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  • Britain's Patient-Safety Crisis Holds Lessons for All
    actual place At Mid Staffs instead of this essential connection there was a yawning gap When frontline workers raised concerns about staffing levels experience on the night shifts and supply shortages the Mid Staffs leaders walked away from leading They stayed away from the wards rebuffing the expert knowledge that could have protected dignity and saved lives The staff came to work each day filled with anger and desperation and in many cases took out their frustration on the helpless patients in their care Leaders need to build reliable processes to hear the staff Some of the best leaders I know have created effective ways to ensure daily interaction among all leaders caregivers and patients Rob Colones CEO at McLeod Health in Florence South Carolina has every senior leader start his or her day by rounding on units and talking with staff and patients John O Brien former CEO at Cambridge Health Alliance and the University of Massachusetts Health System held monthly breakfast meetings with any staff who had been patients in the system that month or who had family in the hospital At the breakfasts he asked What rules did you break to make your care great His agenda became lowering or removing those barriers staff were working around 2 Ask four questions On my visits to health care organizations I often ask these four questions to assess the overall level of quality and to understand how the leaders drive for best performance Do you know how good you are I ll look at the dashboards or other quality reports they use to measure performance I ll also ask about the qualitative methods the leaders use to understand the patients views on their care Do you know where you stand relative to the best Most often leaders look at their own performance But when they know how big the gap between them and the best performers is they are inspired to change Do you know where the variation exists Most leaders still look at averages and miss the opportunity to build will for improvement by assessing the entire range of performance across various providers and departments Do you know the rate of improvement over time Many leaders overestimate their progress The data on rates of change over time compel new improvement progress These questions help focus attention on the right things and set the right priorities They communicate the necessity of understanding quality as a living changing thing not as a static metric And they also impart a healthy dose of competition the kind that leverages curiosity and pride to generate learning 3 Build reliable and effective ways to hear the voices of the patients and family members The Mid Staffs leaders used only basic methods to hear the voice of their patients and family members The most effective leaders have reliable and vibrant ways to seek out input from patients and families on designs of services programs and care models Effective leadership creates easy ways for patients to

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=81ca4a47-4ccd-4e9e-89d9-14d88ec59e8d&ID=31 (2016-02-01)
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  • Surmounting Sepsis: An Interview with Dr. Sean Townsend
    the right care i e begins implementing the Sepsis Bundles so we can really have control and coordination Q In the past most of the focus on sepsis has been in the emergency department but the IHI Expedition on Treating Sepsis in the Emergency Department and Beyond will be giving participants a chance to identify key opportunities and test changes on the medical surgical floors Is this where you see the key opportunities for improvement A A lot of diagnostic work occurs in the emergency department Staff are attuned to a new patient showing up with a set of conditions and trying to understand why this person has this set of symptoms what do we need to do for testing how do we get them to a safe place A medical surgical floor on the other hand receives patients who have had all of the diagnostic work done for the most part and then keeps them in a stable position or delivers therapies that have already been pre selected to make sure patients are getting better so they can go home There is a different perspective that each area has However patients on the floor often develop sepsis while they are in the hospital because they are admitted with some problem that predisposes them to developing sepsis If you came in with pneumonia or a UTI or pyelonephritis or a gall bladder infection for example all of those things put someone at risk to have systemic infection and possibly develop sepsis The infection may stay localized and the patient could just be treated on the medical surgical floor for the specific condition for which they were admitted But if the infection progresses often that progression is not typically detected on medical surgical floors because unlike the emergency department where staff are attuned to rapidly changing conditions the floor staff expect a certain degree of stability in patients If we look at patients who present from the emergency department and are diagnosed with sepsis their mortality rate is lower than patients who present from the floor with a diagnosis of sepsis Q Does some of this build on what we have learned from implementing Rapid Response Teams A Yes this kind of builds on that notion The Sepsis Bundles require a sort of Rapid Response Team plus strategy At CPMC we recommend a screening strategy every shift on the floor that looks at changing conditions and specifically asks Does this patient have sepsis In that way it is different than a Rapid Response Team which would not screen for specific conditions The second thing is that we are fortunate to have a 24 hour intensivist in our CPMC facilities so we have added the intensivist to our code sepsis team The team is a lot like the Rapid Response Team plus the intensivist so that person arrives and makes a quick determination of whether they agree this person should be transferred to the ICU Q How do you feel about sepsis

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=17 (2016-02-01)
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  • Hand Hygiene Matters
    as a being one of the keys to success What does that mean to you A To me it means we are all in this as a team and we have a shared accountability for our practice With that we commit to providing each other with gentle reminders such as I noticed you might have missed washing your hands Q A number of organizations that have improved their hand hygiene have had hand hygiene campaigns Do you think that organizations need to formally declare it as a campaign to make significant improvement A I don t think a campaign per se is necessary I do think that visible reminders and making adjustments in the environment to promote hand washing which could be under the campaign umbrella are important I also personally think that making reminders visible to patients and family and visitors can be incredibly helpful As a patient I would not hesitate to remind someone to wash their hands Others may not be as comfortable doing that Making things visible reminding both staff and visitors of the importance of hand hygiene can really change the behavior and culture within hospitals It isn t necessary to spend a lot of money on an official campaign Finding ways to keep hand hygiene in front of busy people who have many things on their minds can enhance hand hygiene Hand hygiene is one thing on a long list of priorities people have so the key is to think about how we can make it easier Q There are differing opinions about the role of patients when it comes to hand hygiene Some initiatives have focused specifically on encouraging patients to ask careproviders to wash their hands and others argue that patients should not be put in that position What is your perspective on that A I can see it from both sides I don t think we can put the onus on patients At the same time I think we can develop a shared accountability in which patients are informed and feel comfortable raising it with staff and providers rather than an expectation that patients and families remind us To the extent that they are comfortable and willing patients should certainly have a voice and be invited to be part of the reminder system Q How do you think tools like the Joint Commission s Targeted Solutions Tool that will be part of the upcoming Impacting Hand Hygiene at the Front Line Expedition can support teams that are working on hand hygiene A Some type of measurement system or objective assessment of compliance with hand hygiene is very important The Joint Commission Targeted Solutions Tool is one approach that many organizations have found useful and supportive Organizations benefit greatly by using some objective way to assess and gather data Measurement on some level needs to be a foundational component of improving hand hygiene Q There is research indicating that if the attending physician or first person in a group entering a room

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=13 (2016-02-01)
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  • New Healthcare Executive Article: What does it take to be “Conversation Ready”?
    with guaifenesin in it Since that day every time I show up at a medical appointment at any doctor s office in my community at the walk in clinic or at the emergency department a conversation ensues about my mental status changes when taking guaifenesin One might think from the high reliability and seriousness of these conversations that this is the single most important thing there is to know about me I might argue that it is the least important in the grand scheme but nonetheless reliable human and IT systems have been constructed to ensure that this information is both available to my providers and that it is part of their process to review it More Important Conversations In contrast the systems in most health care settings to track information about what is most important to patients for their providers to know about their wishes regarding end of life care are disconnected and unreliable The notion of reliably receiving recording and respecting this information has been the focus for the last nine months of the Institute for Healthcare Improvement s Conversation Ready initiative Early Tests of the Idea I have had the pleasure of helping lead this work with our nine dedicated Pioneer Sponsor organizations who have been testing and refining the ideas of what it means to be Conversation Ready The work of the Pioneer Sponsors is highlighted this month in a piece in Healthcare Executive and we are happy to be able to share it with you Tags Conversation Ready Patient Safety Quality Patient Family Centered Care Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Osfica Horan 2 23 2014 9 12 40 AM My daughter enjoys the flexibility of having a combination of dinners and packed lunches Um yeah Students accustomed to homework sets and solutions must instead formulate their very own problems and â œfigure out the best paths to consider â says Colton who shaped this Energy Studies Minor optional The farther away an object is within space the older it is With the first leg to come upon Thursday Watford have not got long to flush the disappointment away from their system before they head to the actual King Power Stadium The idea Hover says is for the robot to cover every point within the mesh in this case each point is spaced 10 centimeters aside narrow enough to detect a small my own I loading Did you find this user comment useful people found this user comment useful Report This Show More Comments Loading You are about to report a violation of our Terms of Use All reports are strictly confidential Reason Select One Contains profanity or violence Spam Defamatory Illegal Unlawful Copyright Violation Other Please select a reason for this report Add a Note Your comments were submitted successfully There was an error reporting your complaint Follow Me Subscribe Blog

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=44 (2016-02-01)
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  • How Safe Are You on That Long-Distance Flight?
    Distance Flight Safety First Blog Safety First Blog IHI safety experts Frank Federico Carol Haraden and others comment on the ongoing struggle to make health care safer while detailing their own efforts to further the all important goal of a safe health care system Blog Home Older How Safe Are You on That Long Distance Flight Posted by Pierre Barker on Tuesday Jun 25 2013 A couple of months ago I was somewhere over the Atlantic heading back to the US on the 15 ½ hour non stop flight from Johannesburg to Atlanta At 3 30am I had given up trying to doze off upright in seat 30A Through the semi dark I was aware that the fellow traveler in row 28A was struggling to breathe I was trying to decide whether this was just a case of bad snoring sleep apnea or something worse Moments later when the passenger stopped breathing I became embroiled in a full scale resuscitation It turns out this drama at 30 000 feet happens more often than you may think A study published this week in the New England Journal of Medicine found that there was a medical emergency on one of every 600 flights that translates to an estimated 44 000 inflight emergencies each year across the world About 10 percent of the time these incidents result in flight diversions It turns out you have about a 50 50 chance of a doctor being on board and often there are other health personnel amongst the passengers Read more at The Huffington Post Tags Patient Safety Quality Improvement aviation industry Health Care Industry Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments Show More Comments

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=12 (2016-02-01)
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  • Spotlight on St. Charles: Using Stories to Create Lasting Lessons
    would provide a unique and valuable perspective on the importance of quality improvement We used the title Causal Analysis in lieu of Root Cause Analysis because there is often more than a single cause to a problem or error that occurs in a complex adaptive system such as a hospital The Causal Analysis class is one of twelve in our year long curriculum The same design format is used for each class 20 minute lecture 30 minutes of practical application and a 10 minute discussion The classes are designed to be dynamic and interactive and provide context as to why each improvement concept is important and how it can be put to use We use storytelling hands on exercises and group work to engage caregivers in ways that leave a lasting impression Following the lecture portion of the Causal Analysis class the attendees created a fishbone diagram and used the 5 Why s technique to determine the root causes behind the patient s death The class did a great job at analyzing the case and using the tools discussed in the lecture to help identify root causes Following that we discussed causal analysis and how it applies to the Model for Improvement and our everyday work The class proved to be engaging and the exercise was effective at reinforcing key improvement concepts Despite a successful period of technical instruction there is nothing that compares to the power of a story that connects with an audience or class through emotion In their book Made to Stick Chip and Dan Heath write Stories should put knowledge into a frame work that is more lifelike With this in mind our Chief Clinical Officer ended class by telling the story of the patient in the case study who had died as a result of the medical error He knew the story well because it was his patient He went on to explain how he was part of a system of communication that had broken down and ultimately resulted in the patient s death It was a story that took courage to tell and it had a palpable effect on everyone in the class The story brought the lesson to life and it set an example of transparency that quickly spread beyond the walls of the classroom Anytime a story is used to emphasize a key point or lend context to data or systems the effect can be significant Each month at St Charles our leaders teach basic quality improvement skills and discuss why they are important While the skills taught have a practical value the leadership perspective and shared experiences are invaluable It is proving to be an effective way to further engage caregivers and to help transform our culture Tags Quality Improvement Patient Safety Leadership Chapter Network Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Sara Mosher 6 26 2013 6 19

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=134 (2016-02-01)
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  • The Elusive Coverage and Completeness
    is no significant improvement nationwide between the two despite a wide number of improvement projects and patient safety initiatives Why is that My interpretation is that we have a problem with sustainability and spread To your list of tactics I would add building infrastructure and capability for improvement By this I mean making sure we have indicators to measure progress information systems to capture it education and knowledge management to support it experts available Based on what I have learned from healthcare systems leading in Quality Improvement I believe this infrastructure can help supporting spread and designing for sustainability Thank you for your work loading Did you find this user comment useful people found this user comment useful Report This by Helen Bevan 5 29 2013 3 05 58 PM Hi Carol and colleagues It s so timely that you raise these important issues I write my comments as someone who has spent the last 15 years seeking to spread good improvement practice throughout a large healthcare system I think you are right in suggesting in your blog that there are more questions than answers but I also think the questions might need to go back even further What do we actually mean by spread I believe it is a question of mindset the theories of change in our heads that lead us to take the actions we take and that we can t move onto strategy and tactics for spread until we have unpicked these mental models Often we adopt a mechanistic mindset seeking to capture a set of components that add up to great care in a particular local context seeking to work out the magic formula and replicate this elsewhere We have been trying to do this for 15 years and whilst we can show some encouraging results it doesn t usually get us to widespread coverage and completeness For those of us who work in large healthcare systems we see policy makers and leaders using payment by result and performance management systems to incentivise specific behaviours and outcomes but too often this feels done to the people who deliver care rather than them doing it themselves because they believe in it which is a pre requisite for sustainable change I don t know of any system that has delivered sustainable transformational change through top down compliance based spread So I think that as well as the continuation of the great work that has been undertaken on spread over the past 15 years there is room for some additional thinking and practice I believe that we should look beyond mainstream improvement thinking to other fields such as social movement thinking emerging theory about networks social era and constructivist approaches to organisational development to break through some of our current mental models about spread An example of an approach that I think would aid perspective is polarity management http c ymcdn com sites www odnetwork org resource resmgr 2011 conf ppts c2 polarities are everywhere pdf Just from

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=7 (2016-02-01)
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  • Burning Platform for Improving Quality and Safety in Healthcare
    but he did not know In April every year for the past three years I have attended the International Forum on Quality and Safety inHealthcare in Europe Organized by the British Medical Journal and IHI it is a spirited gathering of the faithful in the global quality healthcare movement At this forum we present the impressive results of our work with Project Fives Alive which aims to assist Ghana to accelerate the attainment of MDG 4 through a quality improvement approach During the event last month in London Maureen Bisognano advised health professionals in her keynote address to move away from asking our patients What s the matter to What matters to you as a fundamental prerequisite for developing a patient centered care system Listening to you and to others I cannot fail to hear what matters to you You want us to demonstrate that we of all people appreciate the distinction between emergency and non emergency medical conditions and to respond appropriately and with compassion You want us to prioritize care to those most in need You wish for adequate information from health workers You want us to involve you in the management of the condition and not take decisions for you on some unreliable assumption of what you can or cannot afford You want us to prescribe medications thoughtfully As I ponder these I too remember my friend who was almost given mismatched blood but for my timely chance arrival on the ward I remember another friend who was three months ago described by healthcare workers as too know and actually insulted for insisting that medication he was being administered early one morning was actually the wrong one He flatly refused to take the medication forcing the health worker to double check The medication was indeed some else s I recall the dread in his eyes when he demanded to be discharged because given the rate of medication errors he was afraid we were going to kill him in the hospital The problem then is not one that lends itself to easy finger pointing seeing how deeply systemic it is To tackle this problem calls for understanding its root causes Unfortunately however we do not seem to have quantified the extent of poor care and possible harm that patients might be exposed to in our facilities in order to remedy it Without quantification we ignore it with most of us pretending quality or the lack thereof is not an issue What is the extent of medication errors readmissions average length of stay client satisfaction wrong surgery sites patient waiting times and emergency caesarean section response times etc How different would our sense of urgency be if we routinely collected analyzed and acted upon such information Without this kind of data to focus our burning platform we operate in darkness fly blind and grossly underrate the full extent of the problem I dare say though that there is hope Nana Akosua When I hear Dr Ken Sagoe of Tamale

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=17e9894b-377a-4f7f-8278-e2b17d86b4c6&ID=7 (2016-02-01)
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