Leading a Patient Safety Program

Madeleine Biondolillo, MDMassachusetts Department of Public Health

Gordon Schiff, MDBrigham & Women’s Hospital; Harvard Medical School

Objectives

By the end of this module you will be able to:

1. Explain the relationship between patient safety and the risk of medical malpractice.

2. Describe the characteristics of a patient safety program for primary care.

3. Identify staff in your practice who would best manage a patient safety program.

A Patient Safety Example

“Freedom from accidental injury” (IOM 1999)

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Gordy Schiff, MD

JAMA 12/14/2011

NEJM 8/18/11

Proportion of Physicians Facing a

Malpractice Claim

Annually.

Amount of Malpractice Payments, According to

Specialty.

NEJM 8/18/11

Patient Safety & Medical Malpractice

Safety and Malpractice Risk: Two sides to the same coin

With all the demands on primary care practices, how do you improve?

Outcomes = systems + culture

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System “interdependent elements interacting to achieve a

common aim” Institute of Medicine, 1999 The office practice setting is a complex system Work processes produce the outcomes that

patients experience. When something goes wrong, the root cause is

likely a bad process, not a bad person; Handoffs are key To improve flawed systems, examine and improve

the work processes - make them as safe and reliable as possible

PROMISES Federal grant helping primary

care settings improve patient safety and malpractice.

3 processes: referral follow-up; lab test tracking; and medication management

+1: communications What keeps you up at night?

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Madeleine Biondolillo, MD

How to Improve

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Patient Safety Program is not about unique or bountiful resources

Learn to creatively use available resources All staff members have two jobs: doing the job

and improving it Detecting problems Solving problems Spreading solutions

Leadership must model and support the principles

S. Spear The High Velocity Edge, 2010

From the Front Lines

But the referral, if you think of a giant circle, the patient is now in the center. (Practice Manager)

The PROMISES program works. Attacking it in small fundamental bites, and mapping out the process and finding out where the actual problems are is a process that I hope everyone learns. (Practice Manager)

When you look back now, you think, ‘how did we not do that 18 months ago?’ (Practice Manager)

Value of Community/Coaching

Seeing all the practices, and having somebody ask the same question that you might have been thinking, was extremely valuable.(Practice Manager)

Starting a Massachusetts Patient Safety Program

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Primary Care Patient Safety Checklist

Massachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from Patients Deal with errors: When Things Go Wrong

Primary Care Patient Safety Checklist

Massachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

Safety Culture –Structure

Support the safety culture by participating in and modeling the values of a safe culture

• Collaboration and teamwork• Clear and open communication• Safety on all meeting agendas • Work to build improved processes - Avoid “Shame

and blame”• Safety discussed at Independent Practice

Association meetings (if applicable)

Safety Culture - Process

Recognition that to err is human Driving out fear so people aren’t afraid to ask

questions or share things that go wrong Organizational emphasis on learning from

mistakes When dealing with adverse events, replacing

blame and fear with learning and improvement. Leaders model commitment for trust to needed

overcome fear and take risks to make change

Primary Care Patient Safety Checklist

Massachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

Managing Patient Safety

• Patient safety is everyone’s job, but a team needs a coordinator.

Point person to ensure that:

Your improvement team meets regularly.

Schedule safety discussion for all meetings. Identify and follow up on adverse events.

Designate a safety contact. Make this clear and accessible for patients and families.

Primary Care Patient Safety ChecklistMassachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

Quality Improvement MethodsTesting Small-scale Changes

Identify problems together Gather some data Agree on shared aims Brainstorm ideas Test solutions Measure for improvement Learn and test the next step

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Primary Care Patient Safety Checklist

Massachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

Learning from Patients Patients offer a valuable and unique perspective

on your practices and safety culture Develop a method for patients and family

communication to voice safety concerns Conduct a periodic patient survey Review results, suggestions at staff meetings Engage patients in improvement initiatives

Primary Care Patient Safety Checklist

Massachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

WTGW

Disclose and discuss all significant events First ensure patient safety by providing any needed

further care Express and act with empathy Provide feedback and follow through Support clinicians as well as patients

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Primary Care Patient Safety Checklist

Massachusetts: Safety in all settings?

Lead: Develop a safety culture Manage: Point person for safety Test: Use quality improvement methods Engage patients: Learn from patients Deal with errors: When Things Go Wrong

Success StorySame thing happened with a 62 year old Portuguese guy who didn’t want to have a colonoscopy, and I convinced him to do the FIT. It came back positive...with a big, big tumor growing, still within the polyp. He got partial resection of the colon, and he is cured. - Dr. Folch

PROMISES Curriculum1. Leading a Patient Safety Program2. Leadership Case Study 3. Improving Your Primary Care Practice #1  4. Improvement Case Study 5. Improving Your Primary Care Practice #2 

6. Communication Case Study   7. Communication     8. Test and Referral Management Follow Up  9. Test Results Case Study   10. Referrals Case Study   11. Medication Management 

12. “When Things Go Wrong in the Ambulatory Setting” 13. Sustaining Change  14. Patient Engagement

32http://www.brighamandwomens.org/PBRN/promises

Getting Started

Continuous Improvement

Improving Process

Communications

Get Started Today

Think about areas of vulnerability Share the Outpatient Courses with your colleagues.

Watch sessions at your next staff meeting

Choose a staff members who would like to help start the work

Identify a staff member for your safety program Reach out to others

Your professional association Your malpractice insurer Your patients

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A Few References PATIENT SAFETY MANUAL: “GUIDELINE FOR

PATIENT SAFETY PROGRAMS IN ALL HEALTHCARE SETTINGS” APPROVED BY HCQCC COUNCIL - MAY 16, 2012

High Velocity Edge, S. Spear 2010

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