8/10/2019 7 steps to Patient Safety.ppt
1/33
Patient Safetyand Quality of Care
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
2/33
Seven steps to patient safety
1. Build a safety culture2. Lead and support your staff (Professional
Development)3. Integrate your risk management activity4. Clinical performance & audit5. Involve patients and the public6. Learn and share safety lessons7. Implement solutions to prevent harm
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
3/33
Step 1Build a safety culture Action points
For you r o rgan i sat i on : ensure your policies state what staff should do following an incident, how it should be investigated , and what support should be given topatients, families and staff; ensure your policies describe individual roles and accountability for when things go wrong; assess your organisations reporting and learning culture using a safety assessment survey (see Resources from the NPSA on page 10).
For you r t eam:
ensure your colleagues feel able to talk about their concerns and report when things go wrong; demonstrate to your team the measures your organisation takes toensure reports are dealt with fairly and that the appropriate learningand action takes place .
8/10/2019 7 steps to Patient Safety.ppt
4/33
1. Build a safety culture
Operations
Demonstrate top leadership commitment to safety
Communications
Multidisciplinary teamwork
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
5/33
1. Build a safety culture
Operations
Trust-beyond blame
Incident Report Check list Cross / double check
Update and socialize procedure Inspecting system Identification label
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
6/33
1. Build a safety culture
Operations
Signage
Practicing standard precaution (hand hygiene practices)
Implementation for PPM (Plan Preventive Maintenance) forBio-Medical Equipments
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
7/33
1. Build a safety culture
Operations
Staff Competency the right man for the right task Identification Label
Design & Safety Layout Alarm System
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
8/33
8/10/2019 7 steps to Patient Safety.ppt
9/33
Step 2Lead and support your staffAction points
For you r o rgan i sa ti on : ensure there is an executive board member with responsibility for patient safety; identify patient safety champions in each directorate, division or department;
put patient safety high on the agenda of board or management team meetings; build patient safety into the training programmes for all your staff and ensure this training is accessible and measure its effectiveness.
For you r t eam:
nominate your own champion or lead for patient safety; explain the relevance and importance of patient safety to your team, and the benefits it brings; promote an ethos where all individuals within your team are respected and feel able to challenge when they think something may be goingwrong.
8/10/2019 7 steps to Patient Safety.ppt
10/33
2. Lead and support your staff(Professional Development)
Operations
Evidence based skills training Postgraduate training Hospital credentialing policy
Indemnity Nurse training in collaboration with ECU
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
11/33
2. Lead and support your staff(Professional Development)
Operations Staff training
Safety & quality training
Appraisal system (reward & punishment) Rotation within departments Daily briefings Staff counseling Career ladder
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
12/33
2. Lead and support your staff
(Professional Development)
ExpectedOutcomes
Clinician credentialing and re-credentialing Improved professional development and skills
training for workforce Improved performance management Improved staff satisfaction
Improved patient outcomes
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
13/33
8/10/2019 7 steps to Patient Safety.ppt
14/33
8/10/2019 7 steps to Patient Safety.ppt
15/33
3. Integrate your risk management activity
Operations Sentinel events reporting (Miss / Near Miss) Clinical incident investigation & training
Quality improvement committee reports Medication safety clinical pharmacologist Clinical microbiologist Planned Preventive Maintenance (Bio-Medic) Risk management officer in every department
Scheduled risk management officer meeting Regular MOU checking & update Infection control program & committee Medico legal advisor
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
16/33
3. Integrate your risk management activity
ExpectedOutcomes
Improved monitoring and reporting of incidents and
adverse events Improved investigation of clinical incident andadverse events
Improved risk management processes Reduced health care costs through reduced
number and severity of adverse events Improved patient outcomes
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
17/33
Step 4Promote reportingAction points
For your o rgan i sa t ion : complete a local implementation plan (see below) which describes how and when your organisation will begin reporting nationally to the NPSA.
For you r t eam: encourage your colleagues to actively report patient safety incidents that happen and those that have been prevented from happening butthat carry important lessons.
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
18/33
4. Clinical performance & audit
Operations
Mortality report & audit
Clinical Indicators Internal clinical guidelines Collaborations with overseas centers of
excellence Working with GPs and Specialist in the
surrounding area Quality indicator Nursing care quality audit Latest equipment provision
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
19/33
4. Clinical performance & audit
Agreed pathways for clinical practice
Reduced variation in clinical practice Improved patient outcomes Reduced health care costs through reduced
adverse event
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
20/33
8/10/2019 7 steps to Patient Safety.ppt
21/33
Step 5Involve and communicate with patients and the public
Action points For your o rgan i sa t ion :
develop a local policy covering open communication about incidents with patients and their families; ensure patients and their families are informed when things have gone
wrong and they have been harmed as a result; provide your staff with the support, training and encouragement they need to be open with patients and their families.
For you r t eam: ensure your team respects and supports the active involvement of patients and their families when something has gone wrong; prioritise the need to tell patients and their families when incidents occur, and to provide them with clear, accurate and timely information; make sure patients and their families receive an immediate apology where it is due, and are dealt with in a respectful and sympathetic way.
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
22/33
5. Involve patients and the public
Operations
Consumer participation training
Informed consent
Complaint management
Customer information center
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
23/33
5. Involve patients and the public
Operations
Seminars for public & medical professionals
Patient liaison
Parentcraft, Post natal care education
Patients gathering
Stroke club
Pastoral careRapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
24/33
5. Involve patients and the public
Greater consumer participation in health
service delivery and management Enhanced patient and consumer knowledge Improved patient outcomes
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
25/33
Step 6Learn and share safety lessons
Action points For your o rgan i sa t ion :
ensure relevant staff are trained to undertake appropriate incident investigations that will identify the underlying causes; develop a local policy which describes the criteria for when your
organisation should undertake a Root Cause Analysis (RCA) orSignificant Event Audit (SEA). These criteria should include all incidentsthat have lead to permanent harm or death.
For you r t eam: share lessons from the analysis of patient safety incidents within your team; identify which other departments might be affected in future, and shareyour learning more widely.
8/10/2019 7 steps to Patient Safety.ppt
26/33
6. Learn and share safety lessons
Operations
Infection control nurse training
Adapting overseas safety & quality policies
Socializing adapted safety & quality policies
Intensivist training
Training for external participants
Benchmarking
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
27/33
6. Learn and share safety lessons
ExpectedOutcomes
Decreasing the number of infection Improvement on safety & quality policies
Improving the quality of patient care
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
28/33
8/10/2019 7 steps to Patient Safety.ppt
29/33
Step 7Implement solutions to prevent harmAction points
For your o rgan i sa t ion :
use the information generated from incident reporting systems, risk assessments, and incident investigation, audit and analysis to identifylocal solutions. This could include re-designing systems and processes,and adapting staff training or clinical practice; assess the risks for any changes you plan to make;
measure the impact of your changes; draw on solutions developed externally. These could be solutions developed at a national level by the NPSA or best practice identifiedelsewhere in the NHS; provide staff with feedback on any actions taken as a result of reported incidents.
For you r t eam: involve your team in developing ways to make patient care better and safer; review changes made with your team to ensure they are sustained; ensure your team receives feedback on any follow -up to reported
incidents.
8/10/2019 7 steps to Patient Safety.ppt
30/33
7. Implement solutions to prevent harm
Operations
Rapid diagnostics
X-Ray Result has to be finished in 15 minutes
Lab Clinical Pathology 2 hours
Appointment system at OPD Pharmacy
No compound medicine Drugs interaction is controlled by clinicalpharmacologist In-patient pharmacist
Out-patient pharmacist
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
31/33
7. Implement solutions to prevent harm
Operations
True partnership with our consumers Full time specialist in all disciplines Consumer involvement from Doctors, Patients andtheir family
Active medical advisory board Accreditation & ISO certification Improvement in patient care Genuine empowerment
Bottom-up process Top / down guidance, direction and support
Specialist on-call system Building confidence & new capabilities in Doctors & Staff 24 hours general & maintenance support Preparation for further accreditation under Americanstandard ( JCIA )
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
32/33
Expected
Outcomes
7. Implement solutions to prevent harm
Improvement in patient care
Building confidence & new capabilities in doctors & staff
Implementation of evidence based practice
New culture of change and optimism
Bringing together consumers and staff from all levels tosolve many of very difficult problems in healthcare.
Sense of excitement from a tired and often cynical staffbecause someone is finally listening to them and doingsomething.
Rapat Kordinasi Instalasi RSK Mojowarno
8/10/2019 7 steps to Patient Safety.ppt
33/33