Midwestern State University the Patient Safety Framework Case Study Clarification to the assignmentI’ve gotten a few questions about further explanation fo

Midwestern State University the Patient Safety Framework Case Study Clarification to the assignmentI’ve gotten a few questions about further explanation for the second case study. Here is some additional info…. For this assignment, I would like you to read the three assigned articles in module 10, then use them to provide examples for the elements of the framework. The goal is to find actual examples from the articles to support each element. The chart in the instructions may be helpful as a starting point. Use your IHI, text, or other sources to define each element. Then, go back to your articles to find examples of each element. Finally, weave these definitions and examples into a cohesive paper. Conclude your paper with a critique of the current state of patient safety using what you have discussed previously in the examples. What was successful? What didn’t work as well? Why? Hopefully, this is helpful! Let me know if you have further questions. And stay well! Applying the Patient Safety Framework
IHI’s patient safety experts created a framework to help organizations understand the
components of safe systems of care. The framework focuses on three components of safe
systems:
1) Leadership
2) Organizational culture, which is the product of individual and group values, attitudes,
competencies, and behaviors related to safety
3) Learning systems, which measure performance and help teams make improvements
•
Leadership: leaders who promote and facilitate teamwork, improvement, respect, and
psychological safety (see below).
• Transparency: openly sharing information about the safety and quality of care with
staff, partners, patients, and families.
• Teamwork and communication: promoting teams that develop shared understanding,
anticipate needs and problems, and apply standard tools for managing communication
and conflict.
• Psychological safety: creating an environment where people feel comfortable raising
concerns and asking questions and have opportunities to do so.
• Negotiation: gaining genuine agreement on matters of importance to team members,
patients, and families.
• Accountability: holding individuals responsible for acting in a safe and respectful
manner when they are given the training and support to do so.
• Continuous learning: regularly identifying and learning from defects and successes.
• Reliability: applying best evidence and promoting standard practices with the goal of
failure-free operation over time.
• Improvement and measurement: improving work processes and patient outcomes
using improvement science, including measurement over time.
The IHI Open Courses and the textbook chapters explore each of these elements more fully.
In this Case Study, you will apply the IHI Patient Safety Framework to a set of articles that
describe the work of various organizations and experts in the field. Your goals are to (1) link
examples from the articles to the elements of the Framework and (2) critique the current state
of patient safety by identifying common keys to success and barriers to improvement.
Critical thinking for this assignment will rely on a basic understanding of the material (text
chapters and IHI courses) assigned during weeks seven, eight and nine. Go back and review the
key ideas to inform and support your response. Your final submission for this assignment will be
a professionally organized paper that analyzes the programs implemented by several
institutions – those discussed in the three preceding articles.
Structure your paper using the following headings:
Introduction
Applying the Patient Safety Framework
Leadership
Organizational Culture (4 elements)
Learning System (4 elements)
Critique of the Current State of Patient Safety
Common Keys to Success
Common Barriers and Challenges
Conclusion
The overarching question that is answered by this assignment: How do organizations implement
and demonstrate the elements of the Patient Safety Framework? In the field of patient safety,
what are the common keys to success and barriers to improvement?
To begin your paper, you may want to use the chart below. This is one way to synthesize and
organize your thoughts for the paper. Each section of the paper would include an explanation
or definition of the element and a description of specific examples from the case studies that
demonstrate the element in action. (Organizing the content up front will save time in the end!)
Elements of the Framework
Leadership
Culture: Transparency
Culture: Psychological Safety
Culture: Teamwork and Communication
Culture: Negotiation
Learning: Accountability
Learning: Continuous Learning
Learning: Reliability
Learning: Improvement and Measurement
Definitions and Explanations
(from Course Materials)
Examples
(from Articles)
I’ve gotten a few questions about further explanation for the second case study. Here is some
additional info….
For this assignment, I would like you to read the three assigned articles in module 10,
then use them to provide examples for the elements of the framework. The goal is to
find actual examples from the articles to support each element.
The chart in the instructions may be helpful as a starting point. Use your IHI, text, or
other sources to define each element. Then, go back to your articles to find examples of
each element.
Finally, weave these definitions and examples into a cohesive paper. Conclude your
paper with a critique of the current state of patient safety using what you have
discussed previously in the examples. What was successful? What didn’t work as well?
Why?
Hopefully, this is helpful! Let me know if you have further questions. And stay well!
Please be sure to use APA formatting guidelines. If the assignment instructions or expectations are unclear, ask for
clarification.
Rubric
Case Study Grading Rubric
Case Study Grading Rubric
Criteria
This criterion is
linked to a Learning
OutcomeExplanation
of Issues
Stated argument and
thesis development
Ratings
20.0 pts
Issue/problem to be
considered is stated clearly
and described
comprehensively. Critical
thinking beyond the surface
is evident. Describes all
relevant information
necessary for full
understanding.
17.0 pts
Issue/problem to be
considered is stated and
adequately described so
that understanding is
not seriously impeded
by omissions. Thinking
remains somewhat on
the surface.
14.0 pts
Issue/problem to be
considered is stated but
description leaves some
terms undefined,
ambiguities unexplored,
boundaries undetermined,
and/or backgrounds
unknown. Addresses only
the surface issues.
Pts
12.0 pts
Issue/problem to be
considered is stated
without clarification
or description.
Restates, rather than
evaluates, facts from
the case.
0.0 pts
Missing
20.0 pts
Case Study Grading Rubric
Criteria
This criterion is
linked to a Learning
OutcomeEvidence
Selecting and using
information to
investigate a point of
view or conclusion
This criterion is
linked to a Learning
OutcomeCritical
Thinking and
Conclusions
Scrutinizing context
and assumptions;
Analyzing
implications and
consequences
Ratings
25.0 pts
Information is taken from
the case and evaluated with
substantive interpretation
and evaluation to develop a
comprehensive analysis.
Fully and explicitly
integrates relevant course
material and credible
external sources.
21.0 pts
Information is taken
from the case with
enough interpretation
and evaluation to
develop a coherent
analysis or synthesis.
Explicitly integrates
relevant course
material.
18.0 pts
Information is taken
from cases with some
interpretation and
evaluation, but not
enough to develop a
coherent and thoughtful
analysis or synthesis.
Course material is
referenced but not well
integrated.
25.0 pts
Thoroughly analyzes and
questions assumptions and
carefully evaluates the
relevance of contexts when
presenting a position.
Conclusions are logical and
reflect student’s informed
evaluation and ability to
place the evidence in
priority order.
21.0 pts
Minimally identifies
and questions
assumptions and
several relevant
contexts when
presenting a position.
Conclusion is logically
tied to a range of
information that is
clearly described.
18.0 pts
Identifies some
assumptions and relevant
contexts but does not
analyze or critique
assumptions and contexts.
Conclusion is logically
tied to information but
information appears to be
chosen with bias to fit the
desired conclusion.
Pts
15.0 pts
Information is taken
from cases without any
interpretation and
evaluation. Viewpoints
are taken as fact,
without question or
critical thinking.
Course material is not
incorporated.
15.0 pts
May make assumptions
about contexts, without
identifying or
critiquing influence on
position. Conclusion is
inconsistently tied to
some of the
information discussed.
0.0 pts
Missing
25.0 pts
0.0 pts
Missing
25.0 pts
Case Study Grading Rubric
Criteria
This criterion is
linked to a Learning
OutcomeWriting
Mechanics and Style
Organization,
construction, unity,
and use of writing
conventions.
Ratings
15.0 pts
Paper is well organized
with a compelling
introduction, welldeveloped body with
analysis, and conclusion.
Syntax is effective
paragraph-to-paragraph,
sentence-to-sentence. Goes
beyond mastery of surface
correctness to elegant
writing.
13.0 pts
Paper is well-organized
and has a strong
introduction, body with
analysis, and conclusion.
Few syntactical errors
that do not affect clarity.
Demonstrates mastery of
surface correctness and
competent use of
language.
11.0 pts
Paper is organized and
has an introduction,
body, and a conclusion.
Flow of syntax may be
choppy, with some
distraction of
readability. Mastery of
surface correctness is
problematic.
Pts
9.0 pts
Paper has an
elementary
organization with
introduction, body, and
conclusion; Several
syntax errors that
distract from meaning.
Surface correctness
issues present a barrier
to readers.
0.0 pts
Missing
15.0 pts
Case Study Grading Rubric
Criteria
This criterion is
linked to a Learning
OutcomeFormatting
Adheres to
guidelines and APA
formatting.
Total Points: 100.0
PreviousNext
Ratings
15.0 pts
Follows all
instructions for paper
formatting.
Demonstrates
compliance with APA
for in-text and
bibliographic
citations. Attribution
is well documented,
indicates synthesis of
several authors.
12.0 pts
Follows all instructions
for paper formatting.
Demonstrates
compliance with APA
for in-text and
bibliographic citations
but contains some
minor errors.
Attribution is
documented, but with a
minimal number of
sources.
9.0 pts
Follows most
instructions for paper
formatting.
Demonstrates, with
several errors, attempt
to use APA format.
Distinguishes between
common knowledge
and information
requiring attribution.
Pts
5.0 pts
Does not follow
instructions for paper
formatting. Does not
include in-text and/or
bibliographic citations.
Ineffective attribution;
may have 20% or more
direct quotations, might
not distinguish common
knowledge from
information requiring
attribution.
0.0 pts
No attempt
at APA
formatting.
15.0 pts
Chapter 12: Creating a Culture of Safety
and High Reliability
Chapter Outline
• The Players
• The Plan
• Session One: Making the Commitment to a HighReliability Organization
• Session Two: Designing the High-Reliability
Organization
• Session Three: Influencing Individuals
• Session Four: Creating a Culture of Safety
1
The Players
• Dr. Jeff Donovan
– New chief medical officer
– Has worked at the hospital for more than ten years
• Dr. Elizabeth Adams
– Senior physician
– Has held a series of senior medical positions
2
The Plan
1. Build self-awareness as a quality leader and foster
personal commitment to patient safety
2. Review the basic concepts of high reliability
3. Increase skill at influencing other physicians, both one at
a time and in small groups
4. Foster an ability to initiate and maintain large-scale
culture change
The most important ingredient to launching a successful career
as a change agent for a culture of safety is to have a mentor to
guide the way.
3
Session One: Making the Commitment to a
High-Reliability Organization
• Neither physicians nor managers alone can create the high
reliability system needed to keep patients safe.
• Why people don’t change
– Competing commitments
– Leaders sending mixed messages
• Passionate preparation
• Knowledge and resources
• Relentless execution
• Transformational leadership
4
Session Two: Designing the High-Reliability
Organization
• High-reliability organization (HRO)
– Corporate mindfulness
– Appreciation that risk is complex
– Preoccupation with failure, using every error as a pointer to
the need for root-cause analysis and improvement work
– Respect for the experts within the system
– Resilience that adapts immediately to whatever is required
• “Every system is perfectly designed to get the results it
currently gets.”
• Preventing, detecting, and mitigating errors
5
Session Three: Influencing Individuals
•
•
•
•
Behavior change models
Measurement
Drivers and outcomes
Facilitating functions and forcing functions
6
Session Four: Creating a Culture of Safety
• Culture is largely a subjective experience with a lot of
individual perspectives.
• Eight steps of change (Kotter model):
1.
2.
3.
4.
5.
6.
7.
8.
Sense of urgency
Guiding coalition
Create a strategic vision
Communicate this strategy widely
Empower broad-based action
Short-term wins
Consolidate gains
New status quo
7
Chapter 11: Patient Safety and Medical Errors
Chapter Outline
Background and Terminology
Patient Safety and Medical Errors
Scope and Use in Healthcare Organizations
Leading Improved Patient Safety
Dealing with Adverse Events
Designing Safe Processes
Clinical and Operational Issues
Case Study: OSF Healthcare System
1
Background and Terminology
• Patient safety – “freedom from accidental injury”
• Error – “an occasion in which a planned sequence of
events fails to achieve its intended outcome”
2
Patient Safety and Medical Errors
• When a patient does experience harm from a medical
intervention, the occurrence is called an adverse event.
– Not all adverse events are the result of error; some medical
interventions can cause harm even when planned and executed
correctly.
• Errors originate from two types of failures:
– Planning failure: The wrong plan was initiated, even though
it was carried out as intended.
– Execution failure: The plan was correct, but it was not
carried out as intended.
3
Patient Safety and Medical Errors
• Patient safety practice: Application of a process or
structure that reduces the probability of adverse events
resulting from exposure to the healthcare system
• Systems designed for patient safety: Systems in which
errors are expected to occur, processes are designed and
improved with human factors and safety in mind, and
reporting is encouraged and rewarded
4
Scope and Use in Healthcare Organizations
• Parallels to the aviation industry
• Teamwork and patient safety
– Culture
– Communication
5
Leading Improved Patient Safety
• Leadership of an organization is the driving force behind
the culture that exists and the perceptions that it creates.
• Messages must be visible and consistent.
• Leaders should round.
• Policies should be non-punitive.
6
Dealing with Adverse Events
• Leaders and management must work to prevent a blamefocused or punitive response.
• Disclosure of harm to patients and families must be
managed.
• Involving patients and families in discussions about their
care throughout the entire process is an essential element
in cultural change.
7
Reporting Errors and Adverse Events
• Voluntary reporting systems are often not reliable, and
underreporting is a significant problem.
• To increase reporting:
– Education fairs, posters, safety hotlines, shorter reporting forms,
raffles or prizes for departments with the most reports
• Emphasis should be placed on the guaranteed anonymity of
reporting mechanisms and the assurance of nonpunitive approaches.
• To sustain high levels of reporting, the underlying culture must
change.
– Visible leadership commitment
– Dialogue and feedback
8
Reporting Errors and Adverse Events
• Two types of errors:
– Active: effects or consequences occur immediately
– Latent: exists within the system for a long time, not causing
harm until a situation arises where, in combination with
other factors, the error becomes part of a chain of events
resulting in disaster
• In a safety-oriented culture, information about errors and
action taken to reduce them are shared openly.
9
Looking to Other Industries
•
•
•
•
Aviation
Nuclear power plants
Nuclear aircraft carriers
Failure modes and effects analysis (FMEA)
– A systematic, prospective method of evaluating a process to
predict where and how it might fail and of assessing the
relative effects of those failures to identify which parts of
the process need the most revision
10
Using Technology to Improve Patient Safety
• Never automate a bad process.
• New technology introduces new opportunities for error
and failure.
• No technology will eliminate all errors.
• Extra features of technology must be used in a balanced
manner.
11
Designing Safe Processes
1. Start with adoption of recommended, evidence-based
practices and use resources to support implementation.
2. Incorporate human factors into training and procedures.
3. Design processes to be safely and reliably executed by
staff with varying levels of experience, training, and
environmental or personal stress.
4. Design technology and procedures for end users, planning
for failures.
5. Decrease complexity by reducing the number of steps in a
process whenever possible.
12
Designing Safe Processes (continued)
6. Ensure that safety initiatives address prevention,
detection, and mitigation.
7. Standardize processes, tools, technology, and equipment.
8. Clearly label medications, solutions, and individual
doses.
9. Use bar coding.
10. Use forcing functions to prevent certain types of errors
from occurring.
13
Clinical and Operational Issues
• Patient safety research
– Limitations of research
– Effects of fatigue
• Economics and patient safety
14
Case Study: OSF Healthcare System
•
•
•
•
•
•
•
Order of Saint Francis (OSF) Healthcare System
Both top-down and bottom-up improvement strategy
Tie executive compensation to key safety indicators
Build a robust infrastructure
Corporate patient-safety office and physician change agent
Learning community
Cultural changes
Results: In June 2001, the rate of adverse drug events was 5.8 per
1,000 doses. By May 2003, the rate had fallen to only 0.72 per
1,000 doses.
15
BUILDING ON SUCCESS
TO CONQUER PATIENT HARM
By Maggie Van Dyke
Healthcare organizations have been
engaged in intense battles of whacka-mole in recent years to secure
patient safety, says Peter Pronovost,
MD, PhD, senior vice president of
patient safety and quality, Johns
Hopkins Medicine, Baltimore. The
campaigns have mostly focused on
fighting one type of patient harm
at a time such as adopting evidencebased protocols to prevent ventilatorassociated pneumonia.
These focused crusades have produced significant wins: Hospitalacquired conditions—from adverse
drug events to pressure ulcers—fell
by 21 percent between 2010 and
2015, saving the lives of 125,000 people and reducing costs by almost
$28 billion (see the chart on page 22).
Just as important, healthcare organizations have developed needed capacities and raised staff awareness to fight
patient harm. “Twenty years ago, we
didn’t talk about safety or, when we
did, the response was often ‘Errors in
hospitals just happen,’” says Stephen
T. Lawless, MD, senior vice president
and chief clinical officer, Nemours
Children’s Health System, Talleyville,
Del., and an ACHE Member. “Today,
you can’t walk into a hospital where
patient safety is not top of mind.”
Yet the overall war against patient
harm continues. Millions of patients
still suffer from preventable harm,
both inside and outside the hospital.
What will be required to claim victory,
Pronovost believes, is for healthcare
Healthcare Executive
MAR/APR 2017
21
Reprinted with permission. All rights reserved.
BUILDING ON SUCCESS TO CONQUER PATIENT HARM
settings to be redesigned to run as
safely and seamlessly as airplane
cockpits, taking advantage of technology, big data, scientific approaches
and leadership best practices to help
clinicians prevent and respond to all
potential patient harms at once.
“This approach involves building a
performance management system like
those found in the airline and nuclear
power industries,” Pronovost says.
“They don’t view quality as a project
but as an integrated system that
addresses all harms rather than just
one harm at a time like it’s a game of
whack-a-mole.”
How…
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