7 Steps To Patient Safety

Patient Safety
and Quality of Care

Rapat Kordinasi Instalasi RSK Mojowarno
Seven steps to patient safety
1. Build a safety culture
2. Lead and support your staff (Professional
Development)
3. Integrate your risk management activity
4. Clinical performance & audit
5. Involve patients and the public
6. Learn and share safety lessons
7. Implement solutions to prevent harm

Step 1
Build a safety culture
Action points
For your organisation:
ensure your policies state what staff should do following an incident,
how it should be investigated, and what support should be given to
patients, families and staff;
ensure your policies describe individual roles and accountability for
when things go wrong;
assess your organisations reporting and learning culture using a safety
assessment survey (see Resources from the NPSA on page 10).
For your team:
ensure your colleagues feel able to talk about their concerns and report
when things go wrong;
demonstrate to your team the measures your organisation takes to
ensure reports are dealt with fairly and that the appropriate learning
and action takes place.
Operations
Demonstrate top leadership commitment to safety

Communications

Multidisciplinary teamwork
Operations
Trust-beyond blame

Incident Report
Check list
Cross / double check
Update and socialize procedure
Inspecting system
Identification label
Operations

Signage

Practicing standard precaution (hand hygiene practices)

Implementation for PPM (Plan Preventive Maintenance) for
Bio-Medical Equipments
Operations
Staff Competency the right man for the right task
Identification Label

Design & Safety Layout
Alarm System
Expected
Outcomes
Declining infection rate
Prevent harm to staff
Decreasing costs
Step 2
Lead and support your staff
Action points
ensure there is an executive board member with responsibility for
patient safety;
identify patient safety champions in each directorate, division or
department;
put patient safety high on the agenda of board or management team
meetings;
build patient safety into the training programmes for all your staff and
ensure this training is accessible and measure its effectiveness.
For your team:
nominate your own champion or lead for patient safety;
explain the relevance and importance of patient safety to your team,
and the benefits it brings;
promote an ethos where all individuals within your team are respected
and feel able to challenge when they think something may be going
wrong.
2. Lead and support your staff
(Professional Development)
Operations
Evidence based skills training
Postgraduate training
Hospital credentialing policy
Indemnity
Nurse training in collaboration with ECU
Operations
Staff training

Safety & quality training
Appraisal system (reward & punishment)
Rotation within departments
Daily briefings
Staff counseling
Career ladder
Expected
Outcomes
Clinician credentialing and re-credentialing
Improved professional development and skills
training for workforce
Improved performance management
Improved staff satisfaction
Improved patient outcomes
Step 3
Integrate your risk management activity
Action points
review your structures and processes for managing clinical and nonclinical
risk, and ensure these are integrated with patient and staff
safety, complaints and clinical negligence, and financial and
environmental risk;
develop performance indicators for your risk management system
which can be monitored by your board;
use the information generated by your incident reporting system and
organisation-wide risk assessments to proactively improve patient care.
For your team:
set up local forums to discuss risk management and patient safety
issues and provide feedback to the relevant management groups;
assess the risk to individual patients in advance of treatment;
have a regular process for assessing your risks, for defining the
acceptability of each risk and its likelihood, and take appropriate actions
to minimise them;
ensure these risk assessments are fed into the organisation-wide risk
assessment process and risk register.
Operations
Sentinel events reporting (Miss / Near Miss)
Clinical incident investigation & training
Quality improvement committee reports
Medication safety clinical pharmacologist
Clinical microbiologist
Planned Preventive Maintenance (Bio-Medic)
Risk management officer in every department
Scheduled risk management officer meeting
Regular MOU checking & update
Infection control program & committee
Medico legal advisor
Expected
Outcomes
Improved monitoring and reporting of incidents and
adverse events
Improved investigation of clinical incident and
adverse events
Improved risk management processes
Reduced health care costs through reduced
number and severity of adverse events
Step 4
Promote reporting
Action points
complete a local implementation plan (see below) which describes how
and when your organisation will begin reporting nationally to the NPSA.
For your team:
encourage your colleagues to actively report patient safety incidents
that happen and those that have been prevented from happening but
that carry important lessons.
Operations
Mortality report & audit

Clinical Indicators
Internal clinical guidelines
Collaborations with overseas centers of
excellence
Working with GPs and Specialist in the
surrounding area
Quality indicator
Nursing care quality audit
Latest equipment provision
Agreed pathways for clinical practice
Reduced variation in clinical practice
Reduced health care costs through reduced
adverse event
Step 5
Involve and communicate with patients and the public
Action points
develop a local policy covering open communication about incidents
with patients and their families;
ensure patients and their families are informed when things have gone
wrong and they have been harmed as a result;
provide your staff with the support, training and encouragement they
need to be open with patients and their families.
For your team:
ensure your team respects and supports the active involvement of
patients and their families when something has gone wrong;
prioritise the need to tell patients and their families when incidents
occur, and to provide them with clear, accurate and timely information;
make sure patients and their families receive an immediate apology
where it is due, and are dealt with in a respectful and sympathetic way.
Operations
Consumer participation training

Informed consent

Complaint management

Customer information center
Operations
Seminars for public & medical professionals
Patient liaison

Parentcraft, Post natal care education

Patients gathering

Stroke club

Pastoral care

Greater consumer participation in health
service delivery and management
Enhanced patient and consumer knowledge
Step 6
Learn and share safety lessons
Action points
ensure relevant staff are trained to undertake appropriate incident
investigations that will identify the underlying causes;
develop a local policy which describes the criteria for when your
organisation should undertake a Root Cause Analysis (RCA) or
Significant Event Audit (SEA). These criteria should include all incidents
that have lead to permanent harm or death.
For your team:
share lessons from the analysis of patient safety incidents within your
team;
identify which other departments might be affected in future, and share
your learning more widely.

Operations
Infection control nurse training
Adapting overseas safety & quality policies
Socializing adapted safety & quality policies
Intensivist training
Training for external participants

Benchmarking


Expected
Outcomes
Decreasing the number of infection
Improvement on safety & quality policies
Improving the quality of patient care
Step 7
Implement solutions to prevent harm
Action points
use the information generated from incident reporting systems, risk
assessments, and incident investigation, audit and analysis to identify
local solutions. This could include re-designing systems and processes,
and adapting staff training or clinical practice;
assess the risks for any changes you plan to make;
measure the impact of your changes;
draw on solutions developed externally. These could be solutions
developed at a national level by the NPSA or best practice identified
elsewhere in the NHS;
provide staff with feedback on any actions taken as a result of reported
incidents.
For your team:
involve your team in developing ways to make patient care better
and safer;
review changes made with your team to ensure they are sustained;
ensure your team receives feedback on any follow-up to reported
incidents.
Operations
Rapid diagnostics
X-Ray Result has to be finished in 15 minutes
Lab Clinical Pathology 2 hours
Appointment system at OPD
Pharmacy
No compound medicine
Drugs interaction is controlled by clinical
pharmacologist
In-patient pharmacist
Out-patient pharmacist
Operations
True partnership with our consumers
Full time specialist in all disciplines
Consumer involvement from Doctors, Patients and
their family
Active medical advisory board
Accreditation & ISO certification
Improvement in patient care
Genuine empowerment
Bottom-up process
Top / down guidance, direction and support
Specialist on-call system
Building confidence & new capabilities in Doctors & Staff
24 hours general & maintenance support
Preparation for further accreditation under American
standard ( JCIA )
Expected
Outcomes
Improvement in patient care

Building confidence & new capabilities in doctors & staff

Implementation of evidence based practice

New culture of change and optimism

Bringing together consumers and staff from all levels to
solve many of very difficult problems in healthcare.

Sense of excitement from a tired and often cynical staff
because someone is finally listening to them and doing
something.
Safety is not found
in the absence of danger,
but in the presence of GOD!!!

7 Steps To Patient Safety

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Patient Safety

and Quality of Care

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