Quality Improvement Principles of Quality and Safety for HIT Lecture a This material (Comp12_Unit2a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
Quality Improvement Principles of Quality and Safety for HIT Lecture a This material (Comp12_Unit2a) was developed by Johns Hopkins University, funded.
Jan 05, 2016
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Quality Improvement
Principles of Quality and Safety for HIT
Lecture a
This material (Comp12_Unit2a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
Principles of Quality and Safety for HIT
Learning Objectives─Lecture a
• Investigate the fallibility of people and systems.
• Describe the ways that every system is designed to achieve the results it gets.
• Apply the basic principles of safe design.
• Explain the ways that teams make wise decisions with diverse and independent input.
2Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
Bilateral Cued Finger Movements
3Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
X-Ray Reveals Sponge
4Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
Josie King (18 months old) died from medical error
A Fatal Mistake
5Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
The Problem Is Large
In U.S. Healthcare system
• 7% of patients suffer a medication error
• 44,000- 98,000 deaths
• 100,0000 death from HAI
• Patients receive half of recommend therapies
• $50 billion in total costsSimilar results in UK and Australia
6Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
A Question…
• How can this happen?
• We need to view the delivery of health care as a science
7Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
How Can We Improve?Understand the Science of Safety
1. Accept we are fallible—assume things will go wrong rather than right.
2. Every system is perfectly designed to achieve the results it gets.
3. Understand principles of safe design. • Standardize• Create checklists• Learn when things go wrong
4. Recognize these principles apply to technical and team work.
5. Teams make wise decision when there is diverse and independent input.
Caregivers are not to blame
8Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
The Swiss-Cheese Analogy
9Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
System Factors
10Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
A Dosage Error?
11Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
Aviation AccidentsPer Million Departures
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
Image: Boeing, 2001 Statistical Summary of Commercial Jet Airplane Accidents, June 2002
12
Principles of Quality and Safety for HIT
Summary─Lecture a
13Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
Principles of Quality and Safety for HIT
References─Lecture a
References• Boeing. 2001 Statistical Summary of Commercial Jet Airplane Accidents. June 2002• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm• Reason, J. BMJ 2000;320:768-770
14Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Principles of Quality and
Safety for HIT Lecture a
Images
Slide 3: Bilateral Cued Finger Movements . Image courtesy Dr. Peter Pronovost. Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm
Slide 4: Sponge Left in Stomach. Image courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm
Slide 5: Josie King. Image courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm
Slide 9: The Swiss Cheese Model. Adapted by Dr. Peter Pronovost from original in Reason, J. BMJ 2000;320:768-770. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008
Slide 10: System Factors. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Image courtesy Dr. Peter Pronovost.
Slide 11: A Dosage Error? Creative Commons by MBBradford. Available from: http://en.wikipedia.org/wiki/File:Glucagon_vials_and_syringe.JPG
Slide 12: Adapted from : Boeing. 2001 Statistical Summary of Commercial Jet Airplane Accidents. June 2002 . http://www.fearofflying.com/Boeingaccidentstatsum59-01.pdf
Slide 13: Josie King. Image courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm
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