Patient Safety Management - 20150406

Patient Safety Management

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

UNILAB SHARING PROGRAM

April 6, 2015

Patient Safety Management


Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

share

my thoughts, perceptions, opinions, and recommendations (TPOR)

on

Patient Safety Management Program

Patient Safety Program

Outline / Topics

• Patient Safety Program and Safe Hospital Initiative

• Status and Practices of Patient Safety in the Philippines

• ROJoson’s TPOR on Patient Safety Program


Patient Safety Program and Safe Hospital Initiative

in Medical Centers / Hospitals

Questions are:

1) Are they the same?

2) If not, what are the differences?

3) Do they have something in common?




Are they the same?

Patient safety program and safe hospital initiative are not exactly the same.




If not the same, what are the differences? Patient safety program is focused on safety of patients inside the medical center in the aspect of medical management. Safe hospital initiative is focused on safety of patients inside the medical center in the aspect of disaster risk reduction and management.




Do they have something in common?

Safety of patients

is what patient safety program and safe hospital initiative have in common.


Safe Hospital Initiative in Medical Centers / Hospitals

The ultimate goal of safe hospital initiative is that the medical center has a safety levelthat is sufficient to protect patients during and after a disaster event and is likely to continue functioning in disaster situations.



There are three standard indicators being used in safe hospital initiative, namely, structural, non-structural, and functional.



Safe in Structural Component means the hospital will not collapse thereby

protect patients, staff, and properties;

being safe to accommodate patients from external mass casualty incidents;

continue to function during disasters.



Safe in Non-Structural Component means the hospital non-load bearing structures and facilities will not be destroyed / swept away, thereby protect patients, staff, and properties; continue to function effectively and safely during disasters for current patients and external mass casualty incident patients.



Safe in Functional Component means the hospital services will continue to function at its maximum capacityfor its current patients; for surge of patients; and will remain accessible to patients from external mass casualty incidents during disasters.


Patient Safety Program in Medical Centers / Hospitals

The ultimate goal of patient safety program is that the medical center has a safety levelthat is sufficient to protect patients from harm and preventable complication, disability and mortality during medical management.


Outline / Topics




Status and Practices of Patient Safety in the Philippines

Philippines has a

National Policy on Patient Safety (Administrative Order 2008-0023)

issued in 2008.

June 25 – National Patient Safety Day

July 25 – World Patient Safety Day


PH National Policy on Patient Safety

Program Framework





Goal:

to ensure that patient safety is institutionalized as a fundamental principle of the health care delivery system in improving health outcomes.



Objectives:

• To establish a comprehensive patient safety program in all levels of the health care delivery system thru effective governance.



Objectives:

• To develop the critical capacity of the health care workers in the health facilities for the implementation of standards, guidelines, systems, training programs, relative to patient safety.



Objectives:

• To sustain and continuously improve mechanisms that nurtures a culture of safety thru appropriate strategies.



General Policy Statements:

• The establishment and maintenance of a culture of patient safety in an organization is the responsibility of its leadership.

• Enabling / support mechanisms / strategies shall be in place to ensure patient safety in the health facilities.




• The implementation of the Patient Safety Program for all facilities shall be anchored on both DOH licensing and PHIC accreditation standards.




• The key priority areas in patient safety include but not limited to • proper patient identification• assurance of blood safety• safe clinical and surgical procedures


PH National Policy on Patient Safety General Policy Statements: • The key priority areas in patient

safety include but not limited to • provision and maintenance of safe

quality drugs and technology• strengthening of infection control

standards• maintenance of the environment of

care standards and• energy / waste management standards


Could not get adequate and reliable data and information on (as of April 5, 2015)

• What are the programs in place and what are the status of these programs so far?

• Are there consolidated national data on patient safety from 2008 to 2014?


My two general observation and perception:

• All hospitals or medical centers somehow have a patient safety program.

• The patient safety programs vary in the extent of development, a few are well-developed, majority are underdeveloped.



To pass and maintain their licensure requirements, all hospitals must show

they have a patient safety program.



All hospitals are being assessed by the DOH using a tool that contains the following requirements related to patient safety:

• Policies and procedures and implementation evidences on • Safe Practice and Environment including

Patient and Staff Safety• Maintenance of Environment of Care• Infection Control• Energy and Waste Management



Required presence of hospital committees (directly and indirectly related to Patient Safety)

• Blood Transfusion

• HIV/AIDS Core Team

• Waste Management

• Patient Safety

• Infection Control

• Pharmacologic/Therapeutics

• Health Emergency/Crisis Management

• Tissue



Every year, all hospitals have to submit to the DOH an annual hospital statistical report which include among other things that will force them to have somehow a patient safety program -• Quality management program• Healthcare Associated Infection (HAI)


• The patient safety programs vary in the extentof development, a few are well-developed, majority are underdeveloped.

If I were to use the following criteria: 1) design and development blueprint; 2) deployment, education and training and

implementation; 3) evaluation, review and continual

improvement; 4) documentation and archiving; and 5) management review and independent

audits.


• The patient safety programs vary in the extentof development, a few are well-developed, majority are underdeveloped.

• Those hospitals with relatively well-developed are usually those hospitals which sought and have been given international accreditation such as the Joint Commission International and Accreditation Canada International (and there are 7 hospitals in the Philippines).

• These accreditation bodies have more comprehensive and stringent requirements on patient safety compliances.


International Patient Safety Goals

Goal 1 - Identify patients correctly

Goal 2 - Improve effective communication

Goal 3 - Improve the safety of high-alert medications

Goal 4 - Ensure correct site, correct procedure, correct patient surgery

Goal 5 - Reduce risk of health care-associated infections

Goal 6 - Reduce the risk of patient harm resulting from fall


Surgical Safety Checklist


Surgical Safety Checklist


Hand Hygiene


Infection Precaution


Infection Precautions


Infection Precaution


ICU Infection Safety Precaution Posts


Department of Surgery











Status and Practices of Patient Safety in the PhilippinesPatient Safety in Health Science Schools

WHO Patient Safety Curriculum Guide – Multi-Professional Edition - 2011


Outline / Topics




ROJoson’s TPOR on Patient Safety Program

• For a medical center to be completely safe for patients, it must have an excellent patient safety program and safe hospital initiative in place and which are aligned and integrated with each other.


• To achieve alignment and integration of all patient safety initiatives and projects, there must be a medical-center-wide body to coordinate and supervise them.


• SAFETY PROMOTION AND DISASTER PREPAREDNESS COMMITTEE (SPDPC) • Natural Disaster and Fire Safety Program• Security and Man-made Disaster Program• Environmental Safety Program• Infection Safety Program• Patient Care Safety Program• Occupational Health and Safety Program • Search, Rescue, and Evacuation Program• Medical Resuscitation Program• Surge of Patients Program • Emergency and Disaster Information Program• Media and Risk Communication Program


Other medical centers in the Philippines have committees or groups with the following names:

Quality and Patient Safety Group or Committee integrating safety and quality or simply Patient Safety Committee as indicated by DOH.

Note: The name is not as important as the authorized functions, responsibilities and authorities which must be comprehensive and integrative as far as patient safety initiatives are concerned.


For all patient safety programs that may be established in the medical centers, to be judged as excellent, they must have the following key result areas fully developed, aligned, integrated and institutionalized, namely:

1) design and development blueprint;

2) deployment, education and training and implementation;

3) evaluation, review and continual improvement;

4) documentation and archiving; and

5) management review and independent audits.


They must be able to show consistently excellent results in the key performance indicators of patient safety,

with a level that is sufficient to constantly and continuously protect patients from harm and preventable complication, disability and mortalityduring medical management.


I have seen a lot of approaches in establishing and developing patient safety program in medical centers.

Most of them just try to comply to the letter whatever are stated in the requirements of accrediting standards (DOH-PHIC, JCI, ACI, etc.).

This is most probably the easiest way to start the ball rolling.


However, what I would like to propose,

in order for a patient safety program in a medical center to be more systematic, comprehensive, aligned, and integrated,

will be to do a strategic planning ending with a comprehensive design and development blueprint.


In the strategic planning,

there must be a comprehensive identification of all potential, common, and critical hazards related to patient care safety.

After a comprehensive list of potential hazards is drawn up, the next step is to formulate strategies in prevention, mitigation, preparedness, response, and recovery.


In formulating the strategies,

use the principles of all-hazards approach, meaning look for generic critical measures or package of generic critical measures in prevention, mitigation, preparedness, response and recovery that can be used for all types of hazards regardless of the cause.

This contributes to cost-effectiveness and efficient education of staff compared to formulating strategies for each type of hazard.


Put simply,

start macro and gradually go micro or

start with concepts and principles and processes then gradually go particulars until a generic critical package of strategies have been identified.

Specific and contingency strategies may be included as indicated but only after the generic critical package of strategies have been established.


Aside from the identification of hazards and formulation of all-hazards approach strategies in prevention, mitigation, preparedness, response and recovery that should be contained in the design and development blueprint,


there should also be blueprints for

• deployment, education and training and implementation;

• evaluation, review and continual improvement;

• documentation and archiving; and

• management review and independent audits.


EDUCATION and COMMITMENT of all staff (top-down) are the critical success factors of a Patient

Safety Program in a medical center.


EDUCATION of all staff (top-down) as a critical success factor of a Patient Safety Program in a medical center.

ALL staff shall understand the what, why, and general how of patient safety

• Concept

• Principles

• Processes

• General safety precautions and measures

• General contingency responses


EDUCATION of all staff (top-down) as a critical success factor of a Patient Safety Program in a medical center.

SOME staff (because of their specialty) shall understand

• Specific safety precautions and measures

• Specific contingency responses


COMMITMENT of all staff (top-down) as a critical success factor of a Patient Safety Program in a medical center.

ALL staff shall commit themselves to

• Achieve the goals of patient safety in all patients they are managing

• Work as a team (with proper communication, coordination, collaboration) in promoting patient safety

• Practice the principles, processes, and safety precautions on patient safety

• Vigilance against harms and adverse events

• Continual improvement in processes and safety precautions


GOALS in the Management of any Patient:

RESOLUTION OF THE PATIENT’S HEALTH PROBLEM OR CONCERN IN SUCH A WAY HE DOES NOT END UP

• DEAD;

• WITH DISABILITY;

• WITH COMPLICATION;

AND IN SUCH A MANNER

• THAT HE IS SATISFIED AND

• THERE IS NO MEDICOLEGAL SUIT.


SAFETY GOALS in the Management of any Patient:

RESOLUTION OF THE PATIENT’S HEALTH PROBLEM OR CONCERN IN SUCH A WAY THAT THERE IS

• NO HARM;

• NO PREVENTABLE COMPLICATION;

• NO PREVENTABLE DISABILITY; AND

• NO PREVENTABLE DEATH.


SAFETY GOALS (corporate and staff) in the Management of any Patient:

RESOLUTION OF THE PATIENT’S HEALTH PROBLEM OR CONCERN IN SUCH A WAY THAT THERE IS ZEROINCIDENCE OF

• HARM;

• PREVENTABLE COMPLICATION;

• PREVENTABLE DISABILITY; AND

• PREVENTABLE DEATH.


Identification of HAZARDS (threats) in the management of any patient:

(potential, common, and critical)

ROJoson’s Categorization:

• HARM (blatant physical injuries to patients)

• ADVERSE EVENTS• PREVENTABLE COMPLICATION;






ROJoson’s Categorization:

• HARM (blatant physical injuries to patients)

I put in a separate HARM category to bring out the importance of avoiding blatant physical injuries to patients as these are outright res ipsa loquitur (the thing speak for itself) and constitute medical negligence and therefore, should be given priority and avoided at all cost.




• HARM• Fall (from inpatient beds, stretchers)• Burns• Unnecessary procedures (diagnostic and

treatment)• Blatantly wrong diagnosis which lead to harm• Blatantly wrong procedure (wrong patient; wrong

side; wrong medication; wrong diagnostic procedure; wrong treatment procedure)

• Wrong reports which lead to harm• others




• ADVERSE EVENTS• PREVENTABLE COMPLICATION; DISABILITY; AND

DEATH

• Also produce “harm” but usually inconspicuous, at least initially




• ADVERSE EVENTS• Those medical events considered as preventable

complication, disability, and death by medical standards (internal at least, may be by the community or international) and after an audit in patients who underwent an indicated procedure.




• ADVERSE EVENTS• The medical center will have to put up such a list

and the processes to determine which complications, disabilities, and deaths are preventable.

• The list can contain two subcategories: surgery-related and non-surgery-related complications, disabilities, and deaths.


After the identification of hazards,

the next thing to do is

to identify the more common and critical causes, general then specific, and in terms of vulnerability and capacity.


In both the HARM and ADVERSE EVENTS categories,

the general cause of the occurrence of the hazards consists basically of

INADEQUATE LEVEL OF SAFETY PRECAUTIONS OR MEASURES in 5 Ms and 1 S, namely,

• Man

• Method

• Machine

• Monument

• Money

• Systems


The more specific causes are related to the

• competency of staff (inclusive of leaders) on patient safety, particularly on safety culture;

• safety in methods of delivering medical services (formulating clinical diagnosis; diagnostic procedures; treatment procedures; giving advices);

• safety of machines in delivering medical services;


The more specific causes are related to the

• infrastructure needed for safe services;

• money to establish, develop and sustain a patient safety management system;

• and safety systems (such as communication system; coordinating systems; policies and procedures; clinical practice guidelines and clinical pathways).


After spelling out the goals, identifying the potential patient safety related hazards and putting them into 2 categories (based on commonality); and identifying the more common and critical causes,

the next thing to do is

to formulate strategies using principles of all-hazards approach.


Examples of all-hazards-approach strategies that can be used:

• Common framework of prevention-mitigation-preparedness-response-recovery (with policies and procedures, clinical practice guidelines, and clinical pathways) that can be used for all hazards related to patient care safety regardless of specific cause or types.



• Common framework of prevention-mitigation-preparedness-response-recovery (with policies and procedures, clinical practice guidelines, and clinical pathways) (with policies and procedures, clinical practice guidelines, and clinical pathways) (with policies and procedures, clinical practice guidelines, and clinical pathways) for each of the two categories of hazards, namely, HARM and ADVERSE EVENTS.



The approaches in these two categories (HARM and ADVERSE EVENTS) may be different but within the category, the approach may be the same for all specific types of hazards.



Whether it be HARM or ADVERSE EVENTS, there must be

a) design and development blueprint;

b) deployment, education and training and implementation;

c) evaluation, review and continual improvement;

d) documentation and archiving; and

e) management review and independent audits.


After formulating the strategies using the principles of an all-hazard approach, as indicated, specific action and contingency plans are formulated.


5-step strategic planning

• Formulation of Goals

• Identification of Hazards

• Identification of Common Causes of Hazards

• Formulation of Strategies for P-M-P-R-R using All-Hazard Approach

• Formulation of Specific Action and Contingency Response Plans

*PMPRR – Prevention, Mitigation, Preparedness, Response, Recovery


As mentioned, the foremost advantage of these 5-step strategic planning is that it is more

systematic,

comprehensive,

aligned, and

integrated,

that ends with a comprehensive design and development blueprint.


Using the principles of all-hazards approach contributes to cost-effectiveness and efficient education of staff compared to formulating strategies for each type of hazard.


Let me end my sharing with two vignettes that I have observed over the years.


In the management of surgical patients, patient safety in the operating room, just using the surgical patient checklist, is not enough.

Surgical patient care safety precautions and measures should be present in the inpatient floors and other parts of the medical centers where the patient may have to be sent for needed diagnostic and other treatment procedures.


Fall, burns, wrong diagnosis, wrong reports, delay in needed intervention for adverse events, and inadequate safety precaution in other procedures done to the patient outside the operating room should be prevented.

Thus, the patient care safety must be vigilantly and comprehensively carried out anywhere and everywhere in the medical center and by all members of the medical team.


In the management of non-surgical patients in the inpatient floors,

fall, burns, wrong diagnosis, wrong reports, wrong patient, wrong side, wrong diagnostic procedure, wrong treatment procedure, wrong medication, unnecessary procedures, delay in intervention, and other instances of inadequate safety precautions

are common challenges and should be avoided.


Patient care safety measures should also be present in other parts of the medical center where the patient will be sent for needed diagnostic and other treatment procedures.

Thus, the patient care safety must be vigilantly and comprehensively carried out anywhere and everywhere in the medical center and by all members of the medical team and all staff.


These two vignettes emphasize the benefits that can be derived from the systematic and comprehensive approach that I share with you, better than the single-shot approach of patient safety by a specialty and by a sector in the hospital.


EDUCATION and COMMITMENT of all staff (top-down) are the critical success factors of a Patient

Safety Program in a medical center.


SAFETY GOALS (corporate and staff) in the Management of any Patient:

RESOLUTION OF THE PATIENT’S HEALTH PROBLEM OR CONCERN IN SUCH A WAY THAT THERE IS ZEROINCIDENCE OF

• HARM;

• PREVENTABLE COMPLICATION;



Patient Safety ManagementReynaldo O. Joson, MD, MHA, MHPEd, MSc Surg


April 6, 2015

[email protected]

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Patient Safety Management - 20150406

Health & Medicine