quality and medical safety programs page 1 of 26 quality and medical safety program employee...

Quality and Medical Safety Programs

of 26

Quality and Medical Safety Program

Employee education competency module 2009

DMC Quality DepartmentDetroit Medical Center©Revised: December, 2008


of 26

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.


of 26

Quality and Environmental Management Systems

The DMC has incorporated the requirements of a Quality Management System (QMS) as outlined in the ISO 9001-2000 standards and an Environmental Management System (EMS) as outlined in ISO 14001: 2004 standards into its quality program.


of 26

Foundation for Medical Safety

Our commitment to Medical Safety is reflected in our: Environmental Statement Quality Statement


of 26

ENVIRONMENTAL STATEMENT

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

We are committed to:•the prevention of pollution,•compliance with environmental regulations and other requirements, and•continuous improvement.

THINK GREEN Environmental Hotline 1-888-484-9200 THINK CLEAN


of 26

QUALITY STATEMENT

Quality at the DMC includes: Continuous improvement Prevention of medical/health system errors Provision of high quality medical care


of 26

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.


of 26

What is Performance Improvement?

It’s an ongoing effort to find new and better ways of doing things. It’s about:

Getting better results• Involving the whole organization• Improving work processes

Foundation for Performance Improvement:

• PDCA Plan Do Check Act


of 26

Performance Improvement

Plan What are the goals you want to achieve?

Do Measure progress towards goals by collecting data.

Check 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 process?

Act Make Improvements! Celebrate success!


of 26

Medical Safety 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.

How can we do this?

By identifying conditions that are hazardous and changing them.

By acting quickly and appropriately when an incident occurs.

By making medical safety a regular part of our performance improvement activities.

By making concerns for safety part of everything we do.


of 26

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


of 26

Institute of Medicine 6 aims of improving care

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. 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.


of 26

Healthcare Safety Statistics

40 to 50 Patient Injuries per 100 Hospital Admissions40 to 50 Patient Injuries per 100 Hospital Admissions

37 Million Admissions37 Million AdmissionsXX

40 Injuries per 100 Admissions40 Injuries per 100 Admissions==

15 Million Injuries per Year15 Million Injuries per Year

What can we do to change this?


of 26

Institute for Healthcare Improvement (IHI)“Protecting 5 Million lives from Harm” campaign

AIM: Care that is standardized and systematized Zero defects Innovative System Redesign

The DMC has committed to participate with the IHI to protect patients from harm

Everyone is responsible for the quality and safety of healthcare


of 26

Proven InterventionsThe 5 Million Lives Campaign challenges American hospitals to adopt 12 changes in care that save lives and reduce 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


of 26

Proven Interventions con’t.The 5 Million Lives Campaign challenges American hospitals to adopt 12 changes in care that save lives and reduce patient injuries: 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 (www.medqic.org/scip)

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


of 26

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.


of 26

Promoting and Maintaining a Safe Medical Climate

Patient Responsibilities: Encourage patients to:

• Provide accurate and complete information about present complaints, past illnesses, hospitalizations and medications.

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


of 26

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. The Joint Commission is one of these agencies and

comes to our hospitals at least once every 3 years.

What is Joint Commission? 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.


of 26

Hospital Transparency

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

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


of 26

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


of 26

Consumer Centered Hospital Data

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


of 26

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, and nursing homes 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 http://www.mihospitalinform.org/ State of Michigan healthcare quality website


of 26

Quality of Care

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 [email protected] or call 1-800-994-6610.


of 26

Quality and Medical Safety Programs Summary

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.


of 26

Summary

We hope this NetLearning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Click any of the following menu selections located on the left side of the screen:

• Take Test button to complete the requirements for this course

• My Records button to return to your CBL Courses to Complete list

• Exit button to close the Student Interface

quality and medical safety programs page 1 of 26 quality and medical safety program employee...

Documents