Patient Safety Policy and Procedure Team Update Team Members - PowerPoint PPT Presentation

Dec 09, 2022 •364 likes •463 views

Just Culture: Accountability for Patient Safety Policy and Procedure Team Update Team Members Lisa Bonacci (co-chair), Vice President, HR Services and Operations Joanne Sorensen (co-chair), Director, Care and Quality Management

Just Culture: Accountability for Patient Safety Policy and Procedure Team Update
Team Members • Lisa Bonacci (co-chair), Vice President, HR Services and Operations • Joanne Sorensen (co-chair), Director, Care and Quality Management • Chris Cepullio, Patient Safety Coordinator • Linda Conroy, Director, Accreditation & Regulatory Compliance • Glenda Davis, Director, PCS Administration • Mark Frick, Vice President, Human Resources • Tony Gigliotti, Program Director, Talent Management • Lisa Painter, Director, Risk Management • Chaton Turner, Assistant Counsel 2
Team Objectives • Create an algorithm that provides: – a structured process to guide managers through the evaluation of an event or near miss; – an outline for conducting an investigation of an event by posing critical questions; – a decision tree for identifying system failures and human errors; and – a tool for assessing accountability (remedial, punitive, etc.) for those involved in an event. • Ensure that key UPMC policies support the Just Culture philosophy. 3
Our Duties • Duty to produce an outcome – Applies when an individual knows the desired outcome and should be able to produce it (e.g. the safe removal of an appendix or urinary catheter) • Duty to follow a procedural rule – Applies when an individual knows the proper procedure and it is possible to follow the rule • Duty to avoid causing unjustifiable risk or harm – Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly Reference: California Hospital Patient Safety Authority, (2010) Accessed January 20, 2011 @ http://www.chso.org/just/index.asp 4
UPMC Just Culture Algorithm: Key Questions • Four key questions guide investigation of an event: – Were the actions as intended? – Does there appear to be evidence of ill health or substance abuse? – Did the individual depart from agreed protocols and/or safe procedures? – Would another individual coming from the same professional group (within or outside UPMC), possessing comparable qualifications and experience, behave in the same way in similar circumstances? 5
UPMC Just Culture Algorithm: Outcomes Type of Behavior Behavioral Definition Possible Outcomes Malicious behavior Harm was intentional. Corrective action (including discharge), legal proceedings Unfit for duty Performance is impaired by illegal or Fitness for Duty Policy legal substances; cognitive or physical impairments; other health issues; and/or severe psychological stressors. Reckless action Rules are knowingly violated, and/or a Corrective action, retraining, dangerous/unsafe decision was made. teaching others Risky action Potentially unsafe choice was made. Coaching, teaching others, corrective action (for repeated issues) Individual human Human error was made, and/or system Consoling, fixing system error or system infrastructure increased chances of error. issues, communicating to failure staff, retraining, coaching 6
DRAFT 7
Under Review • Corrective Action and Discharge Policy • Performance Management Policy • UPMC Code of Conduct • UPMC Patient Safety Plans 8
Questions and Feedback 9

Recommend

The UCLPartners Patient Safety Programme: Update Peter Toohey, Patient Safety Improvement Manager,

The UCLPartners Patient Safety Programme: Update Peter Toohey, Patient Safety Improvement Manager, UCLPartners #QIinAKI #QIinSepsis @UCLPartnersPSP @pete_toohey Patient Safety Priority Matrix Together, Sepsis & AKI account for two thirds

146 views • 10 slides

Behavior Patient Safety Connection Behavior Patient Safety Connection Does Any Doubt Remain?

Behavior Patient Safety Connection Behavior Patient Safety Connection Does Any Doubt Remain? Charlotte Jefferies Horty, Springer & Mattern Those Who Provide Care Impact and implications of disruptive behavior in the perioperative

403 views • 9 slides

prevention? Dr Frances Healey , RN, PhD, Deputy Director of Patient Safety (Insight) September

Patient safety struggles and successes are there lessons we can apply to falls prevention? Dr Frances Healey , RN, PhD, Deputy Director of Patient Safety (Insight) September 2017 Aiming to cover Some patient safety culture Some ideas

555 views • 54 slides

The Role for Boards in Quality/Patient Safety 1 Carol Wagner Vice President Patient Safety

The Role for Boards in Quality/Patient Safety 1 Carol Wagner Vice President Patient Safety Washington State Hospital Association Judi Brenes Board Member Southwest Washington Medical Center and Health System January 26, 2010 Presenters 2

668 views • 27 slides

Patient engagement in medication safety at the point of care September 15, 2016 Thank you to:

Patient engagement in medication safety at the point of care September 15, 2016 Thank you to: World Health Organization Patients for Patient Safety Advisory Committee Patients for Patient Safety Canada Knowledge Transfer Working

871 views • 39 slides

Phlebotomy Safety for All Ages Safety Measures for Phlebotomy Patient Identification

Phlebotomy Safety for All Ages Safety Measures for Phlebotomy Patient Identification Preparing Equipment and Supplies Preparing Patient Post Phlebotomy Care Safety tips for specific age groups Safety for the Phlebotomist

707 views • 42 slides

Medical Education and Patient Safety: A Patient-Doctor Dialogue Maeve OBeirne Vincent Dumez

Medical Education and Patient Safety: A Patient-Doctor Dialogue Maeve OBeirne Vincent Dumez Outline 1. Review the definition and scope of patient safety: Including challenges in community based practice and aging patients 2. Discuss

652 views • 50 slides

Patient Safety & Healthcare Transparency Health Watch USA sm 2015 Patient Safety Conference

Patient Safety & Healthcare Transparency Health Watch USA sm 2015 Patient Safety Conference Disclaimer All information presented at this conference is the express opinion of the presenters, moderators and/or participants regarding

630 views • 5 slides

Health IT and Patient Safety Sponsored by Health IT and Patient Safety Visit www.advisenltd.com

Health IT and Patient Safety Sponsored by Health IT and Patient Safety Visit www.advisenltd.com at the end of this webinar to download: Copy of these slides Recording of todays webinar 2 Many Thanks to our Sponsors! Riskonnect

700 views • 30 slides

Scale Up 4 Safety Wessex Patient Safety Collaborative Connecting and sharing across Wessex to

Scale Up 4 Safety Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety Wessex PSC is looking to partner with up to 5 teams in 17/18 to support patient safety scale up projects across Wessex Partners

544 views • 10 slides

GS1 STANDARD for PATIENT SAFETY Cholatip Pongskul, MD 2 3 Patient safety Magnitude Incidence

1 GS1 STANDARD for PATIENT SAFETY Cholatip Pongskul, MD 2 3 Patient safety Magnitude Incidence Medication 1 in 10 43 Million $ 42 Billion As many as 1 in 10 Approximately 43 million Medication error cost an patients are harmed

446 views • 20 slides

Patient Safety 101 for Physicians Resident Core Curriculum Retreat March 5 & 7, 2012

Patient Safety 101 for Physicians Resident Core Curriculum Retreat March 5 & 7, 2012 Partners Patient Safety Leaders Outline Brief Introduction and Objectives Background and details of safety reporting Video Break into groups

434 views • 21 slides

Patient safety and healthcare associated infections Report from the Commission to the Council

Patient safety and healthcare associated infections Report from the Commission to the Council Council Recommendation 2009/C 151/01 Actions for Member States: Develop national policies on patient safety Inform and empower patients

191 views • 16 slides

How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are

How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are affecting patient safety 9 th December 2015 April 2015 Dr David Gerrett Senior Pharmacist Patient Safety NHS E Agenda 1. Scene setting 2. MSO and

1.02k views • 43 slides

Building a Culture of Patient Safety in Todays Healthcare Environment A Discussion of the

Building a Culture of Patient Safety in Todays Healthcare Environment A Discussion of the Tools and Healthcare Policies Driving Improvements in Patient Safety PANELISTS Paul Hiltz, MHA, FACHE Kelly E. Curry Discus uss toda odays

596 views • 24 slides

Moving into the Future: Promoting safe patient handling for worker and patient safety in

Moving into the Future: Promoting safe patient handling for worker and patient safety in Massachusetts Hospitals In healthcare, the primary ethical imperative is First, do no harm. Although we have traditionally applied this obligation

453 views • 26 slides

Ensuring patient safety is on our health data agenda A/Prof. Farah Magrabi Leader, Patient

Ensuring patient safety is on our health data agenda A/Prof. Farah Magrabi Leader, Patient Safety Informatics Australian Institute of Health Innovation, Macquarie University Fellow, Assuring Autonomy International Programme University of York

788 views • 39 slides

OPTIMAL CONCEPT OF INFECTION CONTROL FOR PATIENT SAFETY IN HOSPITALS The French comitment Dr

Czech Presidency conference The microbial threat to patient safety in Europe France OPTIMAL CONCEPT OF INFECTION CONTROL FOR PATIENT SAFETY IN HOSPITALS The French comitment Dr Valrie SALOMON Head of Department E2 healthcare

406 views • 16 slides

A re-design evaluation from the real world Annemarie Hellebek MD phd Head of Patient Safety

A re-design evaluation from the real world Annemarie Hellebek MD phd Head of Patient Safety Capital Region of Denmark Assistant professor University of Copenhagen Consultant, The Danish Society for Patient Safety Member of EMA- NRG Group since

410 views • 11 slides

Helping Leaders Blink Correctly Split-second decisions have patient safety implications. than

Patient Safety Helping Leaders Blink Correctly Split-second decisions have patient safety implications. than esthetic judgment. Now I real- problematic. It is not uncommon, for In 1983, the J. Paul Getty Museum in California was approached

79 views • 3 slides

Never Events EU Patient Safety Exchange 2013 Definition Never Events are defined as serious,

Never Events EU Patient Safety Exchange 2013 Definition Never Events are defined as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare

306 views • 12 slides

Patient Adherence & Patient Safety Bernard Vrijens, PhD Chief Science Officer, WestRock

October 2015 Patient Adherence & Patient Safety Bernard Vrijens, PhD Chief Science Officer, WestRock Healthcare Associate Professor of Biostatistics University of Lige, Belgium Adherence is Key to Therapeutic Success Effective

579 views • 16 slides

The business case of unsafe The business case of unsafe care care 16 billion injections a

Health care causes harm to patients Better knowledge for safer care GCC Conference on Patient Safety 6-8 April 2009 Research for Patient Safety Itziar Larizgoitia Head Research & knowledge Management Patient Safety WHO The business case

318 views • 4 slides

WHATS NEXT? NEXT STEPS TO IMPLEMENTING THE OB HEMORRHAGE PATIENT SAFETY BUNDLE GLOBAL AIM

WHATS NEXT? NEXT STEPS TO IMPLEMENTING THE OB HEMORRHAGE PATIENT SAFETY BUNDLE GLOBAL AIM WEST VIRGINIA COLLABORATING PARTNERS WILL ENGAGE ALL OBSTETRICAL UNITS/FACILITIES IN THE AIM OBSTETRICAL HEMORRHAGE PATIENT SAFETY INITIATIVE.

436 views • 12 slides