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Implementation of quality standards to build a patient safe hospital.ppt
The document outlines the implementation of quality standards in hospitals to ensure patient safety and manage complex healthcare environments. It emphasizes teamwork, top management involvement, and proper accreditation as essential elements for improving care quality. Various case studies highlight the importance of protocols in emergency situations and call for continuous monitoring and training to prevent medical errors and enhance patient safety.
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Slide 1 introduces the presentation on implementing quality standards for patient safety in hospitals. Slide 2 emphasizes the complexity of managing healthcare organizations.
Slides 3-4 outline expectations for hospitals versus their current condition, highlighting challenges in achieving patient safety, with additional reference made to a source in Slide 5.
Slide 6 discusses medical errors based on a source. Slide 7 details the complex patient interactions in healthcare, emphasizing the need for error prevention.
Slides 10-12 discuss teamwork benefits in hospitals, including improved care quality and shared responsibility. Slide 13 links accreditation with effective teamwork and patient safety.
Slide 14 outlines the minimum, evidence-based accreditation standards necessary for hospitals to follow.
Slides 15-16 detail a fire incident at AMRI Hospital, identifying root causes and the need for emergency preparedness. Slide 17 relates NABH standards relevant to fire safety.
Slides 21-22 recount a power outage incident causing patient deaths, analyzing root causes. Slide 23 outlines NABH standards related to electrical and patient safety.
Slides 24-26 discuss surgical errors, including operating on the wrong leg and medication mistakes. Slide 27 details NABH standards for ensuring medication safety.
Slides 28-29 describe an incident with MRI equipment and its root causes. Slide 30 cites NABH equipment safety standards necessary for patient protection.
Slides 31-32 summarize the hospital safety program, focusing on prevention, incident reporting, training, and corrective action to ensure patient safety.
Slide 33 emphasizes that quality standards are part of an ongoing process for patient safety, requiring top management involvement and fostering a culture of safety.
Slide 35 personalizes the responsibility of treating patients, urging healthcare workers to care for patients as if they were their own family members.
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Implementation of quality standards to build a patient safe hospital.ppt
- 1. IMPLEMENTATION OF QUALITY STANDARDSTO BUILD A PATIENT SAFE HOSPITAL Dr. Lallu Joseph Quality Manager CMC, Vellore
- 2. HOSPITALS “Healthcare Organizations arethe most complex organizations to manage” Peter Drucker “Running a Hospital isn’t Brain Surgery…. …..Its Harder
- 3. How we wantthe hospitals to be……
- 4.
- 5. Source: 2002. IHI.Leape
- 6. MEDICAL ERROR Source –The Philadelphia Inquirer
- 7. PATIENT INTERFACE IN HEALTHCARE Complexinteractions Many stakeholders involved Every patient is different Every situation is different Highly sensitive and emotional Errors cannot happen
- 8.
- 9.
- 10. TEAM WORK INHOSPITALS When caregivers work together- benefits for the employees, the patients and the health-care facility Patients receive thorough care when providers collaborate Providers can concentrate on their areas of expertise, knowing they are part of a team looking after the whole patient- shared responsibility Quality of care improves Hospitals save money with effective team care
- 12. TEAMWORK IS ENHANCEDBY QUALITY MANAGEMENT AND ACCREDITATION
- 13. ACCREDITATION, TEAM WORKAND PATIENT SAFETY Accreditation is proven to be the best possible tool to achieve quality and safety Top management involvement is the key to effective implementation All stakeholders to be involved from the chairman to the doorman The right intent has to be understood and Implementation should focus on the intent Accountability at all levels and processes Checks and balances at all levels Continuous Monitoring SHARED RESPONSIBILITY AND COMMUNICATION IS THE KEY
- 14. ACCREDITATION STANDARDS Basic minimumstandards Achievable Non- negotiable Based on evidences Best practices
- 15. INFRASTRUCTURE AND FIRE SAFETY AMRIHOSPITAL, KOLKOTTA Occurrence of accident 2:15 AM Fire started from the basement. 3:30 AM Smoke started spreading through AC ducts 4:10 AM Fire Brigade called 4:30 AM Rescue process started 7:30 AM Firemen broke the wall of basement and started flooding the wall. Could not enter due to smoke and poisonous gas 8:00 AM Snorkel arrived and rescue by breaking the glasses of the building facade
- 16. ROOT CAUSE ANALYSIS Thebasement was full with Inflammable article like paper, cotton, mattress, chemicals etc Alarm did not get activated as it was made inactive, due to many false alarms Fire extinguishers at the basement did not work as they were not checked. No evacuation was initiated even after 1 ½ hrs. Central AC system and electricity supply were not stopped Carbon monoxide gas started spreading through AC ducts No trained person to deal the emergencies, specially how to evacuate critically ill patients. No signage for emergency exits. No arrangement for alternate ventilation. No escape route. Set back around the building had vehicles parked.
- 17. STANDARDS ON FIRESAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE ROM 2a, 2b, 2c, 2d Fire installation as per NBC and fire license, implementation of the requirements, updation and amendments Top Management FMS 1a, 1d, 1e, 1f Safety committee to oversee the activities, facility rounds Multidisciplinary team FMS 6a Provisions for detection, abatement and containment of fire emergencies and checked periodically/ maintenance Engineering/ fire team FMS 6b Documented safe exit plan and provisions Engineering/ fire team FMS 6c, 1g Staff awareness and training of their role in emergencies HR/ Training dept/ fire team FMS 6d, CQI 4b Mock drills conducted periodically and audit of the deviations Top management/ quality/ safety committee/ fire
- 21. POWER OUTAGE ATPUDUCHERRY HOSPITAL KILLS THREE DIALYSIS PATIENTS March 9th 2017 Indira Gandhi Medical College and Research Institute (IGMCRI)- Pondicherry Three patients, including two women- undergoing haemodialysis died No battery back up Generator supply restored after 15 minutes Previous incident- 21 died in Gandhi Hospital, Hyderabad, 2016 Source: NDTV
- 22. ROOT CAUSE ANALYSIS Backup battery supply for 20 minutes Generator supply- delay in starting Emergency response by the clinical team Machine maintenance Emergency alarms
- 23. STANDARDS ON ELECTRICAL, EQUIPMENTAND PATIENT SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE FMS 2f Electricity is available round the clock Engineering FMS 2g Alternate sources for electricity are provided for backup for any failure/ shortage Engineering FMS 2h The alternate sources are regularly tested Engineering FMS 3f, 3h Operational and maintenance plan for all utility equipment, maintenance plan for electrical systems Engineering FMS 4d Qualified and trained personnel operate and maintain medical equipment Top management/ biomed Engineering/ clinical depts FMS 4e, 4f Proper inspection, calibration and maintenance of equipment biomed Engineering/ clinical depts COP 7 Qualified personnel perform and monitor Clinical depts
- 24. DOCTORS OPERATE ONWRONG LEG OF 24-YEAR-OLD June 22, Fortis Hospital, Delhi Fractured right foot due to fall in the stair case Operated on the healthy left ankle of a 24 year old Multiple screws placed on the left ankle Temporary cast placed on the fractured foot
- 25. STANDARDS ON SURGICAL SAFETY-NABH CHAPTER STANDARDS TEAM RESPONSIBLE COP 15b Pre-operative assessment and documentation Surgical dept COP 15d Identification tags and checking of tags when the patient enters the OT Nursing COP 15d Appropriate surgical site marking and checking of the same Surgical and nursing team COP 15d Surgical safety checklist and cross checks Surgical, anaesthesia and nursing team COP 15d, CQI 3e Surgical time out and audit of the same Surgical, anaesthesia and nursing team CQI 2 Patient safety program, patient safety officer, audits and monitoring of the implementation of IPSG Top management/ Safety team
- 26. 15 HOSPITALISED AFTERWRONG DRUG INJECTED BEFORE STERILIZATION 12 Jan 2017, Kamalapur, Ballari district 15 women admitted for tubectomy, for tubectomy Hospitalised after being injected wrong medicine before the surgery. Adrenaline administered instead of Atropine sulfate injection Women felt giddy, began to vomit and felt their hearts race and rushed to Taluk Hospital Root Cause: LOOK ALIKE
- 27. STANDARDS ON MEDICATION SAFETY-NABH CHAPTER STANDARDS TEAM RESPONSIBLE MOM 3d Look alike and sound alike medications are identified in all areas Pharmacy/ Nursing in wards/ OT MOM 3d LASA medications are stored separately Pharmacy/ Nursing in wards/ OT MOM 4j High risk medications are identified and double checked before administration Nursing/ Clinical team MOM 6d Medication is verified from the order and physically verified before administration Nursing/ Clinical team
- 28. TWO STUCK TOMRI MACHINE FOR 4 HRS Nov 11, 2014, Tata Memorial Hospital 7 pm at the Tata Memorial- run (ACTREC) Attending doctor asked attendant to get oxygen mask. Attendant who never worked in MRI room, had no idea that no metal is allowed anywhere near the machine, brought oxygen cylinder. 2 staff stuck for 4 hours
- 29. ROOT CAUSE ANALYSIS Nostaff training Communication issues Metal detectors and other entry restrictions not in place Emergency run down/ quenching de-activated
- 30. STANDARDS ON EQUIPMENT, PATIENTSAFETY- NABH CHAPTER STANDARDS TEAM RESPONSIBLE AAC 11c Patients are appropriately screened for safety in imaging Radiology team/ Safety team AAC 11g Imaging and ancillary personnel are trained in radiation safety Radiology team/ Safety team AAC 11h Signage are prominently displayed Radiology team/ Safety team FMS 4e Equipment are periodically inspected for their proper functioning Radiology team/ Biomedical Engg
- 31. HOSPITAL SAFETY PROGRAM CAPAAND SYSTEM CORRECTION INCIDENT REPORTING EDUCATION AND TRAINING SYSTEM AND ACCOUNTABILITY PREVENTION AND CONTROL RISK IDENTIFICATION HOSPITAL SAFETY PROGRAM
- 32. SURGICAL PATIENT SAFETY CAPAAND SYSTEM CORRECTION INCIDENT REPORTING & AUDITS EDUCATION AND TRAINING SYSTEM AND ACCOUNTABILITY PREVENTION AND CONTROL RISK IDENTIFICATION HOSPITAL SAFETY PROGRAM Wrong patient can be operated 1. Patient ID Tag 2. UHID 3. Surgical safety checklist 1. Nurse in ward to check tag 2. To countercheck with chart and patient 3. Checklist at holding bay- nurse 4. Intra-OP- Time out by surgeon, anaesthetist and scrub nurse 5. Post OP for count If incidents happen to be reported Continuous audits for compliance to protocol Training to HCW RCA by multidisciplinary committee, change in protocol if required
- 33. IMPLEMENTATION OF QUALITY STANDARDSAND BUILDING SAFE HOSPITAL It is a continuous improvement process It does not happen overnight Every effort and every passing day brings improvement and innovations Safety culture needs to be built and inculcated Top management involvement in safety initiatives is a must Manage through committees Encourage reporting and learning from mistakes- Avoid blame and shame Accreditation acts as a good reminder and a guide towards a formal safety program With every assessment, improvement and culture change will be evidenced Perseverance is the key
- 35. THE PATIENT…… THE SOLEBREAD WINNER OF THE FAMILY, HE IS THE FATHER OF A SMALL KID, SON OF AN OLD FATHER, HUSBAND OF A YOUNG LADY, AND IS NOW YOUR RESPONSIBILITY TO TREAT HIM AND SEND HIM SAFE TO HIS LOVED ONES IMAGINE YOUR OWN THERE TAKE CARE OF HIM LIKE YOUR BROTHER Dr. Lallu Joseph
Editor's Notes
- #7 This figure comes from the Philadelphia Inquirer.