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Quality and Medical Safety Programs
Quality and Medical Safety Program
Employee education competency module 2009
DMC Quality Department
Detroit Medical Center©
Revised: December, 2008
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Quality and Medical Safety Programs
Commitment to Quality and Safety
 The Detroit Medical Center is committed to providing
safe, high quality medical care.
 This is part of our mission and it is also reflected by our
certification and accreditation with regulatory agencies
and participation with local, state, and national quality
and safety improvement projects.
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Quality and Medical Safety Programs
Quality and Environmental Management Systems
 The DMC has incorporated the requirements of a Quality Management
System (QMS) as outlined in the ISO 9001-2000 standards and an
Environmental Management System (EMS) as outlined in ISO 14001:
2004 standards into its quality program.
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Quality and Medical Safety Programs
Foundation for Medical Safety
 Our commitment to Medical Safety is reflected in our:
 Environmental Statement
 Quality Statement
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Quality and Medical Safety Programs
ENVIRONMENTAL STATEMENT
The Detroit Medical Center is dedicated to
the health and safety of its patients,
employees, customers, community and
environment.
We are committed to:
•the prevention of pollution,
•compliance with environmental
regulations and other requirements, and
•continuous improvement.
THINK GREEN
Environmental Hotline 1-800-8ETHICS
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THINK CLEAN
Quality and Medical Safety Programs
QUALITY STATEMENT
Quality at the DMC includes:
 Continuous improvement
 Prevention of medical/health system errors
 Provision of high quality medical care
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Quality and Medical Safety Programs
Improving Quality and Safety
Most events or errors occur due to process issues
 Multiple events at multiple levels lead to the event –
almost never just one process failure.
 Rarely a “person” failure
By improving our systems and processes, we
improve healthcare quality and safety.
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Quality and Medical Safety Programs
What is Performance Improvement?
It’s an ongoing effort to find new and better ways of doing things.
 It’s about:
 Getting better results
• Involving the whole organization
• Improving work processes
Foundation for Performance Improvement:
• PDCA




Plan
Do
Check
Act
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Quality and Medical Safety Programs
Performance Improvement
 Plan
 What are the goals you want to achieve?
 Do
 Measure progress towards goals by collecting data.
 Check
 Look closely at (analyze) your data to answer these questions:
• How well are we performing?
• Why are we performing well (or not well)?
• Which areas should we focus on first to improve our process?
 Act
 Make Improvements!
 Celebrate success!
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Quality and Medical Safety Programs
Medical Safety

What does Medical Safety mean?
 It means we constantly look for ways to
make the care or service we provide safer
for our patients and employees.

How can we do this?
 By identifying conditions that are
hazardous and changing them.
 By acting quickly and appropriately when
an incident occurs.
 By making medical safety a regular part of
our performance improvement activities.
 By making concerns for safety part of
everything we do.
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Quality and Medical Safety Programs
Medical Safety = Quality Care
 The DMC is committed to adopting the Institute of
Medicine’s 6 aims for improving the quality and
safety of healthcare
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Quality and Medical Safety Programs
Institute of Medicine 6 aims of improving care
Healthcare needs to be:
1. Safe: avoiding injuries to patients from the care that is intended to help them.
2. Effective: providing services based on scientific knowledge to all who could
benefit, and refraining from providing services to those not likely to benefit.
3. Patient-centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that patient
values guide all clinical decisions.
4. Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care.
5. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and
energy.
6. Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status. A health care system that achieves major gains in these
six areas would be far better at meeting patient needs.
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Quality and Medical Safety Programs
Healthcare Safety Statistics
40 to 50 Patient Injuries per 100 Hospital Admissions
37 Million Admissions
X
40 Injuries per 100 Admissions
=
15 Million Injuries per Year
What can we do to change this?
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Quality and Medical Safety Programs
Institute for Healthcare Improvement (IHI)
“Protecting 5 Million lives from Harm” campaign
AIM:




Care that is standardized and systematized
Zero defects
Innovative
System Redesign
The DMC has committed to participate with the
IHI to protect patients from harm
Everyone is responsible for the quality and
safety of healthcare
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Quality and Medical Safety Programs
Proven Interventions
The 5 Million Lives Campaign challenges American hospitals to
adopt 12 changes in care that save lives and reduce patient
injuries:

Deploy Rapid Response Teams…at the first sign of patient decline

Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent
deaths from heart attack

Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation

Prevent Central Line Infections…by implementing a series of interdependent,
scientifically grounded steps

Prevent Surgical Site Infections…by reliably delivering the correct perioperative
antibiotics at the proper time

Prevent Ventilator-Associated Pneumonia…by implementing a series of
interdependent, scientifically grounded steps
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Quality and Medical Safety Programs
Proven Interventions con’t.
The 5 Million Lives Campaign challenges American hospitals to
adopt 12 changes in care that save lives and reduce patient
injuries:

Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants,
sedatives, narcotics, and insulin

Reduce Surgical Complications... by reliably implementing all of the changes in care
recommended by SCIP, the Surgical Care Improvement Project (www.medqic.org/scip)

Prevent Pressure Ulcers... by reliably using science-based guidelines for their
prevention

Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by
reliably implementing scientifically proven infection control practices

Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid
readmissions

Get Boards on Board … by defining and spreading the best-known leveraged
processes for hospital Boards of Directors, so that they can become far more effective
in accelerating organizational progress toward safe care
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Quality and Medical Safety Programs
Promoting and Maintaining a Safe Medical
Climate
 Staff Responsibilities:
 Take action to provide necessary care and protect patients in the event
of a unsafe event or error.
 Report all errors, near misses and hazardous conditions (web based
incident reporting system).
 Complete yearly, educational competencies.
 Participate in departmental improvement efforts.
 Be part of interdepartmental, multidisciplinary improvement teams.
 Share ideas to improve employee or patient safety with supervisor or
quality department
 SPEAK UP if you see an opportunity to avoid an unsafe practice or
violation of policy
 Instruct patients and families to report safety concerns.
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Quality and Medical Safety Programs
Promoting and Maintaining a Safe Medical Climate
 Patient Responsibilities:
 Encourage patients to:
• Provide accurate and complete information about present
complaints, past illnesses, hospitalizations and
medications.
• Ask questions when they do not understand what they
have been told or what they are expected to do.
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Quality and Medical Safety Programs
Accreditation
 Accreditation means that an organization has met
requirements related to the delivery of safe, quality care.
 The DMC is surveyed and accredited by many different
agencies.
 The Joint Commission is one of these agencies and
comes to our hospitals at least once every 3 years.
What is Joint Commission?
 The Joint Commission is an accreditation agency who’s
objective is to improve the quality of healthcare provided to
the public by establishing clinical standards; evaluating
health care organizations; rendering accreditation; and
providing education and consultative support to healthcare
professionals.
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Quality and Medical Safety Programs
Hospital Transparency
 Hospital “transparency” is providing information to the
public on patient safety & quality, cost, and performance
indicators
 Transparency assists hospitals to become more efficient,
rewards those hospitals that provide high quality care,
and allows consumers to make informed decisions
 The DMC provides information on safety and quality that
is publicly reported
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Quality and Medical Safety Programs
Quality Improvement
 The DMC participates in many local, state and national
Quality Improvement projects some of which are:
 The National Quality Forum (NQF)
 Leapfrog
 Institute for Healthcare Improvement (IHI)
 Michigan Hospital Association (MHA – Keystone
project)
 Greater Detroit Area Health Coalition (GDAHC – Save
Lives-Save Dollars campaign)
 Blue Cross Blue Shield of Michigan
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Quality and Medical Safety Programs
Consumer Centered
Hospital Data
 In recent years, there has been an increased emphasis on hospital
quality and transparency
 Consumers can find Internet sites to provide information such as
procedure cost, levels of clinical/patient care, and patient satisfaction
scores
 It is important to remember that all DMC employees play a role in
ensuring that our patients leave with a satisfying experience
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Quality and Medical Safety Programs
Healthcare Quality Websites


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

The Joint Commission www.jointcommission.org
 Provides information regarding hospital accreditation and compliance
AHRQ Report Card www.ahrq.gov
 Features information on the quality of hospitals, medical groups, health
plans, and nursing homes
CMS/Hospital Compare
www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp
 Provides consumers with hospital-reported information on quality,
performance, and customer satisfaction
Leapfrog Group www.leapfroggroup.org
 Provides consumers with hospital information based on its yearly survey of
quality indicators “leaps” such as ICU Staffing, CPOE, High-Risk
procedures, and NQF Safety Goals
Michigan Hospital Inform http://www.mihospitalinform.org/
 State of Michigan healthcare quality website
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Quality and Medical Safety Programs
Quality of Care
 As employees of the DMC, it is everyone’s responsibility
to ensure safe, quality care for our patients.
 Also, as an employee, you have the right and duty to
speak up if you feel the quality of care or
patient/employee safety is compromised.
 If you have concerns, first speak to your supervisor. If
you are not satisfied, you may contact the Quality
Department or use the compliance hotline.
 If still your concerns are not addressed, you have the
right to contact the Joint Commission at
[email protected] or call 1-800-994-6610.
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Quality and Medical Safety Programs
Quality and Medical Safety Programs Summary
Both the Quality Management System (QMS) and Environmental
Management System (EMS) are part of our integrated quality program.
Medical Safety means we constantly look for ways to make the care or
service we provide safer for our patients and employees.
The DMC publicly reports it’s quality and safety data.
Consumers can find Internet sites to provide information such as procedure
cost, levels of clinical/patient care, and patient satisfaction scores.
As an employee, you have the right and duty to speak up if you feel the
quality of care or patient/employee safety is compromised.
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Quality and Medical Safety Programs
Summary
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