Quality and Regulatory Compliance in Health Care

Nawanan Theera-Ampornpunt, MD, PhD
Health Informatics Division
Faculty of Medicine Ramathibodi Hospital
Mahidol University, Thailand
Modified from slides of Assoc.Prof. Artit Ungkanont

Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award
Number IU24OC000013 (Health IT Workforce Curriculum v.3.0, Component 12/Units 1-12).

 Introduction to Quality Improvement & Health IT
 Principles of Quality and Safety for HIT
 The Culture of Safety
 Learning From Mistakes: Error Reporting and
Analysis and HIT

Introduction to Quality Improvement
and Health Information Technology:
Part 1

This material (Comp12_Unit1a) 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.

First, Do No Harm
Primum non nocere

2011
2009
2004
ONCHIT

2000-2001 HITECH Act
“Meaningful Use”
1991

(IOM, 2000) (IOM, 2001) (IOM, 2011)

 Humans are not perfect and are bound to make
errors
 Highlight problems in the U.S. health care system
that systematically contributes to medical errors
and poor quality
 Recommends reform that would change how health
care works and how technology innovations can
help improve quality/safety
 Health IT plays a role in improving patient safety
(but it may also carry risks to safety in certain
ways)

“Healthcare reform without attention to the nature and nurture of
healthcare as a system is doomed …It will at best simply feed the
beast, pouring precious resources into the overdevelopment of
parts and never attending to the whole — that is care as our
patients, their families and their communities experience it.”
(Berwick, 2009)

“The performance of a system — its achievement of its aims —
depends as much on the interactions among elements as on the
elements themselves. (Berwick, 2009)

“The improvement of health and healthcare depends on systems
thinking and systems redesign… ‘Reform’ without systems
thinking isn’t reform at all.” (Berwick, 2009)

Health IT Workforce Curriculum Quality Improvement
Version 3.0/Spring 2012 Introduction to QI and HIT 8
Lecture a

MEANINGFUL USE
Providers show they're using certified EHR technology in
ways that can be measured significantly in quality and in
quantity.

PATIENT-CENTERED MEDICAL HOME
Providers organize care around patients, working in teams,
coordinating care, and tracking over time.

ACCOUNTABLE CARE ORGANIZATION
Provider reimbursements are tied to quality metrics and
reductions in the total cost of care for assigned population of
patients.

Lecture a

“Meaningful
Pumpkin
Use”
of a Pumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

“Even hospitals with fully functioning
EMRs still make extensive use of
digitized scans of manually completed
forms and textual checklists. With no
forms or screens to capture data in a
structured way, hospitals fail to report
quality measures as a routine byproduct
of the practices, relying instead on a
retrospective chart abstracting process.”
(Holland, 2010)

Lecture a

 The American Recovery and Reinvestment Act of 2009
“…authorizes the Centers for Medicare & Medicaid
Services (CMS) to provide reimbursement incentives
for eligible professionals and hospitals who are
successful in becoming ‘meaningful users’ of certified
electronic health record technology …” (The American
Reinvestment and Recovery Act of 2009)

• The HITECH (Health Information Technology for
Economic and Clinical Health) Act establishes programs
under CMS in coordination with the Office of the
National Coordinator to accomplish this charge.

Lecture a

 Improve quality, safety, & efficiency
 Engage patients & their families
 Improve care coordination
 Improve population & public health;
reduce disparities
 Ensure privacy & security protections

Lecture a

Lecture a

 The quality of care received needs
improvement.
 In the current healthcare environment there are
a number of initiatives that aim to improve the
care in the U.S. context through the use of HIT.
• Meaningful Use
• Patient Centered Medical Home
• Accountable Care Organization

Lecture a

References
• Affordable Care Act. Available from: www.healthcare.gov/law/index.html
• Berwick, D. October 30, 2009, speech, Harvard School of Public Health
• Center for Medicaid Services. Shared Services Program. Available from:
https://www.cms.gov/sharedsavingsprogram/
• Endorsing national consensus standards for measuring and publicly reporting on performance; California Academy
of Family Physicians Diabetes Initiative Care Model Change Package originally developed by Lumetra
• Holland, Marc. In Health Information Exchange: From Meaningful Use to Healthcare Transformation. Available
from: http://www.himss.org/content/files/Carefx%20_HIE_meaningful-use2.pdf
• The National Coalition on Health Care (NCHC, 2007). Available from: http://nchc.org/
Patient-Centered Primary Care Collaborative. What We Do (PCMH). Available from:
http://www.pcpcc.net/what-we-do
• Patient Protection and Affordable Care Act (PPACA). Available from: http://www.healthcare.gov/law/index.html
• President Barack Obama. Barack Obama, speech at George Mason University, January 12, 2009
• U.S. Department of Health and Human Services. (June 22, 2011). Up to $500 million in Affordable Care Act funding
will help health providers improve care. Retrieved from:
http://www.hhs.gov/news/press/2011pres/06/20110622a.html

Images
Slide 14: Meaningful Use Stages. Courtesy of Dr. Anna Maria Izquierdo-Porrera

Lecture a

Part 2

This material (Comp12_Unit1b) was developed by Johns Hopkins University, funded by the Department of Health and Human

 Explainhealthcare quality and quality
improvement (QI).
 Describe quality improvement as a goal of
meaningful use.

Lecture b

“Quality of care is the degree to which
health services for individuals and
populations increase the likelihood of
desired outcomes and are consistent with
current professional knowledge.” (IOM, 2001)

Lecture b

Lecture b

 National Quality Forum (NQF) www.qualityforum.org
 National Committee for Quality Assurance (NCQA) www.ncqa.org
 Provider organizations
• AMA’s Physician Consortium for Performance Improvement
(PCPI) www.ama-assn.org/ama/pub/physician-
resources/clinical-practice-improvement/clinical-
quality/physician-consortium-performance-improvement
 Joint Commission (JC) www.jointcommission.org
 Institute for Healthcare Improvement (IHI)

Lecture b

 The Healthcare Accreditation Institute (Public Organization) www.ha.or.th
 Joint Commission (JC) www.jointcommission.org
 International Organization for Standardization (ISO) www.iso.org
 Provider & professional organizations
• University Hospital Network (UHOSNET) www.uhosnet.com
• The Medical Council of Thailand www.tmc.or.th
• Thai Medical Informatics Association (TMI) www.tmi.or.th
• Other professional councils and organizations
 Regulatory organizations
• Ministry of Public Health
• Ministry of Education
 Thai Qualifications Framework for Higher Education (TQF:HEd)
 Payer organizations
• National Health Security Office (NHSO) www.nhso.go.th
• Social Security Office (SSO)
• Comptroller-General Department
 Other quality frameworks
• Thai Quality Award (TQA) www.tqa.or.th
22

 Needs to be improved, especially for the
uninsured
 Patient safety & healthcare-associated
infections warrant urgent attention
 Quality is improving, but pace is slow,
especially in preventive care & chronic
disease management
 Disparities are common and lack of
insurance is a contributor
 Many disparities are not decreasing; those
that warrant increased attention include
care for cancer, heart failure, and
pneumonia

Lecture b

 National study of physician performance for 30 medical conditions plus
preventive care: physicians provided only 55% of recommended care.
(McGlynn et al. NEJM 2003; 348:2635)

 66% of people with hypertension are inadequately treated.
(JNC 7, JAMA 2003;289: 2560)

 63% of people with diabetes have HbA1c levels greater than 7.0%.
(Saydah, et al. JAMA 2004;291:335)

 62% of people with elevated LDL cholesterol have not reached lipid
goals.
(Afonso, Am J Man Care 2006;12:589)

 50-70% of healthcare-associated infections are preventable.
(Umscheid et al. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.)

 24.7% of Medicare patients admitted to the hospital for heart failure are
readmitted within 30 days.
(CMS, 2009)

Lecture b

 Only 27% of adults with a regular primary care physician
(PCP) could easily contact their physician over the
telephone, obtain care or medical advice after hours, or
experience timely office visits.

 Only 57% of adults rate the information they get about their
health issues as very good; only 43% find it easy to get an
appointment; and only 56% find the physician’s office to be
well-organized and feel their time is not wasted.

Lecture b

 Given the current sub-optimal quality of
care received by patients, the
introduction of QI initiatives is
imperative.

 HIT has an important role to play in QI
initiatives.

Lecture b

“Every system is perfectly designed to
achieve the results it achieves.”
(Paul Batalden, M.D, 2008)

So, the answer must lay in the system
redesign.

Lecture b

Lecture b

 Make it specific
• Assign it a number if possible
 Assign it a timeline
 Make it measurable
 Make sure it is challenging but doable

Lecture b

 PROCESS MEASURE: Are we doing
what we must to get the improvement
we seek?

 OUTCOME MEASURE: Are we
getting what we expect?

 BALANCING MEASURE: Are we
causing new problems in other parts
of the system?

Lecture b

Hospital Ambulatory
• AIM: we will reduce the number of • AIM: we will reduce the amount
ventilator-associated pneumonias of time it takes our patients to get
(VAP) in the ICU from the current an appointment (request to
23% to under 10% in 4 months appointment) from 23 days to 0
• MEASURES: days in 6 months
 Process measure: • MEASURES:
 Ventilator days  Process measure:
 Over-sedation hours  Supply
 Oral care performed
 Demand
 Outcome measure: Number of
VAP  No-show rate
 Balancing Measure:  Outcome measure: third next
available appointment
 Cost of care
 Re-intubation rates  Balancing Measure: Patient
satisfaction

Lecture b

 Concepts and strategies: decide on the overall changes that will
lead to the desired improvement.
 Specific changes:
• Make them small
• Make them fast
• Make them frequent
 You may need to include additional measures specifically to
decide if a change you have tested is worth keeping or did not
lead to improvement.
 Consider using pre-existing change packages.

Lecture b

• One of the most important aspects of QI is to
understand how your systems actually perform,
under a range of conditions.
• Deming’s theory of profound knowledge is based
on the principle that each organization is
composed of a system of interrelated processes
and people.
• The improvement of the system depends on the
capability to organize the balance of each
component to enhance the entire system.
• Understanding and learning about your system is
essential to improve it.

Lecture b

• PDCA (Deming Cycle)

Plan

Act Do

Check

http://en.wikipedia.org/wiki/Shewhart_cycle 34

• Continuous Quality Improvement (CQI)
http://en.wikipedia.org/wiki/Continual_improveme
nt_process
Quality improvement is an ongoing, continuous effort
• Total Quality Management (TQM)
http://en.wikipedia.org/wiki/Total_quality_manage
ment
Quality of products and processes is the responsibility of
everyone involved in the products or services
• Six Sigma
http://en.wikipedia.org/wiki/Six_Sigma
Seeks to improve quality by removing causes of defects and
minimizing variability in manufacturing and business processes

35

• Lean
http://en.wikipedia.org/wiki/Lean_manufacturing
Considers expenditure of resources that does not create value a
waste -> “Preserving value with less work”
Including tools such as Value Stream Mapping, 5S, Kanban (pull
systems), Just in time (JIT), etc.
• Routine to Research (R2R)
http://home.kku.ac.th/kitsir/research/html/download/ne
ws/r2r.pdf
Improves the routine work processes through research
• Risk Management
http://en.wikipedia.org/wiki/Risk_management
Identification, assessment, prioritization , prevention, mitigation,
monitoring, and control of risks

36

Nonaka SECI Model

Image source: Senoo et al. (2007) http://dx.doi.org/10.1108/14601060710776725

 The quality of care received needs
improvement.
 Quality improvement is an ongoing process
that includes the setting of an aim and a
progressive measurement, change test, and
understanding of the system.
 There are various complementary approaches
to quality improvement

Lecture b

References
• Agency for Healthcare Research and Quality (AHRQ). Available from: http://www.ahrq.gov/
• Batalden, Paul M.D in The Improvement Collaborative: An Approach to Rapidly Improve Health Care and Scale Up
Quality Services. June 2008. Available from:
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CCQQFjAB&url=http%3A%2F%2Fw
ww.ovcsupport.net%2Flibsys%2FAdmin%2Fd%2FDocumentHandler.ashx%3Fid%3D790&ei=g2nWTtbdFoHn0QH
8uP39AQ&usg=AFQjCNEnga43Tn8Y_Mmf0uUbcRUzhevA0w&sig2=RG7ZXVjV_eKlghcJarz_1A
• Beal et al. Closing the Divide: How Medical Homes Promote Equity in Health Care. Commonwealth Fund, 2007
• Centers for Medicare and Medicaid Services. http://www.cms.gov/
• IOM—International Institute of Medicine. Available from: http://iom.edu/
• Institute for Healthcare Improvement (IHI) Available from: http://www.ihi.org/Pages/default.aspx
• Joint Commission. Available from: http://www.jointcommission.org/
• National Committee for Quality Assurance. Available from: http://www.ncqa.org/
• National Quality Forum (NQF). Available from: http://www.qualityforum.org/Home.aspx
• Physician Consortium for Performance Improvement (PCPI)- American Medial Association. Available from:
http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-
consortium-performance-improvement.page
• Wasson, J. & Benjamin, R. How is your health: what you can do to make your health and healthcare better, 2009.
Available from: http://www.howsyourhealth.org/html/HowsYourHealth_4thEd.pdf

Lecture b

Images
Slide 20: Quality Health Care: Who Defines It? Courtesy of Dr. Anna Maria Izquierdo-Porrera
Slide 23: Cover of the 2009 National Quality Healthcare Report and the 2009 National Healthcare Disparities
Report. Available from: http://www.ahrq.gov/qual/qrdr09.htm
Slide 28: Basics of Quality Improvement. Courtesy of Dr. Anna Maria Izquierdo-Porrera

Lecture b

Part 3

This material (Comp12_Unit1c) was developed by Johns Hopkins University, funded by the Department of Health and Human

Lecture c

Has the potential to:
 improve health care quality
 prevent medical errors
 increase health care efficiency & reduce
unnecessary costs
 increase administrative efficiencies
 decrease paperwork
 expand access to affordable care
 improve population health

Lecture c

CPOE e-MAR
 Computerized provider order entry  Computerized medication administration
 Can reduce errors in drug prescribing record
and dosing  Can reduce errors in drug administration
Medical Device Interface e-Allergy List
 Automated vital sign capture  Computerized allergy list
 Can reduce errors in transcription  Can reduce errors in preventable adverse
Knowledge Links drug events
 Reference information links Reminders
 Can reduce errors due to lack of  Prompts and flags
knowledge  Can reduce errors in omission
Monitoring Structured Notes
 Quality metric reporting  Standardized observations
 Can identify opportunities for  Can reduce errors related to failure to
improvement detect subtle changes in status

Lecture c

System change:
A medical logic module (MLM) was created that
provides the following functionality: When selected
drugs are ordered at a frequency of every 24 hours or
longer, the prescriber is automatically presented with
the last administration time if the drug had been
ordered previously.

Lecture c

Early detection and effective treatment are the
cornerstones of treatment for pneumonia. Adults
aged 65 and older should receive the influenza and
pneumococcal immunization to prevent pneumonia
and its complications.

Lecture c

Knowledge access Patient portal
 Patient-friendly websites  Patient access and manage
 Can provide medical own health record
information and access to  Can enable self-
support groups management
Tailor to Patient Needs Disease management
 Clinical decision support  Customized health
 Can tailor information education and disease
according to patient management messaging
characteristics and  Can enable self-
condition management

Lecture c

Event:
A standard protocol (document specifying best
practices for care) and electronic prescriber order
sets are used for all adult patients receiving
intravenous blood thinners. There are new changes
to the protocol due to a switch to new laboratory
tests for monitoring drug activity.

Lecture c

System Change:
The current protocol and electronic order
sets were revised to include orders for the
new laboratory tests. The new order sets
include changes to the therapeutic goals of
nurse-managed therapy.
Lecture c

Knowledge access Patient portal
 Patient-friendly websites  Patient access and manage
 Can provide medical own health record
information and access to  Can enable self-
support groups management
Tailor to Patient Needs Disease management
 Clinical decision support  Customized health
 Can tailor information education and disease
according to patient management messaging
characteristics and  Can enable self-
condition management

Lecture c

Event:
Mr. Jackson took his mother to a pre-operative evaluation
center in preparation for her impending surgery. He was
asked to help her complete an information form that
included her home medications. Mr. Jackson’s sister
manages these medications and he had forgotten to bring
the list. He was unable to contact her on her cell phone and
became increasingly frustrated since, after all, his mother’s
doctors should know what medicines she is taking!

Lecture c

System Change:
The ambulatory care center implemented a web-
based patient portal that would allow patients or
caregivers to enter much of the history
information in advance, from home. Satisfaction
scores for patients improved with this active role
in their care.
Lecture c

A medical office practice is considering the use of
a web-based secure messaging system to improve
patient-provider communication and enhance
patient satisfaction.

Lecture c

Telemedicine Clinicians Reminders
• Internet-based access  Task list schedules
• Can provide immediate  Can remind nurses when
access to medical treatments are due
information
Time-sensitive Prompts Patient Reminders
 Appointment scheduling
 Timed draw alerts
 Can remind patients
 Can remind nurses when
when they need to
to draw blood based on
return for follow-up
a medication
intervention visits

Lecture c

Event:
Medication patches are small, flesh-colored, and are usually
placed in discreet locations, e.g. the upper shoulder area or
on the back of the upper arm. Some patches are
appropriately left on for 2-3 days or longer. It is difficult to
track the placement and removal of these patches over time,
leading to errors in which medication patches were not
removed and the patient received too much medicine.

Lecture c

System Change:
A change was made to the electronic medication record
(eMAR). After the nurse documents the application of the
patch in the eMAR, a follow-up task to remove the patch at
the ordered date and time is automatically generated. If the
follow-up task is still active during a transfer in care, the
receiving nurse will see this task on the eMAR.

Lecture c

A healthcare system saw increases in adverse
events in its home care company due to inadequate
transfer of clinical information at hospital
discharge. An electronic hospital discharge
summary with auto-faxing was developed to
increase availability of discharge information at the
time of follow-up care.

Lecture c

Wireless mobile Character expansion
technology • Ability to translate a few

• Vital Sign Capture
characters into phrases,
• Can eliminate need to
sentences or paragraphs
• Can decrease typing
write or type vital signs time
System integration Clinical decision
• Pull forward historical support
information • Prompt for duplicate
• Can reduce data labs
collection time • Can reduce redundant
laboratory testing
Lecture c

Event:
The emergency department (ED) staff at a community hospital
used a large whiteboard mounted on the wall that could be
quickly updated with felt-tip markers to track patients and
treatments. The problem was that staff could not obtain
information from the board unless they were physically standing
in front of it. In addition, information on the board only reflected
what was already known by the ED staff.

Lecture c

System Change:
The hospital implemented an automated ED
patient tracking system that used business
intelligence technology. This technology
enabled more efficient patient flow using real-
time data.

Lecture c

Hope Memorial Hospital implemented an
electronic picture archiving and communication
system (PACS) for requesting radiological
examinations and displaying images. They saw a
reduction in repeat chest X-ray films at outpatient
appointments.

Lecture c

Data capture Multi-Modal functionality
 Monitoring by population  Various ways for patients to
characteristics get health information
 Can uncover health care  Can decrease health care
disparities disparity
Tailor to Patient Needs Decision support
 Competency-based patient  Drug cost information
education  Can assist providers in
 Can tailor information to selecting alternatives for low
educational background and income patients
development status

Lecture c

 All healthcare settings can benefit from
the assistance of HIT professionals in
identifying electronic solutions to quality
concerns.

Lecture c

References
• Institute of Medicine. Crossing the quality chasm. Washington DC: National Academy Press, p. 232. 2001.

Images
Slide 42: What is Health Care Quality? Courtesy Dr.Anna Maria Izquierdo-Porrera

Lecture c

Part 4

This material (Comp12_Unit1d) was developed by Johns Hopkins University, funded by the Department of Health and Human

 Analyze the ways that HIT can either help or hinder
quality improvement.

Lecture d

 Work-arounds and artifacts can lead to unintended
consequences

Lecture d

Defined Example
 Alternative processes
that help workers avoid  Nurses taking verbal
demands placed on orders rather than
them that they perceive prescribers entering
to be unrealistic or
harmful the order into POE
 Unanticipated due to workflow
behaviors directly or timing of event
indirectly caused by the
EHR when the system
impedes one’s work

Lecture d

 When a bar-coding medication system interfered with
their workflow, nurses devised work-arounds, such as
removing the armband from the patient and attaching it
to the bed because the barcode reader failed to
interpret bar codes when the bracelet curved tightly
around a small arm.

Lecture d

 Investigators found increased mortality among children admitted to
Children’s Hospital in Pittsburgh after CPOE implementation.
 Three reasons were cited for this unexpected outcome:
• CPOE changed the workflow
• Order entry required as many as 10 clicks & took as long as 2 minutes
• When the team changed its workflow to accommodate CPOE, face-to-
face contact among team members diminished.

Lecture d

 Well-crafted HIT solutions can:
• Improve safety, effectiveness, efficiency, equity,
timeliness, and patient-centeredness of care
• Work to accomplish the best care for the whole
population at the lowest cost
 Poorly designed HIT solutions can:
• Lead to work-arounds and unintended
consequences that may lead to patient risks or
bad outcomes

Lecture d

References
• Connolly, C. (2005, March 21). Cedars-Sinai doctors cling to pen and paper. Washington Post, p. A01. Available from:
http://gunston.gmu.edu/.../cedars-sinai%20cpoe%20washpost%203-21-05
• Doyle, M. Impact of the Bar Code Medication Administration (BCMA) system on medication administration errors.
Unpublished doctoral dissertation, University of Arizona, Tucson in Nursing Informatics and the Foundation of Knowledge.
Jones and Bartlett Publishers Sudbury, Massachusetts. 2005.
• Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., et al. Unexpected increased mortality after implementation of a commercially
sold computerized physician order entry system. Pediatrics. 116;1506-1512. 2005

Images
Slide 69: Patient Armbands. Department of Defense. Available from:
http://www.defense.gov/HomePagePhotos/LeadPhotoImage.aspx?id=74561
Slide 70: Children's Hospital, Pittsburgh, PA. Available from: http://www.chp.edu/CHP/Community+Preview+Photo+Gallery

Lecture d

Principles of Quality
and Safety for HIT
Part 1


Version 3.0/Spring 2012 Principles of Quality and Safety for HIT 74
Lecture a

In U.S. Healthcare system
 7% of patients suffer a medication error
 44,000- 98,000 deaths
 100,0000 death from hospital-acquired
infections
 Patients receive half of recommend
therapies
 $50 billion in total costs
Similar results in UK and Australia

Lecture a

 How can this happen?

 We need to view the delivery of health
care as a science

Lecture a

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

Lecture a

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

Images
Slide 74: 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 78: 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 79: System Factors. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Image
courtesy Dr. Peter Pronovost.
Slide 80: A Dosage Error? Creative Commons by MBBradford. Available from:
http://en.wikipedia.org/wiki/File:Glucagon_vials_and_syringe.JPG

Lecture a

Principles of Quality
and Safety for HIT
Part 2


 Standardize.
• Eliminate steps if possible.
 Create independent checks.
 Learn when things go wrong.
• What happened?
• Why did it happen?
• What did you do to reduce risk?
• How do you know it worked?

Lecture b

Lecture b

 Assume things will go wrong
 Develop lenses to see systems
 Work to Mitigate Technical and Teamwork
Hazards
• Standardize work
• Create independent checks
• Learn from mistakes
 Make wise decisions by getting input from
others
 Keep the patient the north star

Lecture b

In this unit we’ve learned about the ways
that teams make wise decisions with
diverse and independent input. We’ve
also explored the importance of
communication and especially the place
of critical listening.

Lecture b

References
• Dayton, E. Joint Commission Journal, Jan. 2007
• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm
• Reason, J. BMJ 2000;320:768-770

Images
Slide 85: A Bank of ATMs. Creative Commons: Piotrus. Available from:
http://commons.wikimedia.org/wiki/File:PNC_bank_ATMs.JPG
Slide 86. A Three-Point Seat Belt in a Lincoln Town Car. Courtesy Creative Commons Gerdbrendel. Available from:
http://en.wikipedia.org/wiki/File:Seatbelt.jpg
Slide 87. Jelly Beans. Creative Commons Brandon D
Available from: http://3.bp.blogspot.com/-oxxwjc9sQp8/TbCxyVKPtWI/AAAAAAAAAcA/NkPtINLsFjw/s1600/jelly-
beans.jpg

Lecture b

The Culture of Safety

This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human

Video 1

Version 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 92

Pointing the finger at people rather than
systems.


 Limitslearning
 Increases likelihood of repeat errors
 Drives self-reporting underground


Video 2


In this unit we explored the characteristics
of high reliability organizations and
learned more about establishing an
organizational culture of safety.


References
• AHRQ Patient Safety Primers. Safety Culture. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=5
• Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD. AHRQ
Publication No. 08-0022, 2008 April. Agency for Healthcare Research and Quality. Available from:
http://www.ahrq.gov/qual/hroadvice/
• Riley, W., Davis, S.E., Miller, K.K., & McCullough, M. A model for developing high reliability teams. J Nurs Manag.
2010 Jul18(5):556-563.

Charts, Tables, Figures
Table 4_1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn
is a prerequisite for safety. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

Images
Slide 92: Aircraft Carrier USS Enterprise. Courtesy U.S. Navy, photo by Photographer's Mate Airman Rob Gaston.
Available from: http://www.navy.mil/view_single.asp?id=15089
Slide 94: Blame. Created by Dr. Stephanie Poe.
Slide 95: Blame Arrows. Created by Dr. Stephanie Poe.
Slide 96: How to Promote a Culture of Learning 1. Courtesy: Dr. Anna Maria Izquierdo-Porrera
Slide 97: How to Promote a Culture of Learning 2 Courtesy: Dr. Anna Maria Izquierdo-Porrera
Slide 98:How to Promote a Culture of Learning 3 Courtesy: Dr. Anna Maria Izquierdo-Porrera
Slide 99: Culture of Safety Characteristics. Courtesy: Dr. Anna Maria Izquierdo-Porrera
Slide 100: Honey Bee. Creative Commons by William Warby. Available from: http://www.flickr.com/photos/wwarby/


Learning From Mistakes:
Error Reporting and
Analysis and HIT: Part 1


“A new delivery system must be built to
achieve substantial improvements in
patient safety – a system that is capable
of preventing errors from occurring in
the first place, while at the same time
incorporating lessons learned from any
errors that do occur.”
(IOM,2004)

104
Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis
and HIT─Lecture a

105
and HIT─Lecture a

106
and HIT─Lecture a

 Admit that providing health care is potentially
hazardous
 Take responsibility for reducing risks
 Encourage error reporting without blame
 Learn from mistakes
 Communicate across traditional hierarchies and
boundaries; encourage open discussion of errors
 Use a systems (not individual) approach to analyze
errors
 Advocate for multidisciplinary teamwork
 Establish structures for accountability to patient safety

107
and HIT─Lecture a

 Near Miss  Harm

108
and HIT─Lecture a

 Swiss cheese model of error
 A culture of safety
 Three HIT mechanisms to help control
error
• surveillance systems, on-line event reporting,
and predictive analytics/data modeling
 Risk assessment model (near-miss VS
harm)

109
and HIT─Lecture a

References
• AHRQ Patient Safety Network. Glossary. Available from: http://psnet.ahrq.gov/glossary.aspx
• AHRQ. Glossary: Failure Mode Effects Analysis. Available from:
http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysis
• Kilbridge PM, & Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am
Med Inform Assoc. 2008 Jul-Aug;15(4):397-407. Epub 2008 Apr 24.
• Reason J. Human error: models and management. BMJ. 320:768-770. 2000.

Images
Slide 105: Adapted from Reason J. Human Error: Models and Management. BMJ 320:768 2000. by Dr. Peter
Pronovost. Available from: http://www.bmj.com/content/320/7237/768.long
Slide 106: Adapted from Reason J. Human Error: Models and Management. BMJ 320:768 2000. by Dr. Peter
Pronovost. Available from: http://www.bmj.com/content/320/7237/768.long
Slide 108: Types of Outcomes. Dr. Anna Maria Izquierdo-Porrera

Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis 110
and HIT─Lecture a

Error Reporting and


Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 112
HIT─Lecture b

HIT─Lecture b

 Classification of error
• AHRQ
• James Reason
• Slips & mistakes
• Latent conditions & active failures
• Sharp end & blunt end

HIT─Lecture b

References
• Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended
consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-423.
• Reason J. Human error: models and management. BMJ. 320:768-770. 2000.
• Siegler EL, Adelman R. Copy and paste. A remediable hazard of electronic health records. Am J Med. 2009
Jun;122(6):495-6.

Images
Slide 112: Types of Error –Commission/Ommission. Dr. Anna Maria Izquierdo-Porrera
Slide 113: Types of Error. Dr. Anna Maria Izquierdo-Porrera
Slide 114: Types of Error II. Dr. Anna Maria Izquierdo-Porrera

HIT─Lecture b

Error Reporting and

This material (Comp12_Unit12c) was developed by Johns Hopkins University, funded by the Department of Health and Human

HIT─Lecture c

 Structured problem-solving
process
 Considers all potential causal or
contributing factors
 Human factors
 System factors
 Detailed chronological list of
events surrounding incident
 Premise: one can learn from one’s
mistakes

HIT─Lecture c

HIT─Lecture c

Healthcare Example: Mrs. A. received blood in
the Emergency Department. Within 15 minutes,
she experienced a bad reaction. Her nurse
realized that she had received blood intended for
another patient. She was transferred to the
intensive care unit to be stabilized. The ED staff
wanted to know how this could have happened
so they assembled a team to identify possible
causes.

HIT─Lecture c

 Briefly describe event
 Identify affected areas/services
 Assemble a team
 Diagram the process (flow chart)
 Identify potential root causes
 Prioritize root causes
 Develop action plan
 Evaluate results!

HIT─Lecture c

HIT─Lecture c

Story: Before I had children, I invited one of my
high school friends and her family, including a
toddler, to dinner. I was worried that her toddler
would somehow manage to hurt himself in my
house, which was designed for a childless
couple.

HIT─Lecture c

Select a high risk process, one that is
known to have problems, and assemble a
team.

HIT─Lecture c

HIT─Lecture c

The higher the number, the more urgent the need to
prevent a failure.
HIT─Lecture c

Event: After reading several articles about
laboratory specimen errors that result in lab tests
being done on the wrong patients, doctors at a
community office practice decide to examine the
potential for this problem to happen in their
office laboratory.

HIT─Lecture c

 Select a high risk process (patient identification):
• Affects a large number of patients
• Carries a high risk for patients
• Has known process problems identified by other
organizations (e.g., Joint Commission Sentinel Event Alert!)
 Assemble a team
• People closest to issue involved
• People critical to implementation of potential changes
• Respected, credible team leader
• Someone with decision-making authority
• People with diverse knowledge bases

HIT─Lecture c

HIT─Lecture c

The higher the number, the more urgent the need to prevent a
failure.
HIT─Lecture c

HIT─Lecture c

 Tools
• Root Cause Analysis (RCA)
• Failure Mode Effect Analysis (FMEA)
• Hazard Analysis
• Flow Charting

HIT─Lecture c

References

Charts, Tables, Figures
Table12.1 Conduct a Hazard Analysis. Dr. Stephanie Poe
Table12.2 Conduct a Hazard Analysis II. Dr. Stephanie Poe

Images
Slide 119: Quality Improvement Tools. Dr. Stephanie Poe
Slide 121: Root Cause Analysis. Dr. Stephanie Poe
Slide 124: Failure Mode Effects Analysis. Dr. Stephanie Poe
Slide 127: FMEA: Steps. Dr. Stephanie Poe
Slide 128: FMEA Diagram. Dr. Stephanie Poe
Slide 133: Quality Improvement Tools. Dr. Stephanie Poe

HIT─Lecture c

Quality and Regulatory Compliance in Health Care

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