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forethought on the part of individual providers Safety of care - Freedom from accidental injury Sentinel event - An unexpected occurrence involving death, serious physical harm or psychological injury or risk thereof. It requires immediate response and investigation. 16 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 8 1999 - TO ERR IS HUMAN To Err is Human: Building a Safer Health System in 1999, brought the subject of patient safety and prevention of medical error to national attention. – 98,000 deaths annually – 1,000,000 injuries annually Publication of the Institute of Medicine’s (IOM) report, To Err is Human: Building a Safer Health System in 1999, brought the subject of patient safety and prevention of medical error to national attention. It reported the claim that approximately 98,000 people were dying annually from preventable medical errors and over one million people were being injured annually. Slide 9 An Epidemic of Errors The majority of medical errors do not derive from recklessness or the actions of an individual or a particular group. The primary conclusion of the report was that the majority of medical errors do not derive from recklessness or the actions of an individual or a particular group: they most commonly occur through the use of faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them. Slide 10 Strategy to Reduce Medical Errors ‒ Government ‒ Health care providers ‒ Industry ‒ Consumers should work together The committee who created the report laid out a comprehensive strategy by which government, health care providers, industry and consumers could work together to reduce preventable medical errors. It struck a balance between regulatory and market-based initiatives and between the roles of professionals and organizations. 17 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 11 Make Healthcare Safer Make it: HARD to do something WRONG EASY to do something RIGHT The aim was to make health care safer through making it harder for people to do something wrong and easier for them to do something right. Slide 12 2001 Crossing the Quality Chasm Focused on reinvention of the health care system ‒Foster innovation ‒Improve delivery of care Crossing the Quality Chasm: A New Health System for the 21st Century (2001), a follow-up report from the IOM panel of the Quality Health Care project, focused on reinvention of the health care system to foster innovation and improve delivery of care. The committee presented a comprehensive strategy and action for the following decade. Slide 13 2001 Crossing the Quality Chasm Defined six aims for improvement and the need for healthcare to be: ‒ Safe ‒ Effective ‒ Patient centered ‒ Timely ‒ Efficient ‒ Equitable The 2001 Crossing the Quality Chasm Report defined six aims for healthcare. Healthcare should be: • Safe - avoiding injury to patients from the care intended to help them • Effective - providing services based on scientific knowledge • Patient centered-providing care that is respectful of and responsive to individual patient preferences, needs and values and allowed to guide clinical decisions • Timely - reducing waits and harmful delays 18 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide • Efficient - avoiding waste • Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socioeconomic status Slide 14 10 Rules for Healthcare Redesign 1. Care should be based on continuous healing relationships 2. Care should be customized to patient needs & values 3. The patient should be the source of control 4. Clinicians & patients should share knowledge 5. Care should be evidence-based Continued… 1. Patients should receive care whenever they need it, and in many forms, not just face-to-face visits. 2. The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences. 3. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. 4. Patients should have unfettered access to their own medical information and to clinical knowledge. 5. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 19 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 15 10 Rules for Healthcare Redesign 6. Systems should reduce risk and ensure safety 7. Healthcare systems should be transparent in performance 8. Healthcare systems should anticipate patient needs 9. Healthcare systems should continuously decrease waste 10. Providers should collaborate and communicate 6. Patients should be safe from injury caused by the care system. 7. The health care system should make information available to patients and their families that allow them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. 8. The health system should anticipate patient needs, rather than simply reacting to events. 9. The health system should not waste resources or patient time. 10. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. Slide 16 #1 Rule for Healthcare Redesign Care should be based on continuous healing relationships Patients should receive care whenever they need it, and in many forms, not just face-to-face visits. This rule implies that the healthcare system should be responsive at all times (24 hours a day, every day), and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits. The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences. Slide 18 #3 Rule for Healthcare Redesign The PATIENT should be the source of control Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision-making. Slide 19 #4 Rule for Healthcare Redesign Clinicians and patients should communicate effectively & share knowledge Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information. 21 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 20 #5 Rule for Healthcare Redesign Care should be evidence-based Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. Slide 21 #6 Rule for Healthcare Redesign Systems should be designed to prevent & mitigate errors Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. Slide 22 #7 Rule for Healthcare Redesign The healthcare system should be Transparent in performance PERFORMANCE REPORT-BEST HOSPITAL OF FLORIDA SAFETY Safer than most-5 falls in 2010 EVIDENCE-BASED PRACTICE Nearly always uses PATIENT SATISFACTION Most people like it The health care system should make information available to patients and their families that allow them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system's