthcare
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Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. Milb Q 2013;91(3):459-90
LeadershipSafety
Culture
Robust Process Improvement®
Commitment to zero harm
Empowering staff to speak
up
Systematic, data-driven approach to complex problem
solving
High Reliability Model for
Health Care
7/28/2018
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31© 2018, Joint Commission Center for Transforming Healthcare
Evolution of Healthcare
32© 2018, Joint Commission Center for Transforming Healthcare
Swiss Cheese model of Error
Reason J. Human error: models and management. BMJ. 2000;320:768–70..
33© 2018, Joint Commission Center for Transforming Healthcare
TRUST
REPORTIMPROVE
Adapted from Reason J and Hobbs A. Managing Maintenance Error: A Practical Guide. Ashgate. 2003. 34
© 2018, Joint Commission Center for Transforming Healthcare
Unsafe conditions or
daily annoyances?
35© 2018, Joint Commission Center for Transforming Healthcare
Evolution of Safety Culture
− Today, we mostly react to adverse events
− Unsafe conditions are further upstream from harm than close calls
− Close calls are “free lessons” that can lead to risk reduction—if they are recognized, reported and acted upon
− Ultimately, proactive, routine assessment of safety systems to identify and repair weaknesses gets closer to high reliability
36© 2018, Joint Commission Center for Transforming Healthcare
− Aim is not a “blame‐free” culture
− A true safety culture balances learning with accountability
− Must separate blameless errors (for learning) from blameworthy ones (for discipline, equitably applied)
− Assess errors and patterns uniformly
− Eliminate intimidating behaviors
Safety Culture Challenges
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What is RPI®?
− Robust Process Improvement® or RPI ® is a set of tools, methods, and training programs adopted by many organizations, including The Joint Commission, to improve business processes and results. Some health care organizations use RPI ® to improve clinical quality and safety outcomes.
− RPI ® is a blended model incorporating Lean, Six Sigma and formal Change Management methods concurrently, utilizing different parts of the tool kit to address specific improvement problems.
− RPI® is a pathway to high reliability.
38© 2018, Joint Commission Center for Transforming Healthcare
The most detrimental error is failure to learn
from an error. ~James Reason
39© 2018, The Joint Commission
Through Joint Commission Laboratory Accreditation
− SAFER™ matrix
− Tracer methodology
− Employed professional surveyors
− Increased awareness and engagement with hospital leadership
− Allows organizations to speak the same language across all patient care settings
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SAFER™ Matrix
− A transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys
− Provides one comprehensive visual representation of survey findings
− Helps organizations prioritize and focus corrective actions
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Survey Analysis for Evaluation Risk SAFER™ Matrix
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Unique Tracer Methodology
− “Trace” the care experiences that a patient had while at an organization
− Analyzes the organization’s system of providing treatment or services using actual patients as the framework for assessing standards compliance
− Highlights the critical connection between the lab, hospital and the patient
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Laboratory’s Impact on Patient Care
− “Laboratory medicine influences 60% to 70% of all critical decisions that affect downstream patient care.” Clin Chem, 1996;42:813‐816
− Survey readiness ensures test results are accurate
− Survey readiness is part of your journey of “Leading the Way to Zero”
Survey Readiness
Patient Readiness
Leading the way to Zero
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Survey Ready = Patient Ready
Under Laboratory Director Leadership:
− Prepare every day
− Review the standards
− Engage your staff
− Assess your risks proactively
− Promote a Culture of Safety and a Just Culture
− Promote a questioning attitude
− Use the Tracer Methodology: connect the lab with other departments
− Create a safe journey for patients
Zero Harm: An Achievable Goal
© 2018 The Joint Commission. All Rights Reserved.
If not us, then who?
If not now, then
when?
47© 2018, Joint Commission Center for Transforming Healthcare
The Joint Commission Disclaimer
⎻ This presentation is current as of July 30, 2018. The Joint Commission reserves the right to change the content of the
information, as appropriate.
⎻ This presentation is copyrighted to The Joint Commission
and cannot be reproduced or otherwise distributed without
express written permission by the speaker. Distribution of
the speaker’s presentation other than in PDF format is
expressly prohibited.
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