DMC Quality and Medical Safety Programs Page 1 of 28 DMC Quality and Medical Safety Programs DMC...

DMC Quality and Medical Safety Programs

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DMC Corporate Quality DepartmentDetroit Medical Center©Revised: February, 2010


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Commitment to Quality and Safety

The Detroit Medical Center is committed to providing safe, high quality medical care.

This is part of our mission and it is also reflected by our certification and accreditation with regulatory agencies and participation with local, state, and national quality and safety improvement projects.


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Quality and Environmental Management Systems

The DMC has incorporated the requirements of a Quality Management System (QMS) as outlined in the ISO 9001-2008 standards and an Environmental Management System (EMS) as outlined in ISO 14001: 2004 standards into its quality program.


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Foundation for Medical Safety

DMC commitment to medical safety is reflected in our: Quality Statement which includes:

Continuous improvement

Prevention of medical/health systems errors

Provision of high quality medical care

Environmental Statement:

The Detroit Medical Center is dedicated to the health and safety of its patients, employees, customers, community and environment.

DMC is committed to:

The prevention of pollution

Compliance with environmental regulations and other requirements Continuous improvement Environmental hotline 1.888.484.9200


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Improving Quality and Safety

Most events or errors occur due to process issues:

Multiple events at multiple levels lead to the event – almost never just ‘one process’ failure

Rarely a ‘person’ failure

By improving our systems and processes, we improve healthcare quality and safety.


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What is Performance Improvement?

It is an ongoing effort to find new and better ways of doing things by:

Getting better results

Involving the whole organization

Improving work processes

Foundation for Performance Improvement – PDCA (also known as PDSA):

PLAN

DO

CHECK (or STUDY)

ACT


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Performance Improvement

PLAN: What are the goals you want to achieve?

DO: Measure progress towards goals by collecting data.

CHECK/STUDY: Look closely at/Analyze your data to answer these questions:

• How well are we performing?• Why are we performing well or not well?• Which areas should we focus on first to improve our processes?

ACT: Make improvements!

Celebrate success!


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What Does Medical Safety Mean?

It means we constantly look for ways to make the care or service we provide safer for our patients and employees.

We can accomplish this by: Identifying conditions that are hazardous and changing

them.

Acting quickly and appropriately when an incident occurs.

Making medical safety a regular part of our performance improvement activities.

By making concerns for safety part of everything we do.


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Medical Safety = Quality Care

The DMC is committed to adopting the Institute of Medicine’s 6 aims for improving the quality and safety of healthcare (see additional information at www.iom)

Healthcare needs to be:

1. Safe: Avoiding injuries to patients from the care that is intended to help them.

2. Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.


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Medical Safety = Quality Care

Healthcare needs to be: continued

3. Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

4. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.

5. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.

6. Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. A health care system that achieves major gains in these six areas would be far better at meeting patient needs.


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Healthcare Safety Statistics

40 to 50 Patient Injuries per 100 Hospital Admissions

37 million hospital admissions

X

40 injuries per 100 hospital admissions

=

15 million injuries per year

What can we do to change this?


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The Institute for Healthcare Improvement’s (IHI)“Protecting 5 Million Lives from Harm” campaign (Seewww.ihi.org for additional information). The aim of the campaign is to have care that:

Is standardized and systemized

Has zero defects

Is innovative

Includes system redesign, where necessary

The DMC has committed to participate with the IHI toprotect patients from harm. Everyone is responsiblefor the quality and safety of healthcare.

“Protecting 5 Million Lives from Harm” Campaign


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Proven Interventions

The “Protecting 5 Million Lives from Harm” campaign challengesAmerican hospitals to adopt twelve changes in care that save lives andreduce patient injuries:

Deploy Rapid Response Teams…at the first sign of patient decline.

Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack.

Prevent Adverse Drug Events (ADEs)…by implementing medication

reconciliation.

Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps.

Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time.

Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps.


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Proven Interventions

Twelve changes in care that save lives and reduce patient injuries:(continued)

Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin.

Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project.

Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention.

Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices.

Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions.

Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care.


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Institute for Healthcare Improvement (IHI) Web Site


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IHI Open School The IHI Open School for Health Professions is an interprofessional

educational community that gives students the skills to become change agents in health care improvement:

Skills like quality improvement, patient safety, teamwork, leadership, and patient-centered care

IHI Open School offers:

Online courses written by world-renowned faculty A network of students Case studies, podcasts, videos, featured articles IHI Certificates of Completion

The IHI Open School — including online tools and resources, and online courses — is open and free for students of all health care professions and non-students alike.


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IHI Improvement Map

The IHI Improvement Map is an open resource, available free of charge for anyone, anywhere who shares IHI’s mission of improving healthcare.

User-friendly, online tool used to create an overall improvement plan, set and align priorities and key process improvements that lead to exceptional patient care.

Example: Core Processes for AMI


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Excellent - full implementationAverage implementation Have begun to implement some processesPoor – have not implemented any processes

DMC Improvement Map - Where DMC stands on each of the IHI improvement map core processes (NOTE: Not necessarily representative of individual DMC facilities).


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Promoting and Maintaining a Safe Medical Climate

Staff responsibilities: Take action to provide necessary care and protect patients in the

event of a unsafe event or error.

Report all errors, near misses and hazardous conditions (web based incident reporting system).

Complete yearly, educational competencies.

Participate in departmental improvement efforts.

Be part of interdepartmental, multidisciplinary improvement teams.

Share ideas to improve employee or patient safety with supervisor or quality department.

Speak-up if you see an opportunity to avoid an unsafe practice or violation of policy.

Instruct patients and families to report safety concerns.


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Promoting and Maintaining a Safe Medical Climate

Patient responsibilities – encourage patients to: Provide accurate and

complete information about present complaints, past illnesses, hospitalizations and medicines.

Ask questions when they do not understand what they have been told or what they are expected to do.


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Accreditation Accreditation means that an organization has met requirements

related to the delivery of safe, quality care.

The DMC is surveyed and accredited by many different agencies.

What is Joint Commission?

The Joint Commission is an accreditation agency that surveys our hospitals at least once every 3 years.

The Joint Commission is an accreditation agency who’s objective is to improve the quality of healthcare provided to the public by establishing clinical standards; evaluating health care organizations; rendering accreditation; and providing education and consultative support to healthcare professionals (See www.jointcommission.org for additional information)


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The DMC participates in many local, state and national Quality Improvement projects some of which are:

The National Quality Forum (NQF)

Leapfrog

Institute for Healthcare Improvement (IHI)

Michigan Hospital Association (MHA – Keystone project)

Greater Detroit Area Health Coalition (GDAHC – Save Lives-Save Dollars campaign)

Blue Cross Blue Shield of Michigan

Quality Improvement


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In recent years, there has been an increased emphasis on hospital quality and transparency.

Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores.

It is important to remember that all DMC employees play a role in ensuring that our patients leave with a satisfying experience.

Consumer-Centered Hospital Data


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Hospital transparency is providing information to the public on patient safety and quality, cost, and performance indicators.

Hospital transparency assists hospitals to become more efficient, rewards those hospitals that provide high quality care, and allows consumers to make informed decisions.

The DMC provides information on safety and quality that is publicly reported.

Hospital Transparency


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The Joint Commission www.jointcommission.org Provides information regarding hospital accreditation and compliance.

AHRQ Report Card www.ahrq.gov Features information on the quality of hospitals, medical groups, health

plans, nursing homes and clinical information on evidence based practices.

CMS/Hospital Compare www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp

Provides consumers with hospital-reported information on quality, performance, and customer satisfaction.

Leapfrog Group www.leapfroggroup.org Provides consumers with hospital information based on its yearly survey of

quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk procedures, and NQF Safety Goals

Michigan Hospital Inform www.mihospitalinform.org/ State of Michigan healthcare quality website.

Healthcare Quality Websites

The Joint Commission www.jointcommission.org Provides information regarding hospital accreditation and compliance.

AHRQ Report Card www.ahrq.gov Features information on the quality of hospitals, medical groups, health

plans, nursing homes and clinical information on evidence based practices.

CMS/Hospital Compare www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp

Provides consumers with hospital-reported information on quality, performance, and customer satisfaction.

Leapfrog Group www.leapfroggroup.org Provides consumers with hospital information based on its yearly survey of

quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk procedures, and NQF Safety Goals

Michigan Hospital Inform www.mihospitalinform.org State of Michigan healthcare quality website.


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As employees of the DMC, it is everyone’s responsibility to ensure safe, quality care for our patients.

Also, as an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.

If you have concerns, first speak to your supervisor. If you are not satisfied, you may contact the Quality Department or use the compliance hotline.

If still your concerns are not addressed, you have the right to contact the Joint Commission at http://www.jointcommission.org/GeneralPublic/Complaint/ or call 1.800.994.6610.

Quality of Care


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Both the Quality Management System (QMS) and Environmental Management System (EMS) are part of our integrated quality program.

Medical Safety means we constantly look for ways to make the care or service we provide safer for our patients and employees.

The DMC publicly reports it’s quality and safety data.

Consumers can find Internet sites to provide information such as procedure cost, levels of clinical/patient care, and patient satisfaction scores.

As an employee, you have the right and duty to speak up if you feel the quality of care or patient/employee safety is compromised.

Course Summary


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We hope this NetLearning course has been both informative and helpful. Please feel free to review this course until you are confident about your knowledge of the material presented. Click the Take Test button, located on the left side of the screen, to complete the requirements for this course.

For future reference this module is available on the NetLearning Library under the 2010 Core Compliance category. The NetLearning Library is found on the DMC Intraweb screen under the NetLearning drop-down list.

Thank You

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