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The Board’s Role in Quality and Patient Safety 1.0This presentation was madepossible by The Board’s Role in Qualityand Patient Safety 1.0Knowledge PointsKnowledge Points Current state of hospital safety The board’s role: Quality andsafety are job one Transparency and publicaccountability Quality measurement andreporting Partnerships necessary forsuccess with value-basedpaymentsThe Current StateThe Cost of Waste in Health Care Discussion pointsof Quality and Patient Safety 750billion inwaste1
The Board’s Role in Quality and Patient Safety 1.0The Cost of Medical Errors Deaths from medical errorsexceed motor vehicle accidents,breast cancer and AIDS Experts:– Lapses in patient safety cause200,000 deaths– 2.4 billion extra hospital days– 17- 29 billion annuallyMedical Errors Have FarReaching ImpactsReimbursementQuality ofCarePatientSatisfactionMedicalErrors MedicalStaffMoraleEmployeeMoraleSources: To Err is Human: Building a Safer Health System. Institute of Medicine.Never Event Frequency “Troubling,” Standards Lacking. HealthLeaders Media. June 17, 2015.The Cost of Medical Errors HasWide-Ranging Effects on Patients High Quality PaysHigh quality providers have thepotential for .Loss of trust in thehealth care systemDiminished ysical andpsychological discomfortInclusioninNetworksLower overall healthstatusSource: To Err is Human: Building a Safer Health System. Institute of Medicine. and on Health Care ProfessionalsLoss of trust in thehealth care systemDeclining morale andincreased frustrationDiminished jobsatisfactionLost productivityThe “Triple Aim”Better healthfor thepopulationCareprovided at areasonablecostImprovedexperienceof care &qualitySource: To Err is Human: Building a Safer Health System. Institute of Medicine.Source: Institute of Healthcare Improvement’s Triple Aim.2
The Board’s Role in Quality and Patient Safety 1.0Inadequate SystemsThe System is Fragmented The Biggest Quality and Safety ProblemPatients see differentproviders for differenthealth issuesProviders have limitedaccess to patientinformationCare is poorlycoordinated amongstproviders“What can orshould ourhospital orhealth system doto support safe,high-qualitycare?”The IOM’s 6 Aims of CareThe IOM’s 6 Aims of CareSafe, avoid injuries to patientsfrom care intended to helpEffective, services based onevidence for those who couldbenefitPatient-Centered, care that isrespectful and responsive to patientpreferences, needs, valuesJob Oneis Quality and Patient SafetyTimely, reducing waits, harmfuldelays for those receiving and givingcareEfficient, avoiding waste ofequipment, supplies, ideas, energyEquitable, equal care regardless ofgender, race, ethnicity, age,geography, socio-economic status3
The Board’s Role in Quality and Patient Safety 1.0How goodis ourquality?How safeis ourhospital?What is our“culture” ofquality andsafety?What does thepublic expectfrom us?More Important Questions to Ask Do we publicly disclose and discussour quality and safety performance?What are the top safety issues for ourhospital or health system?How can weimprove? Whatare our goals?What shouldwe bemeasuring?More Important Questions to Ask What should we hold the executiveteam and medical staff responsible forin improving our patients’ safety?Is it easy and safe to report errors atour hospital? What is the process?How much do medical errors cost ourhospital annually?What specific steps are we taking toaddress the IOM’s Six Aims?What is our aim for safetyimprovements, how quickly can weachieve our goals?How do we compare to organizationsthat score the best on safety?Consider This Medical liability costs aredriven by lawsuitsLiability fears may causephysicians to leave practiceLiability fears may causephysicians to practice“defensive medicine”Loss of consumerconfidence and market shareSource: To Err is Human: Building a Safer Health System. Institute of Medicine.Transparency and AccountabilityTransparency Taking the Next StepIs valuedby thepublicValuedReassuresthatnothing ishiddenConfidenceDrives fasterquality andpatientsafetyimprovementImprovementIs publicizedregardlessof yourpreferencesPublic4
The Board’s Role in Quality and Patient Safety 1.0Ranking is a RealityEnsuring High Quality, Safe PerformanceValue websites(Nerd Wallet,ReferMe)JointCommission’sQuality CheckReporting and roupDo You Measure Up to the Best?6Measure What’s Most Relevant1Achieving quality andsafety goals2Quality and safety measuresused in determining payments3Adverse events4Hospital Compare websitemeasurements543210The BestAnytown Community HospitalThe AverageMeasure What’s Most Relevant5Infection measures6Employee safety7Community health (such asdiabetes, obesity)8Unique issues important tothe hospital/health systemUnderstanding Preventable ErrorsAdverseEventHarm to a patient as aresult of the medical carethey receiveEvents that should neverhappen in a hospital andthat can almost alwaysbe prevented.SeriousReportableEvents5
The Board’s Role in Quality and Patient Safety 1.0Serious Reportable EventsSerious Reportable EventsOperating on the wrong body part orwrong patientPatient disappearance or suicidePerforming the wrong procedureDeath or disability due to a medicationerrorLeaving foreign objects in a patientDeath or disability associated with afall, burn or use of restraintsContamination, misuse or malfunctionof products and devicesCare ordered by someoneimpersonating a doctor or nurseWrong discharge of an infantAbduction or assaultSource: National Quality Forum Governance Principles.Source: National Quality Forum Governance Principles.Medicare’s Hospital Comparewww.medicare.gov/hospitalcompareMeaning Behind the Websites Help people make decisions Improve quality of careCMS firstdevelopedHospitalCompareCollaborativeeffort with awide dialysisfacilities andhome healthInfection ReportingSurgical site infections Hospitals are required to report(those that aren’t should still use it) Performance used for value-basedpurchasing paymentsValue-Based PaymentsThe Role of QualityCatheter-associated UTINHSNVentilator infectionsCentral line infectionsMRSA infectionsC. Diff infectionsFor more information: www.cdc.gov/nhsn6
The Board’s Role in Quality and Patient Safety 1.0The Value Equation It Can’t Be Done AloneHigh QualityHigh Patient SatisfactionLow CostVALUEEmployersTheBoardCliniciansand StaffPatientsE PB CEmployers Champions for safetyE PB C Promote need forreformE PB C Everyone plays a role Key elements: ureTeamwork Honesty andcommunication Advocate Written information Choose providersbased on evidence Clear treatment plans Provide leadershipClinician and StaffInvolvementPatientsE PB CThe Board Make quality, safety thefoundation On every agenda Set quality and safety goals Hold leadership accountable Infuse quality and safetythroughout boarddiscussions7
The Board’s Role in Quality and Patient Safety 1.0Has your board committedto making quality andpatient safety a distinctcompetitive advantage?DiscussionPointsWhere is your board on thequality understanding andaction continuum?What specific ideas do youhave for improving yourboard’s “quality literacy?”DiscussionPointsHow sure are you thatyour organization-widesystems are designed toensure optimal qualityand patient safety?What initiatives shouldthe board take to bettercarry out it’s quality andsafety accountabilities?The Board’s Role in Qualityand Patient Safety 1.08
and on Health Care Professionals Source: To Err is Human: Building a Safer Health System. Institute of Medicine. Loss of trust in the health care system Declining morale and increased frustration Diminished job satisfaction Lost productivity The "Triple Aim" Source: Institute of Healthcare Improvement's Triple Aim. Better health for the
