Introduction to the science of safety

and patient safety

Dr Mohammad Abu-Mahfouz
January 23, 2024 1
 International Patient Safety Goals (IPSG)

January 23, 2024 17

 International Patient Safety Goals (IPSG)
IPSG 1: Identify patients correctly:

 Use at least two ways to identify patients. For

example, use the patient’s name and date of
birth.

 This is done to make sure that each patient

gets the correct medicine and treatment.

January 23, 2024 18

 International Patient Safety Goals (IPSG)
IPSG 2: Improve effective communication:

 Miscommunication can lead to medical errors and adverse events.

 Healthcare team members should use clear and accurate communication.

 Verbal and telephone orders should be written down when received and read back
to the individual providing the information (e.g., Check-back)

 Reporting critical results or situation (e.g., SBAR)

January 23, 2024 19

 International Patient Safety Goals (IPSG)
• IPSG 3: Improve the safety of high-alert
medication

 High-alert medications are drugs that bear

a heightened risk of causing significant
patient harm when they are used in error.

January 23, 2024 21

 International Patient Safety Goals (IPSG)
• IPSG 3: Improve the safety of high-alert medication

 Before a procedure, label medicines that are not labeled. For example, medicines in
syringes, cups and basins. Do this in the area where medicines and supplies are set up.
 Take extra care with patients who take medicines to thin their blood.
 Record and pass along correct information about a patient’s medicines.

January 23, 2024 22

 International Patient Safety Goals (IPSG)
• IPSG 3: Improve the safety of high-alert medication

 Find out what medicines the patient is taking.

 Compare those medicines to new medicines given to the patient.
 Give the patient written information about the medicines they need to take.
 Tell the patient it is important to bring their up-to-date list of medicines every time
they visit a doctor.

January 23, 2024 23

 International Patient Safety Goals (IPSG)
IPSG 4:Ensure Safe Surgery

 Make sure that the correct surgery is done on the

correct patient and at the correct place on the
patient’s body.

 Mark the correct place on the patient’s body

where the surgery is to be done.

 Pause before the surgery to make sure that a

mistake is not being made.

January 23, 2024 24

 International Patient Safety Goals (IPSG)
IPSG 5: Reduce the Risk of Health Care-Associated Infections

January 23, 2024 25

 International Patient Safety Goals (IPSG)
IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls

 Assess each individual patients’ risk for falling/ every admission.

Patient risk factors include illnesses that cause weakness, medicines that cause
dizziness, including nonprescription medications, delirium, new or unfamiliar
environments, lack of activity, elderly age, especially those who are 85 and over.

 Patients should follow a mobility plan (e.g., Physiotherapy).

 Caregivers should be in arms reach when patients attend the restroom.

January 23, 2024 26

 International Patient Safety Goals (IPSG)
IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls

 Provide safe footwear rather than just advising it (e.g., non-skid footwear such as
rubber-soled slippers or socks with grips).

 Use bed alarms ( the time Intervals of alarm should be between 1-2 seconds).

 Conduct regular safety rounding to make sure that all precautions to prevent falls
are in place.
 Review and/or discontinue medications associated with a high risk of falls.

 Provide easy access to mobility aids.

January 23, 2024 27

 Principles of Patient Safety

January 23, 2024 29

 Principles of Patient Safety

• Patient safety culture: It is the extent to which an

organization's culture supports and promotes patient safety.

 It refers to the values, beliefs, and norms that are shared by

healthcare practitioners and other staff throughout
the organization that influence their actions and behaviors.

 It aims to provide services which prevent harm and

improve health care outcomes (e.g., decrease medication
errors, and improve diagnostic process).

January 23, 2024 30

 Principles of Patient Safety

• Patient safety culture

 Systems and processes are regularly evaluated and updated

to identify and address potential safety risks.

 Learning from errors and near misses is encouraged to

prevent future occurrences.

 A culture of reporting incidents without fear of blame is

fostered.

 Shared responsibility for patient safety exists at all levels.

January 23, 2024 31

 Principles of Patient Safety
• Effective

 Use of Evidence-based knowledge to limit and prevent underuse, and overuse of services.

 By utilizing the best available evidence, healthcare professionals can:

o Identify and implement interventions that have been proven to reduce the risk of harm to
patients (e.g., using the evidence-based guidelines on the prevention of healthcare-associated
infections (HAIs) can lead to a decrease in the incidence of these infections and promote a safer
environment for both patients and staff).

o Identify practices that are either outdated or potentially harmful ( e.g., episiotomies during
childbirth).

January 23, 2024 32

 Principles of Patient Safety
• Patient Centered

• Patients are active participants in their care decisions.

• Their individual needs, preferences, and values are

respected.

• Open communication and information sharing are

essential. This can allow them to spot inaccuracies in
medication history or prescription errors.

• Promoting family and caregiver engagement can

likewise support patient safety by adding yet another set
of eyes looking for inaccuracies in patient care.

January 23, 2024 33

 Principles of Patient Safety
• Timely

 Reduce wait times and delay in providing

health care services.

 When patients cannot access necessary

treatment, they may become increasingly sick
while waiting for an appointment.

 Healthcare organizations must implement

quality appointment scheduling protocol that
keeps appointment wait times at a minimum.

January 23, 2024 34

 Principles of Patient Safety
• Efficient

 Avoid and reduce waste and inefficiencies (e.g., time, energy,

ideas, supplies, equipment, etc..).

 In healthcare, it’s not just about economic resources but also

about human lives and potential.

 For example, overuse of tests, underutilization of preventive

measures can drain both financial and human resources.

January 23, 2024 35

 Principles of Patient Safety
• Equitable

 Providing care that does not vary in quality because of

personal characteristics such as gender, ethnicity,
geographic location, and socioeconomic status.

 In an ideal world, two individuals with similar health

conditions should receive equivalent care, irrespective
of their backgrounds.

January 23, 2024 36

 Patient Safety Intervention Process
 The patient safety intervention process is a structured approach to identifying, developing,
implementing, and evaluating strategies to prevent harm and improve the quality of care
delivered to patients.

 It's a multifaceted journey with distinct stages, each crucial for maximizing the impact of safety
measures.

January 23, 2024 45

 Patient Safety Intervention Process
1. Problem Identification and Prioritization:

 Identify existing patient safety issues by analyzing data from incident reports and surveys.

 Prioritize the problems: consider factors like frequency, severity, preventability, and potential cost
impact to focus your efforts effectively.

2. Intervention Development:

 Research potential solutions by reviewing existing evidence-based interventions and adapt them to
your specific context. Explore various approaches like technology-based systems, training
programs, or policy changes.

 Develop and pilot test the intervention by designing a clear, practical intervention with measurable
outcomes. Run a small-scale pilot to refine its effectiveness before wider implementation.

January 23, 2024 46

 Patient Safety Intervention Process
3. Implementation and Dissemination:

 Gather stakeholder buy-in by engaging leadership, healthcare professionals, and patients in

the process to ensure everyone is aligned and supportive.

 Develop an implementation plan by defining roles and responsibilities, provide

training, and allocate resources for a smooth rollout.

 Disseminate information to ensure everyone involved understands the intervention and its
goals through clear communication channels.

January 23, 2024 47

 Patient Safety Intervention Process
4. Monitoring and Evaluation:

 Collect data: Track relevant metrics to assess the intervention's impact on patient safety
outcomes. Examples include adverse event rates, medication errors, or patient satisfaction
levels.
 Analyze data and report findings: evaluate the intervention's effectiveness and identify
areas for improvement. Share the findings with stakeholders to promote accountability and
adaptation.

 Adapt and refine based on evaluation results, adjust the intervention or develop new
strategies to address remaining gaps. Continuous improvement is essential for sustainable
success.

January 23, 2024 48

 Patient Safety Intervention Process
Example of Patient Safety Intervention Process: Reducing Catheter-Associated Urinary Tract
Infections (CAUTIs)

1. Problem Identification and Prioritization:

 Data analysis reveals CAUTIs are the second most common healthcare-associated infection in your
hospital, with significant costs and patient discomfort.
 Catheterization is a common procedure, making the issue widespread.

2. Intervention Development:

 Research identifies a successful bundle intervention to reduce CAUTIs:

 Daily reminder system for catheter removal.
 Standardized hand hygiene protocol before and after catheter manipulation.
 Educational modules for healthcare staff on CAUTI prevention.

January 23, 2024 49

 Patient Safety Intervention Process
3. Implementation and Dissemination:

 Secure leadership buy-in and funding.

 Form a multidisciplinary team (doctors, nurses, infection control specialists) to oversee implementation.

 Train staff on the intervention protocol and rationale

 Develop communication materials for patients and families.

January 23, 2024 50

 Patient Safety Intervention Process
4. Monitoring and Evaluation:
 Track CAUTI rates before and after intervention implementation.

 Monitor adherence to the intervention protocol through observation and electronic data.

 Conduct surveys with staff and patients to assess understanding and experience.

 Adaptation and Refinement:

 Analyze data after 3-6 months.

 Identify areas for improvement, like tailoring reminders for specific patient groups or enhancing
staff training.
 Refine the intervention based on findings and continue monitoring.

January 23, 2024 51

 Multidisciplinary teams and patient safety outcomes

 Multidisciplinary teams (MDTs) play a crucial role in patient safety, bringing together the diverse
expertise of various healthcare professionals to create a comprehensive and holistic approach to
care.

1. Enhanced Communication and Collaboration

2. Improved Quality of Care

3. Building a Positive Patient Safety Culture

January 23, 2024 53

 Multidisciplinary teams and patient safety outcomes

1. Enhanced Communication and Collaboration

 Breaking down silos across departments: This ensures smoother care coordination, reduces
medical errors, and eliminates redundancy in assessments and interventions.

 Shared decision-making: By drawing on the combined knowledge and experience of different

perspectives, MDTs can make more informed and well-rounded decisions regarding patient care
plans, leading to better outcomes.

 Early identification and mitigation of risks: Regular team meetings and discussions allow for
early identification of potential safety issues and risks specific to each patient's case. This enables
the team to proactively implement preventive measures and minimize the chances of adverse
events.

January 23, 2024 54

 Multidisciplinary teams and patient safety outcomes

2. Improved Quality of Care:

 Holistic assessment: MDTs can provide a more comprehensive assessment of a patient's

condition by considering factors beyond their immediate medical diagnosis. This includes
psychosocial, environmental, and functional aspects, leading to a more tailored treatment plan.

 Continuous monitoring and evaluation: MDTs can continuously monitor a patient's progress
and adapt the care plan as needed. This proactive approach ensures that any potential
complications are identified and addressed promptly.

 Knowledge sharing and dissemination: Through regular interactions, team members can learn
from each other's expertise and share best practices, leading to continuous improvement in the
overall quality of care provided.

January 23, 2024 55

 Multidisciplinary teams and patient safety outcomes

3. Building a Positive Patient Safety Culture:

 Open communication and reporting: MDTs can foster a culture of open communication and
encourage healthcare professionals to report near misses and incidents without fear of
blame. This transparency allows for learning from mistakes and implementing systemic changes
to prevent future occurrences.

 Patient and family engagement: MDTs can actively involve patients and their families in their
care plan, encouraging informed decision-making and promoting shared responsibility for
safety. This empowers patients and builds trust in the healthcare system.

 Leadership and advocacy: MDT members can act as champions for patient safety within their
respective departments and institutions, advocating for safety initiatives and promoting a safety-
first approach to healthcare delivery.

January 23, 2024 56

 Clinical Practice Effectiveness: Bridging
the Gap Between Research and Reality

Dr Mohammad Abu-Mahfouz
January 23, 2024 1
 Introduction
 Clinical Practice Effectiveness (CPF): refer to deliver the best possible care to patients a
real-world setting based on current scientific evidence, clinical expertise and patient values
and preferences, aiming for optimal health outcomes while minimizing harm and waste.

 Clinical effectiveness aims to ensure that healthcare practice is based on the best available
data and evidence of effectiveness.

 It is a key component for improving patient safety and quality health service delivery.

January 23, 2024 5

 Mechanisms to Measure and Assess Clinical Effectiveness

 Clinical Audit: are part of the continuous quality improvement process that focus on specific
issues or aspects of health care and clinical practice. They consist of measuring a clinical
outcome or a process, against well-defined standards set on the principles of evidence-based
medicine.

 Example: In a cardiac unit a clinical audit revealed an increased rate of post-operative atrial
fibrillation following open-heart surgery. The team implemented a standardized pre-operative
medication protocol based on evidence-based practices. Subsequent audit showed a significant
reduction in atrial fibrillation rates, improving patient outcomes cardiac unit.

January 23, 2024 12

 Mechanisms to Measure and Assess Clinical Effectiveness

 Clinical Outcome Measurement: measuring changes in health, function or quality of life that
result from our care.

 Example: A hospital diabetes clinic in Australia implemented a system for routinely measuring
hemoglobin A1c (HbA1c) levels, a key indicator of diabetes control. Data showed that patients
with consistently low HbA1c levels had fewer hospital admissions and complications,
highlighting the importance of continuous monitoring.

January 23, 2024 13

 Mechanisms to Measure and Assess Clinical Effectiveness
 Quality Improvement: is the framework used to systematically improve care. Quality
improvement seeks to standardize processes and structure to reduce variation, achieve
predictable results, and improve outcomes for patients, healthcare systems, and organizations.

 Example: A US nursing home identified high falls rates among residents with dementia. They
implemented a multi-pronged quality improvement initiative, including medication review,
environmental modifications, and staff training in dementia care. Falls rates significantly
decreased, demonstrating the effectiveness of systematic interventions.

January 23, 2024 14

 Mechanisms to Measure and Assess Clinical Effectiveness
 Service Evaluation: A service evaluation is a way to define or measure current practice within a
service. The results of the service evaluation help towards producing recommendations for
improvements.

 Example: A national telehealth program in Canada conducted a comprehensive evaluation to

assess its impact on access to healthcare in rural communities. The evaluation found that
telehealth significantly improved access to specialist consultations, leading to earlier diagnoses
and treatment initiation.

January 23, 2024 15

 Mechanisms to Measure and Assess Clinical Effectiveness
 Benchmarking Data: means comparing the performance of an organization or clinician to
others. The goal of benchmarking in registries is to improve quality, efficiency, and patient
experience.

 Example: An international consortium of hospitals established a collaborative platform for

sharing and comparing data on surgical site infection rates. Benchmarking against high-
performing hospitals identified best practices and led to targeted interventions, reducing infection
rates across the entire network.

January 23, 2024 16

 Challenges to Implementing Clinical Practice Effectiveness

 Knowledge gaps: Staying up-to-date with

the latest evidence can be challenging.

 Attitudes and biases: Resistance to change,

ingrained practices, and unconscious biases
can hinder adoption of new evidence.

 Systemic barriers: Lack of resources,

inadequate infrastructure, and fragmented
healthcare systems can impede
implementation.

January 23, 2024 17

 Strategies for Overcoming Challenges
 Dissemination of evidence-based guidelines: Making research findings accessible and
understandable to healthcare providers.

 Educational interventions: Training and workshops to improve EBP skills and knowledge.

 Performance feedback and incentives: Providing data and feedback to encourage adoption of best
practices.

 Patient education and empowerment: Helping patients understand their options and participate in
decision-making.

January 23, 2024 18

Principles of Health
Care Ethics

21
 Confidentiality

 Patient confidentiality refers to the preservation

of the private nature of health care data specific
to an individual patient (Keep promises about
information)

 E.g. Elevator is not the right place to discuses

patient Information

January 23, 2024 22

 Autonomy
 Medical Autonomy refers to a patient's right to accept or refuse healthcare services
like treatments and procedures.

 One has the right, power, or condition of self governance

 You may show your respect to autonomy by educating patients on their options
without bias and supporting their decisions.

January 23, 2024 23

 Beneficence
 Beneficence is defined as an act of charity, mercy, and kindness with a strong
connotation of doing good to others.

 Moral obligation to do no harm, remove harm, and prevent harm

 All Choices for a patient are made with the intent to do good.

 Examples of beneficence include helping a heart patient shower, keeping side

rails up to prevent falls or providing medication in a timely manner

January 23, 2024 24

 Veracity
 Veracity means to tell the truth—to never lie to patients or give them knowingly
false reassurance, which is also lying.

 For example, if a patient was starting chemotherapy and asked about the side
effects, a nurse practicing veracity would be honest about the side effects they
could expect with chemotherapy.

January 23, 2024 25

 Fidelity
 Practicing fidelity as a nurse means that the nurse keeps both explicit promises
made to their patients.

 Example: “I’ll be back in 10 minutes with your pain medication”

January 23, 2024 26

 Nonmaleficence
 This means that nurses must do no harm intentionally.

 For example, a nurse demonstrating nonmaleficence would perform multiple

checks before administering medication to avoid a dangerous medication error.

January 23, 2024 27

 Justice
 Give that person what is deserved

 In nursing, the ethical principle of justice means to treat fairly.

 For example, if you were juggling multiple patients, you would not provide
better care based on who has the best insurance.

January 23, 2024 28

 Duty
• Nurses have a moral or legal obligation to behave in a responsible matter and
within their scope of practice.

• A few examples of nursing duties include administering correct medications,

monitoring patients for changes, and alerting physicians when there is a change
in the patient's status.

January 23, 2024 29

 Types of Errors
 Skill based errors can be slips or lapses when the actions taken by the provider were not what was
intended.

o Lapse is “I forgot what I was doing or what I was going to do.” ( e.g., Forgetting to administer a medication)

o Slips are errors where the intention is correct, but there is a failure of execution. ( e.g., Accidentally pushing
the wrong button on a piece of equipment)

January 23, 2024 42

 Types of Errors

 Rule-based error: Actions that match intentions but do not achieve their intended outcome due to
incorrect application of a rule or inadequacy of the plan.

 Example: An experienced nurse administering the wrong medication by picking up the wrong syringe

 Example: if a certain drug should be injected through the thigh, but the nurse uses a different route.

January 23, 2024 43

 Types of Errors
 Near miss is an error that results in no harm or very minimal patient harm (IOM, 2000, p. 87).

 Near misses are useful in identifying and remedying vulnerabilities in a system before harm can occur.

 Example: a high-risk patient needs to ambulate to maintain his strength while on bed rest. However, the
non-skid socks the patient is supposed to wear are left behind in his room as he takes a walk around the
unit. A staff member notices the socks and notifies a supervisor to prevent patient injury.

January 23, 2024 44

 Types of Errors

• Adverse event is injury to a patient caused by medical

management rather than an underlying condition of the
patient (IOM, 2000). Adverse events have been
classified into four types as illustrated in box (10-7).

January 23, 2024 45

 Types of Errors

 Accident. An accident is an event that involves damage to a defined system that disrupts the
ongoing or future output of that system.

 Example: A nurse is preparing to administer medication to a patient through an IV drip. However,

due to a faulty connection between the tubing and the IV bag, the medication begins leaking onto
the floor instead of flowing into the patient's vein.

January 23, 2024 46

 Error Identification and Reporting

 Nurses are on the front line in identifying and reporting errors. However, many errors are not reported
or go undetected.

 Providers and organizations may fear blame or punishment for mistakes or errors.

 To achieve safe patient care, a culture of safety must exist.

 Organizations and senior leadership must drive change to develop a culture of safety—a blame-free
environment in which reporting of errors is promoted and rewarded.

 Reported errors provide data and information necessary to understand why or how the error occurred,
thus improving care and preventing harm.

January 23, 2024 47

 Error Identification and Reporting

 Root cause analysis (RCA) is a crucial tool to investigate errors, understand their causes, and prevent
recurrence.

• Root cause analysis is the process of learning from consequences. The consequences can be desirable,
but most root cause analysis deals with adverse consequences.

• Root cause analysis is a systematic process to identify the underlying causes of an error or adverse
event. Goes beyond superficial causes to uncover systemic issues. Focuses on "why" an event occurred,
not just "what" happened

 An example of a root cause analysis is a review of a medication error, especially one resulting in a
death or severe complications.

January 23, 2024 48

 Principles of RCA
1. Determine what influenced (Identify
contributing factors) the consequences.

2. Establish tightly linked chains of influence.

3. At every level of analysis, determine the

necessary and sufficient influences.

4. Whenever feasible, drill down to root

causes.

5. Know that there are always multiple root

causes.

January 23, 2024 49

 Root Cause Analysis Process

January 23, 2024 52

 Root Cause Analysis Process
 Define the problem: Clearly articulate the specific event or error being investigated.

 Gather data: Collect information from multiple sources (incident reports, interviews, medical
records, etc.).

 Identify contributing factors: Brainstorm and map potential causes, using tools like fishbone
diagrams or cause-and-effect charts.

 Drill down to root causes: Use techniques like the "5 Whys" to uncover the deepest underlying
factors.

 Develop corrective actions: Propose specific interventions to address root causes and prevent
recurrence.

 Implement and monitor: Put corrective actions into practice and track their effectiveness.

January 23, 2024 53

 Risk Management in Healthcare

Dr Mohammad Abu-Mahfouz
January 31, 2024 1
 Introduction
 Risk management in healthcare is a complex set of clinical and administrative systems,
processes, procedures, and reporting structures designed to detect, monitor, assess,
mitigate, and prevent risks to patients.

 Healthcare Risk Management refers to the policies and practices intended to establish a
safe healthcare facility that prioritizes patient safety by operating in compliance with
financial, medical, and legal regulations.

January 31, 2024 5

 The Importance of Risk Management in Healthcare
 Reduced Costs

o It reduces the costs of medical errors and the subsequent claims (identifying potential risks
can reduce your liabilities, resulting in paying fewer fines and penalties)

 Improved Compliance

o It gives you a 360 look at the potential risks your organization faces, including compliance
with industry regulations (When you make plans to identify, analyze, and manage critical
risks, you should prioritize compliance both with regulations and laws)

January 31, 2024 8

 The Importance of Risk Management in Healthcare
 Enhanced Reputation

o It increases trust in your healthcare organization, which can increase the number of patients
you see

 Increased Efficiency

o It helps to streamline processes and shore up alternative resources for productivity to stay
high even when facing potential risks.

January 31, 2024 9

 Risk Management Process
1. Establishing Context

 Identify the scope of risk management: Define the areas and activities within your organization
that will be covered by the process (e.g., clinical practices, administrative procedures, and facility
maintenance).

 Set risk management goals: Determine what you want to achieve through risk management. Do
you want to reduce adverse events by a certain percentage? Improve patient satisfaction scores?
Enhance staff safety? Clearly defined goals will guide your risk management efforts.

 Develop a risk management framework: Choose a structured approach/tools to identify, assess,

and manage risks (e.g., Vitaleyez Software: Risk Matrix, Failure Modes and Effects Analysis
(FMEA), and Bowtie Model)

January 31, 2024 11

 Risk Management Process
2. Identify Risk

 Use a variety of methods: Brainstorming sessions, incident reports, patient feedback, and safety
reviews can all uncover potential risks.

 Consider different types of risks: Operational risks (e.g., medication errors), financial risks
(e.g., fraud), technological risks (e.g., data breaches), and environmental risks (e.g., infections)
should all be taken into account.

 Document identified risks: Create a comprehensive list of potential risks, including their
location, potential severity, and likelihood of occurrence.

January 31, 2024 12

 Risk Management Process
2. Identify Risk

Based on the information provided from other resources, healthcare managers should conduct
organization-specific risk analyses to determine potential risks. The study should identify:

 What could happen?

 How likely is something to happen (measuring risk)?
 How severe would the outcome be if something did happen?
 How can the likelihood of something being mitigated on the forefront, and to what degree?
 What can be done to reduce the impact (and to what degree)?
 What is the potential for exposure, or what cannot be proactively avoided?

January 31, 2024 13

 Risk Management Process
3. Assessing Risks

Analyze the likelihood and impact of each risk: Use risk matrices or scoring systems to prioritize
risks based on their potential consequences and how likely they are to occur.

January 31, 2024 14

 Risk Management Process
4. Developing and Implementing Controls

 Develop control measures: This might involve creating new policies and procedures, training
staff, acquiring new equipment, or improving communication channels.

 Assign responsibility: Clearly assign ownership of each control measure to specific individuals
or departments.

 Allocate resources: Ensure you have the necessary resources (financial, technological, human) to
implement and maintain your risk control measures.

January 31, 2024 15

 Risk Management Process
5. Monitoring and Evaluation

 Track the effectiveness of your controls: Regularly monitor how well your risk control
measures are working in reducing or preventing identified risks.

 Review and update your risk management plan: Conduct periodic reviews of your risk
management plan to identify any new risks or changes in existing ones. Be prepared to adjust
your controls and strategies as needed.

January 31, 2024 16

 Error Disclosure
 Error disclosure: is a communication between a health care provider and a patient, family
members, or the patient’s proxy that acknowledges the occurrence of an error, discusses what
happened, and describes the link between the error and outcomes in a manner that is meaningful
to the patient.

 Error disclosure is an essential process to ensure that patients receive the information needed
to make informed decisions about their care.

January 31, 2024 17

 Approaches of Error disclosure
Approach of Description Benefits Drawbacks
disclosure

Direct Involves openly and Fosters trust and Can be emotionally difficult
honestly informing the transparency, allows for patients and families, and
patient or family about the patients to make informed there may be legal implications
error as soon as possible decisions about their care if not handled correctly.
after it occurs.
Gradual Involves disclosing Easier for patients and Can create distrust if not
information about the error families to handle handled delicately,
in stages, over a period of emotionally,
time.
Conditional Involves only disclosing Can protect the Can seriously damage trust
the error if certain organization from legal between the patient and the
conditions are met, such as liability healthcare provider, and can
if the patient asks about it lead to negative publicity for
or if there is a potential for the organization.
legal action.
Proactive Involves disclosing errors Can demonstrate Can damage the organization's
publicly, even if no one transparency and reputation, and may discourage
has asked about them. accountability, and can patients from seeking care.
help to prevent similar
errors from happening in
the future.
January 31, 2024 18
 Quality in Health Care System (Part 1)

Dr Mohammad Abu-Mahfouz
February 5, 2024 1
 Quality Terminology
 Accreditation: a formal process by which a recognized body, usually a non-governmental
institution, assesses and recognizes that a healthcare organization meets applicable, pre-
determined standards.

 Benchmarking: a process of searching out and studying the best practices that produce
superior performance.

 Best Practices: the most up-to-date patient care interventions, scientifically proven to
result in the best patient outcomes and minimize patients’ risk of death or complications.

February 5, 2024 5
 Quality Terminology
 Certification: a process by which an authorized body, either a governmental or non-
governmental organization, evaluates and recognizes either an individual or an organization
as meeting pre-determined requirements or criteria.

 Clinical Measures: measures representing processes of care and patient outcomes widely
accepted as important to quality care, consistently and accurately tracked in order to
determine quality performance in a given clinical area, such as heart attack, pneumonia, or
hip and knee replacement.

February 5, 2024 6
 Quality Terminology
 Quality Improvement: an approach to the study and improvement of the processes of providing
healthcare services to meet needs of clients.

 Quality Indicator: an agreed-upon process or outcome measure that is used to determine the
level of quality achieved. A measurable variable (or characteristic) that can be used to determine
the degree of adherence to a standard or achievement of quality goals.

 Quality Management: An ongoing effort to provide services that meet or exceed customer
expectations through a structured, systematic process for creating organizational participation in
planning and implementing quality improvements.

February 5, 2024 12
 Quality Terminology
 Quality Measure: A quality measure, also referred to as a quality indicator, is a formula that
converts medical information from patient records into a rate, or percentage, that shows how well
a hospital cares for its patients. Quality measures can help consumers rate the performance of
hospitals, health professionals, and physicians.

 Quality Monitoring : the collection and analysis of data for selected indicators that enable
managers to determine whether key standards are being achieved as planned and are having the
expected effect on the target population.

 Quality of Care: the degree to which healthcare services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional knowledge.

February 5, 2024 13
 Quality Terminology
 Six Sigma: A methodology that provides organizations with the tools to improve the capability of
their business processes. This increase in performance and decrease in process variation lead to
defect reduction and improvement in profits, employee morale and quality of product.

 Standard of Care: a generally accepted, objective standard of measurement such as a performance

standard supported through findings from expert consensus, based on specific research and/or
documentation in scientific literature, against which an individual's or organization's level of
performance may be compared.

February 5, 2024 15
 Quality Terminology
 Timeliness: The ability to provide the appropriate care when it is needed.

 Total Quality Management (TQM): an approach to quality assurance that emphasizes a thorough
understanding by all members of a production unit of the needs and desires of the ultimate service
recipients, a viewpoint of wishing to provide service to internal, intermediate service recipients in
the chain of service, and a knowledge of how to use specific data-related techniques to assess.

February 5, 2024 16
 Accreditation Principles & Practice in Health Care Arena
 Accreditation: is an internationally recognized evaluation process used to assess the healthcare
facility and grant it a certificate verifying the efficiency of its operations, with the stipulation that
it will be re-evaluated and updated within regular timeframes to ensure continuous quality
improvement and enhancement.

 Accreditation helps any hospital or health facility to enhance patient care in a continuous process
to improve quality programs in a way that meets, and possibly exceeds, patient expectations.

February 5, 2024 18
 Types of Accreditation
There are many different types of accreditation for healthcare organizations, including:

1. Institutional Accreditation: evaluates entire healthcare organizations like hospitals, clinics, and
long-term care facilities. Examples include:

 The Joint Commission (TJC): the most prominent institution, accrediting various healthcare
organizations in the world.

 Accreditation Commission for Health Care (ACHC): focuses on ambulatory care centers, home
health agencies, and hospices.

 Det Norske Veritas Healthcare (DNV): global accreditation body with programs for
hospitals, clinics, and other healthcare providers.

February 5, 2024 20
 Types of Accreditation
2. Programmatic Accreditation: focuses on specific programs or services within an
organization, like cardiac care, stroke care, or laboratory testing. Examples include:

 American College of Cardiology (ACC): accredits cardiology centers, electrophysiology

labs, and other cardiac programs.

 College of American Pathologists (CAP): accredits laboratories to ensure quality and accuracy
of diagnostic testing.

 Commission on Accreditation of Rehabilitation Facilities (CARF): accredits rehabilitation

facilities like physical therapy clinics and addiction treatment centers.

February 5, 2024 21
 Types of Health Care Quality Measures
 Measures used to assess and compare the quality of health care organizations are classified as either a
structure, process, or outcome measure. Known as the Donabedian model, this classification system
was named after the physician and researcher who formulated it.

1. Structural Measures: give consumers a sense of a health care provider’s capacity, systems, and
processes to provide high-quality care. For example:

 Whether the health care organization uses electronic medical records or medication order entry
systems.
 The number or proportion of board-certified physicians.
 The ratio of providers to patients.

February 5, 2024 26
 Types of Health Care Quality Measures
2. Process Measures: indicate what a provider does to maintain or improve health, either for healthy
people or for those diagnosed with a health care condition. These measures typically reflect generally
accepted recommendations for clinical practice. For example:

 The percentage of people receiving preventive services (such as mammograms or

immunizations).
 The percentage of people with diabetes who had their blood sugar tested and controlled.

 Process measures can inform consumers about medical care they may expect to receive for a given
condition or disease, and can contribute toward improving health outcomes. The majority of health care
quality measures used for public reporting are process measures.

February 5, 2024 27
 Types of Health Care Quality Measures
3. Outcome Measures: reflect the impact of the health care service or intervention on the health status
of patients. For example:

 The percentage of patients who died as a result of surgery (surgical mortality rates).
 The rate of surgical complications or hospital-acquired infections.

 Outcome measures may seem to represent the “gold standard” in measuring quality, but an outcome is
the result of numerous factors, many beyond providers’ control.

February 5, 2024 28
 Measure Development and Evaluation

5. Analysis & 6. Revision &

4. Data Collection Evaluation Dissemination
2. Development 3. Pilot Testing
1. Conceptualization

Define research Draft initial items Administer to larger Collect data using Analyze data using Refine instrument
question/objectives. based on research. pilot sample. finalized instrument appropriate based on analysis &
Review existing Pre-test with small Evaluate item from target statistical methods. feedback, if needed.
instruments & sample for clarity & performance population. Evaluate Document
identify gaps. feasibility. statistically & Maintain quality instrument's development process
Specify constructs & Refine items based qualitatively. control procedures. psychometric & instrument
theoretical on feedback & expert Refine instrument Monitor data for properties (validity, characteristics.
foundation. review. based on pilot completeness, reliability). Disseminate
Decision Point: Decision Point: Are testing results. consistency, & errors. Interpret results & instrument &
Develop new or items valid & reliable Decision Point: Is draw conclusions findings through
adapt existing? enough? instrument ready for about constructs publications &
full data collection? measured. presentations.
Decision Point: Does
instrument address
research question?

February 5, 2024 29
 Measure Development and Evaluation
Measure Evaluation:

 Validity: Assess if the measure truly reflects the intended aspect of quality.

 Reliability: Evaluate consistency in measurements across different users and settings.

 Feasibility: Measure ease of data collection, analysis, and interpretation.

 Actionability: Analyze if the measure guides improvement actions and informs decision-making.

February 5, 2024 31
 Key Performance Indicators
 A healthcare KPI or metric: is a well-defined performance measurement that is used to monitor,
analyze and optimize all relevant healthcare processes to increase patient satisfaction. Many of these
metrics are actually specific key performance indicators for hospitals.

 Here is the complete list of the 19 most important healthcare KPIs and metrics that healthcare
managers and professionals need to know:
 Average Hospital Stay: Evaluate the amount of time patients are staying

 Bed Occupancy Rate: Monitor the availability of hospital beds

 Medical Equipment Utilization: Track the utilization of your equipment

 Patient Drug Cost Per Stay: Improve cost management of medications

 Treatment Costs: Calculate how much a patient costs to your facility

February 5, 2024 32
 Key Performance Indicators

 Patient Drug Cost Per Stay: Improve cost management of medications

 Treatment Costs: Calculate how much a patient costs to your facility

 Operating Cash Flow: Monitor the financial health of your facility

 Net Profit Margin: Ensure your facility remains profitable

 Patient Room Turnover Rate: Balance the turnover with speed and quality

 Patient Follow-up Rate: Measure the care for your patients over time

 Hospital Readmission Rates: Track how many patients are coming back

 Patient Wait Time: Monitor waiting times to increase patient satisfaction

 Patient Satisfaction: Analyze patient satisfaction in detail

February 5, 2024 33
 Key Performance Indicators
 Claims Denial Rate: Ensure medical costs are covered

 Treatment Error Rate: Make sure you provide the right treatment

 Patient Mortality Rate: Prevent patient mortality under your care

 Staff-to-Patient Ratio: Ensure you have enough staff to care for patients

 Canceled/missed appointments: Keep track of patients’ appointments

 Patient Safety: Prevent incidents happening in your facility

 ER Wait Time: Identify rush hours in your emergency room

 Costs by Payer: Understand the type of health insurance of your patients

February 5, 2024 34
 Quality Policy, Procedures, and Forms in Healthcare

 In healthcare settings, having a robust

quality management system (QMS) is
crucial for ensuring patient safety,
delivering effective care, and
continuously improving processes. Key
components of this system include:

 Quality Policy
 Quality Procedures
 Quality Forms

February 5, 2024 43
 Quality Policy, Procedures, and Forms in Healthcare
1. Quality Policy:

 A concise statement outlining the organization's commitment to quality patient care and continuous
improvement.

 Clearly defines core values, principles, and goals related to quality.

 Serves as a guiding document for all staff and informs decision-making.

 Example: "Our organization is committed to providing high-quality, patient-centered care that is safe,
effective, and efficient. We strive to continuously improve our processes and services through data-driven
analysis, evidence-based practices, and collaboration with patients and staff."

February 5, 2024 44
 Quality Policy, Procedures, and Forms in Healthcare
2. Quality Procedures:

 Detailed documents outlining specific steps and guidelines for key processes to maintain consistent quality.

 Address various aspects like infection control, medication management, patient safety reporting, etc.

 Ensure standardized practices and minimize risk of errors.

 Example: "Procedure for Medication Administration": This procedure outlines the steps for safe and accurate
medication administration, including medication verification, dosage calculation, patient identification, and
documentation.

February 5, 2024 45
 Quality Policy, Procedures, and Forms in Healthcare
3. Quality Forms:

 Standardized documents used to collect and document data related to quality activities.

 Include forms for incident reporting, performance monitoring, patient feedback, audits, etc.

 Facilitate data collection, analysis, and identification of areas for improvement.

 Example: "Incident Report Form": This form allows staff to report any potential or actual safety incidents,
near misses, or adverse events, enabling investigation and preventive actions.

February 5, 2024 46
 Quality in Health Care System (Part 2)

Dr Mohammad Abu-Mahfouz
February 12, 2024 1
 Cause-and-Effect Diagrams
 A Cause and Effect Diagram (also called a Fish bone Diagram or Ishikawa Diagram) is used to provide a
pictorial display of a list in which you identify and organize possible causes of problems, categorized by
factors such as people, equipment, materials, and methods.

 It is an effective tool that allows people to easily see the relationship between factors to study, processes,
situations, and for planning.

 The issues in a Cause and Effect Diagram are often derived from a brainstorming session followed by the
development of an Affinity Diagram.

February 12, 2024 16

 Lean Six Sigma

 Six Sigma is a data-driven methodology originally

developed in the manufacturing industry to minimize
defects and improve process efficiency.

 In recent years, it has been increasingly adopted in

healthcare settings to achieve similar goals of enhancing
quality, reducing errors, and optimizing performance.

February 12, 2024 18

 Lean Six Sigma

 Six Sigma in healthcare typically involves the DMAIC cycle:

 Define: identify the problem or area for improvement.

 Measure: collect data to understand the current state.

 Analyze: utilize statistical tools to identify root causes and

variations.

 Improve: design and implement solutions to minimize defects and

improve efficiency.

 Control: monitor and sustain the improvements achieved.

February 12, 2024 19

 Example of Implementing Lean Six Sigma using the DMAIC method

Problem: A hospital
emergency room (ER)
experiences long wait times
for patients, leading to
frustration, dissatisfaction,
and potential harm for
those with urgent needs.

February 12, 2024 20

 The Benefits of Lean Six Sigma

Six Sigma can be beneficial to the healthcare in terms of :

 Reducing medical errors (identifying and minimizing variations in processes).

 Optimizing treatment protocols and personalize care plans for better patient outcomes
(Enhancing treatment effectiveness)

 Streamlining processes can lead to quicker diagnoses, faster treatment delivery, and ultimately,
shorter hospital stays.

 Eliminating unnecessary steps or inefficiencies in workflows, leading to cost savings

(Minimizing waste).

 Data-driven decision-making allows for better allocation of resources, like staffing and
equipment, to meet patient needs effectively (Optimizing resource allocation)

February 12, 2024 21

 Failure Modes and Effects Analysis (FMEA)

 Failure Modes and Effects Analysis (FMEA) is a tool for

conducting a systematic, proactive analysis of a process in which
harm may occur.

 In an FMEA, a team representing all areas of the process under

review convenes to predict and record where, how, and to what
extent the system might fail.

 Then, team members with appropriate expertise work together to

devise improvements to prevent those failures — especially
failures that are likely to occur or would cause severe harm to
patients or staff.

February 12, 2024 22

 Failure Modes and Effects Analysis

 The FMEA tool prompts teams to review, evaluate, and record the following:

 Failure modes (What could go wrong?)

 Failure causes (Why would the failure happen?)

 Failure effects (What would be the consequences of each failure?)

 Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes
proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention
may reduce risk of harm to both patients and staff.

February 12, 2024 23

 Failure Modes and Effects Analysis

 FMEA is a structured, systematic approach to analyzing potential failures in a process, system, or

product. It involves:

 Defining the process or system.

 Identifying potential failure modes for each step.

 Analyzing the severity, likelihood, and potential consequences of each failure.

 Developing and implementing controls to mitigate risks.

 Monitoring and updating the analysis as needed.

February 12, 2024 25

 Failure Modes and Effects Analysis
FMEA can be applied across various areas in healthcare, including:

 Medication management ( e.g., analyzing potential failures in prescribing, dispensing, and administering
medications to identify and mitigate risks of errors)

 Surgical procedures ( e.g., identifying potential complications, equipment failures, or human errors during
surgery to ensure patient safety)

 Medical device usage (e.g., analyzing potential malfunction or misuse of medical devices to prevent adverse
events)

 Infection control (e.g., identifying potential breaches in sterile techniques or protocols to prevent the spread
of infections.

February 12, 2024 26

 Example of Using FMEA in Healthcare

Scenario: A hospital aims to improve the safety of medication administration by identifying and mitigating
potential failures.

Applying FMEA Process:

1. Define the process: medication administration from order entry to final dispensing and administration to the
patient.

2. Identify potential failure modes:

 Order entry: incorrect dosage, illegible handwriting, allergies not considered.

 Transcribing: transcription errors, misinterpretation of abbreviations.

 Dispensing: wrong medication picked, incorrect labeling, outdated medication used.

 Administration: administering to the wrong patient, administering at the wrong time, incorrect route or dosage.

February 12, 2024 27

 Example of Using FMEA in Healthcare

3. Analyze severity and likelihood:

 Assign scores (e.g., 1-5) to the severity of each potential failure's consequences (e.g., minor discomfort,
death).

 Assign scores (e.g., 1-5) to the likelihood of each failure occurring, considering factors like staff training,
procedures, and technology.

 Calculate a Risk Priority Number (RPN) by multiplying severity and likelihood scores.

February 12, 2024 28

 Example of Using FMEA in Healthcare

February 12, 2024 29

 Example of Using FMEA in Healthcare
4. Address high-risk failures:

 Prioritizing failures based on their RPN scores.

 Developing and implementing control measures to reduce the likelihood or severity of high-risk
failures. Examples:

 Using electronic prescribing systems to reduce order entry errors.

 Implementing barcode scanning for medication dispensing.
 Double-checking medications throughout the process.

5. Monitor and adapt:

 Regularly monitor the effectiveness of control measures and update the FMEA as needed.
 Learn from incidents and near misses to continuously improve medication safety.

February 12, 2024 30

 Statistical Process Control (SPC)

 Uses charts and graphs to

monitor the stability and
performance of a process over
time.

 Helps to identify trends and

variations that may indicate
potential problems.

Figure 1 Time chart example highlighting delays to thrombolysis in minutes

February 12, 2024 31