John G. ReilingPresident/CEO

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The risk of dying as a result of medical error far surpasses the risk of dying in an airline accident.

Death on domestic flights: 1 in 8,000,000 flights.

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Death in hospitals from medical errors: 1 in 343 admits to 1 in 764 admits.

Adverse Events in Hospitals 1 in 27 admits to 1 in 34 admits.

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The participants:

AHA MGMAAMA NPSF AphA PSIASQ WHACenter for Patient UW-MilwaukeeSafety at VA University of MNIHI VHAISMPJCAHO

Jim Adams, Exec. Director & Fellow, IBM Center of Healthcare Management Frank T. Brogan, President, Florida Atlantic University Carolyn Clancy, MD, MPH, Director of Agency for Healthcare Research & Quality William F. Coyne, PhD., Former Senior VP for R&D for 3M, Healthcare for 3M, and 3M Canada Tim Flaherty, M.D., Past Chairman, NPSF & Past Chair of American Medical Association Lillee Smith Gelinas, RN, BSN, MSN, FAAN, Vice President & Chief Nursing Officer of VHA, Inc. Pascal Goldschmidt, MD, Senior Vice President & Dean, University of Miami Miller School of

Medicine Donald Holmquest, M.D., Ph.D., J.D., President & CEO of California Regional Health Information Org Beverly Johnson, President & CEO, Institute for Family Centered Healthcare Lucian L. Leape, MD, Adjunct Professor, Harvard Univ. School of Public Health Kathy Malloch, PhD., MBA, RN, FAAN, Pres of Malloch & Assoc & Director of the MHI Program at ASU David Marx, J.D., President of Outcome Engineering, LLC David Nash, M.D., M.B.A., FACP, Chairman, Jefferson Medical College, Thomas Jefferson University Richard Norling, Chief Executive Officer and Director of Premier, Inc. Dennis O’Leary, President Emeritus of Joint Commission Paul O’Neill, Former Secretary of the U.S. Treasury Mary A. Pittman, Ph.D., American Hospital Association & Current President of the Public Health

Institute & Past President of the Health Research and Educational Trust William Rupp, MD, Past President of Luther Midelfort & Immanuel St. Joseph’s-Mayo Health Systems

& Institute for Healthcare Improvement Donna E. Shalala, Ph.D, President, University of Miami Gail Warden, President Emeritus, Henry Ford Health Systems Bennet Waters, D.H.A., Chief of Staff for the US Dept. of Homeland Security, Office of Chief Medi

Officer

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• The environment (facilities, equipment, technology)

affects performance.

• The processes affect performance.

• The culture affects performance.

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• You can design environments, culture, and processes.

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• Focus environments, processes, and culture on safety and quality by:

• Minimizing risk of failure• Evidence-based medicine.

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• Evidence-based medicine meetspatient safety.

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Latent Conditions: Noise Reduction Scalability, Adaptability, Flexibility Visibility of Patients to Staff Patients Involved with Their Care Standardization Automate Where Possible Minimize Fatigue Immediate Accessibility of Information, Close to the Point

of Service Minimize Handoffs Minimize Patient Movement Communication

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Continuous Flow Pull vs. Push Standardize Work Visual Control Proven Technology Culture of Stopping to Fix Problems Get Quality Right the First Time

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Active Failures

Operative/Post-Op Complications/Infections Events Relating to Medication Errors Deaths of Patients in Restraints Inpatient Suicides Transfusion Related Events Correct Tube-Correct Connector-Correct Hole Patient Falls Deaths Related to Surgery at Wrong Site MRI Hazards

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Matrix Development (Post Learning Lab) FMEA at Each Stage of Design Patients/Families Involved in Design Process Equipment Planning Day 1 Mock-ups Day 1 Design for the Vulnerable Patient Articulate a Set of Principles for Measurement Establish a Checklist for Current/Future Design

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• Shared Values/Beliefs about Safety within the Organization

• Always Anticipating Precarious Events• Informed Employees and Medical Staff• Culture of Reporting • Learning Culture• “Just” Culture• Blame-Free Environment Recognizing Human Fallibility• Physician Team Work• Culture of Continuous Improvement• Empowering Families to Participate in Care of Patients• Informed & Activated Patient

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All latent conditions studied improved with the exception of fatigue:

Noise Reduction Scalability, Adaptability, Flexibility Visibility of Patients to Staff Patients Involved with Their Care Standardization Automate Where Possible Minimize Fatigue Immediate Accessibility of Information, Close to the Point

of Service Minimize Handoffs Minimize Patient Movement

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Medication Errors Observation Study2004 (pre) - 2009 (post)

DepartmentW/out Wrong

TechniqueW/Wrong Technique

ER -58% +51%

Medical/Surgical -21.2% -16.5%

ICU -63.0% -26.0%

Adverse Drug Events

Department 2004 (pre) 2007 (post) % Decline

Medical/Surgical 17.9% 2.8% 84%

ICU 12.9% .5% 96%

Preventable Adverse Drug Events

Department 2004 (pre) 2007 (post)%

DeclineMedical/Surgical 13.1% .4% 97%

ICU 6.9% 0% 100%

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Incidence Report for ADEs

Department Preventable All ADEs

Medical/Surgical -97.0% -84.0%

ICU -100% -96%

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Infections: The only consistent data recorded for infections during the 5 years of this study were for ventilator pneumonia and surgical site infections.

Infections - Surgical Site

Site 2002 (pre)

2008 (post)

% Decline

Surgical Site Infections (procedures)

3.6% .5% 76.2%

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Infections: The only consistent data recorded for infections during the 5 years of this study were for ventilator pneumonia and surgical site infections.

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Infections - Ventilator Pneumonia

Site

20022003

2004

2005 2006 2007 2008

Ventilator Pneumonia (days)

5.6 % 10.9& 5.6% 11.5% 0.0% 2.6% 3.9%

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Patient Falls

The number of patient falls steadily declined during the study period, from 149 to 31 (almost 80%), with one spike in 2006 of 115 falls (the new hospital opened in 2005).

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Transfusion Related Events

The number of transfusion events stayed consistent throughout the study period, at .3%. Almost all of these were considered not preventable.

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• Deaths of Patients in Restraints• Inpatient Suicides• Correct Tube-Correct Connector-Correct Hole• Deaths Related to Surgery at Wrong Site• MRI Hazards

These adverse events had Zero occurrences in 2002 and the incidence rate stayed at Zero during the study period ending 2008.

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Lean/Six Sigma Process Redesign

• Continuous Flow• Pull vs. Push• Standardize Work• Visual Control• Proven Technology• Culture of stopping to fix problems • Get quality right the first time

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Safety Culture• Shared Values/Beliefs about Safety within the Organization • Always Anticipating Precarious Events• Informed Employees and Medical Staff• Culture of Reporting • Learning Culture• “Just” Culture• Blame-Free Environment Recognizing Human Infallibility• Physician Team Work• Culture of Continuous Improvement• Empowering Families to Participate in Care of Patients• Informed & Activated Patient