By making a commitment to ZERO, organizations are committed to implementing and sustaining a foundation for safety and reliability that includes three critical components:
Review the map and table for organizations that have made a commitment to ZERO.
Name: Luis Torres Torija
Phone: 5551452842
Email: luis.torres@hespanol.com
Position: Quality and Patient Safety Cooordinator/Regional Network Chair
Organization Name: Hospital Español
Organization Address:
613 Avenida Ejército Nacional
Ciudad de México, 11520 Mexico
Type of Facilities Run by Organization
| Type of Facilities | Number of These | Number of Beds |
|---|---|---|
| Primary Care Office/Clinic | 1 | |
| Urgent Care/Stand Alone ED | 1 | |
| Ambulatory Surgery Center | 1 | |
| Stand Alone Birthing Center | 1 | |
| Acute Care Hospital | 2 | 26 |
| Rehabilitation/Long Term Care | 1 | 432 |
| Home Health/Hospice | 1 |
Description of Other Facility
Psychiatric Center
Number of Other Facility
1
Why is your organization committed to ZERO?
Because we are convinced of offering our patients safe processes, our organization under the vision of having a healthcare model with the highest possible quality and safety has endeavored over the years to develop an organizational culture aligned with the values and motivations of the institution.
We are working daily on risk management and reduction through a proactive and reactive approach that favors transparency, teamwork and people's trust in the patient safety model of Hospital Español, making sure that everyone who comes to our Hospital will have the best possible experience in our organization.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
Hospital Español has worked to develop a model of quality and patient safety that favors the commitment and participation of all those involved in hospital processes, allowing them to know and learn from our actions. These actions could not be possible if they were not based on a directive leadership that has established the guidelines on the priorities and expected results in matters of patient safety.
We are convinced that the learning process doesn´t end and that we must have sources of information that allow us to analyze and identify situations that put our patients and staff at risk, that is why we have, among different strategies, an adverse event notification system whose objective is to be able to identify situations that pose risks and harm to our patients in order to analyze them and make decisions that strengthen our safety culture. In the same way, we consider that having communication mechanisms based on transparency are vital to our culture, which is why we make all our staff aware of the events that affected our patients so that they can contribute ideas and reflect on ways to reduce risks and improve our processes. Likewise, we have worked on a fair culture system that allows analysis and decision-making by changing the focus from people to systems, giving clarity and confidence to our collaborators, in an environment of continuous improvement. We have developed a support program for the second victim, that is, collaborators who have been affected by adverse events that occurred with our patients.
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Expert
What is your organization doing to establish a holistic, continuous improvement framework?
Safety and patient care cannot be seen as a sole responsibility based on a specific profile or service. We are perhaps one of the most complex and unpredictable industries that exist, so actions should not be based on individual aspects but on a system approach that allows standardizing care processes and reducing variability and risk of damage, for this We have guidelines based on scientific evidence and good practices that guide people's actions throughout the care process.
Hospital Español has various quality management models (CSG, ISO, CEHC), the results have been an organizational guide that allows aligning efforts from management to operational staff and strengthening our own model of quality and patient safety of the Hospital. This has been important since it has allowed us to enter into an continuous improvement process where coordination and communication between work teams play a fundamental role in reinforcing the holistic approach.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Expert
What is your organization doing to sustain an organizational development approach?
Throughout these years, the organization has continued to work on improving the culture of quality and patient safety, since in the first instance it has the commitment and leadership of senior management, as well as a quality management that works hand in hand with the people facilitating changes and improvements in each of the processes, and it is precisely those results that have allowed people to be convinced and committed to improving day by day.
Our safety culture is a reflection of our values, beliefs and customs that have been forged over the years and that are rooted in everything we do, always looking to improve. This is reflected from our strategic planning where each year we align our objectives with strategies that are reflected in the work of each of the people and where one of the pillars that guides our reason for existing is and will be patient safety.
Another component is that our patients perceive our quality and patient safety through different mechanisms (surveys, metrics, direct communication) that allows us to count on their loyalty and be their first option if they require medical attention.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Proficient
Which of the following patient safety challenges is your organization planning to continue working on?
Name: Fernando Contreras Zavala
Phone: 4621671600 ext 102
Email: drferco_gyo@hotmail.com
Position: Director
Organization Name: Hospital Materno Infantil Irapuato
Organization Address:
367 Malvas , Revolución
Irapuato, 36546 Mexico
Type of Facilities Run by Organization
| Type of Facilities | Number of These | Number of Beds |
|---|---|---|
| Primary Care Office/Clinic | ||
| Urgent Care/Stand Alone ED | ||
| Ambulatory Surgery Center | ||
| Stand Alone Birthing Center | ||
| Acute Care Hospital | 1 | 60 |
| Rehabilitation/Long Term Care | ||
| Home Health/Hospice |
Why is your organization committed to ZERO?
La calidad y la seguridad en una institución de salud son elementos estratégicos en los que se fundamenta la transformación y mejora de los sistemas sanitarios modernos.
Es importante involucrar tanto al personal como a los pacientes y familiares para que brinden su punto de vista al plantear atributos de la asistencia sanitaria que son necesarios implementar o mejorar.
El Hospital Materno Infantil Irapuato está comprometido con la seguridad del paciente y la mejora de los procesos por lo que queremos participar en la iniciativa del Movimiento de Seguridad del Paciente con las siguientes acciones a implementar:
1. Diagnóstico y Tratamiento temprano de Sepsis.
2. Caídas de madres y bebés.
3. Compromiso del paciente y familiar.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
El hospital ha implementado diversos modelos de calidad, un ejemplo de ello es el Modelo de Seguridad del Paciente del Sistema Nacional de Certificación de Establecimientos de Atención Médica el cual impulsa a todos los profesionales de la salud a estar comprometidos y realizar acciones que permitan mejorar los procesos en beneficio de los pacientes. También contamos con protocolos y lineamientos basados en las mejores prácticas nacionales e internacionales que favorecen e impulsan una atención estandarizada, efectiva y eficiente.
Nuestro compromiso con la cultura de seguridad del paciente se ve reflejada reflejado de igual forma en nuestra misión, visión y valores; los cuales se describen a continuación:
Misión:
Somos un hospital especializado en brindar atención materna y neonatal de la más alta calidad mediante el trabajo de un equipo multidisciplinario, motivado por el amor a nuestros pacientes, apegado a los más altos estándares de seguridad.
Visión:
Ser un hospital líder en el país, reconocido por trabajar con las mejores prácticas clínicas en la atención gineco-obstétrica y neonatal, consolidado como un centro de excelencia laboral.
Valores:
Honestidad.
Compromiso.
Respeto.
Lealtad.
Equidad.
Humanismo.
Una de las herramientas que son indispensables para estudiar el avance en la cultura de calidad y seguridad en el Hospital Materno Infantil Irapuato es la aplicación del Cuestionario sobre Seguridad de los Pacientes en Hospitales de México de manera anual, el cual se aplica en todos los niveles del Hospital (personal operativo y directivo de todos los Servicios).
Otra actividad es el Sistema de Reporte de Incidentes Relacionados con la Seguridad del Paciente; en este el personal del Hospital notifica de manera anónima al Departamento de Calidad cualquier tipo o grado de impacto de un incidente relacionado con la seguridad del paciente, familiares, persona y proveedores. Las notificaciones pueden englobar incidentes relacionados con el proceso de atención (omisión de algún paso o actividad en un proceso en concreto), fallas o defectos en la infraestructura, omisiones a reglamentos o políticas, etc. La información se analiza de manera mensual, se reporta en el Comité de Calidad y Seguridad del Paciente (COCASEP) y se acuerdan acciones de mejora de manera multidisciplinaria (cada acción de mejora tiene un líder responsable de la aplicación y seguimiento de esta).
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Competent
What is your organization doing to establish a holistic, continuous improvement framework?
Como el nombre del hospital lo indica, está dedicado a la atención de mujeres embarazadas, en periodo de puerperio, mujeres con patología ginecológica y neonatos. Se inaugura el 09 de octubre del 2014, iniciando operaciones el 13 de octubre del mismo año.
Es complicado describir las propiedades del hospital en términos separados, por esto es necesario hablar del Hospital Materno Infantil Irapuato como sistema. La compresión de este se logrará estudiándolo globalmente, involucrando todas las interdependencias de sus partes, las cuales trabajan para lograr un objetivo común.
El Hospital se encuentra certificado bajo el modelo del SiNaCEAM (Sistema Nacional de Certificación de Establecimientos de Atención Médica) desde el 2018, trabajando de esta manera con un enfoque de sistema mediante la identificación, entendimiento y gestión de los procesos interrelacionados, contribuyendo así a la efectividad de la organización y a la eficiencia en alcanzar sus objetivos.
Se toma esta decisión partiendo de la aseveración de que el Consejo de Salubridad General es una de las autoridades sanitarias en el país y determina las acciones e instrumentos necesarios para la evaluación y la certificación de la calidad de los establecimientos de atención médica.
La entrada al sistema se da cuando este recibe personas que requieren atención a la salud, ya sea que acudan de manera espontánea (Urgencias) o referidos de otra unidad (incluyendo Primer Nivel).
La transformación o procesamiento son los procesos relacionados con la prestación de servicios que las personas requieran a la entrada al sistema. Estos son:
Ginecología: patología benigna, clínica de displasias y cirugía oncológica.
Obstetricia: control prenatal de embarazo de alto riesgo, módulo máter, medicina materno fetal, clínica de hemorragia y anticoncepción post evento obstétrico.
Neonatología: seguimiento del prematuro, clínica de lactancia, inmunizaciones.
Pediatría: neuropediatría, neumología pediátrica, tamiz auditivo.
Como áreas donde se lleva a cabo la prestación de servicios se tiene:
Urgencias.
Consulta Externa.
Quirófano.
Labor.
Hospitalización.
Cunero Patológico.
Crecimiento y desarrollo.
Unidad de Cuidados Intensivos Obstétricos.
Unidad de Cuidados Intermedios Obstétricos.
Unidad de Cuidados Intensivos Neonatales.
Unidad de Cuidados Intermedios Neonatales.
Banco de Leche Humana.
En esta parte de transformación o procesamiento se encuentran implementadas las Metas Internacionales para Seguridad del Paciente (implementadas en todos los servicios de la unidad) siendo adecuados los procedimientos para cada uno de los servicios de manera que sea sencillo poner en práctica cada una de las metas en todo el hospital.
Así mismo, en todas las áreas se encuentran implementados los procesos relacionados con atención a la persona marcados por el Modelo de Calidad y Seguridad del Paciente del SiNaCEAM: ACC (acceso y continuidad de la atención, AOP (evaluación de pacientes) y COP (atención de pacientes).
Además de las MISP se encuentran los sistemas críticos del modelo de calidad implementado: MMU (Manejo y Uso de Medicamentos), FMS (Gestión y Seguridad de las Instalaciones), PCI (Prevención y Control de Infecciones y SQE (Competencias y Educación del Personal), los cuales fungen como procesos estratégicos junto con QPS (base del Modelo para la atención en salud con calidad y seguridad donde se encuentra inmersa la Mejora de la Calidad y Seguridad del Paciente), el Aval Ciudadano, la normatividad vigente y el Consejo Hospitalario, guiado por la Dirección (GLD – Gobierno, liderazgo y dirección).
Los servicios de apoyo, los cuales sirven como auxiliares de diagnóstico, tratamiento, referencia y/o seguimiento para la entrega del servicio de salud son:
Anestesiología (Anestesia y atención quirúrgica – ASC).
Medicina interna.
Patología Clínica (Servicios auxiliares de diagnóstico – SAD).
Radiología e Imagen (Servicios auxiliares de diagnóstico – SAD).
Nutrición y dietología.
Enfermería.
Laboratorio Clínico (Servicios auxiliares de diagnóstico – SAD).
Servicio de Transfusión.
Inhaloterapia.
Psicología.
Trabajo Social (Derechos del paciente y su familia y Educación del paciente y su familia – PFR y PFE respectivamente).
Cada uno de estos bloques tiene uno o varios líderes para su gestión trabajando en conjunto para lograr que el sistema funcione correctamente a través de las capacitaciones, infraestructura y requisitos inherentes a cada área de enfoque.
Como parte de la gestión y ejecución para la operación de los servicios se tienen a:
MCI (Manejo de la Comunicación y de la Información, otorgado por Tecnologías de la Información y Estadística y Archivo Clínico).
Ingeniería biomédica.
Mantenimiento y conservación.
Control de inventarios.
Abasto de medicamentos.
Recursos Humanos.
Recursos financieros.
Recursos materiales.
Servicios generales.
Administración.
Los resultados del sistema se encuentran divididos, según las características y demandas de la persona atendida, en egresos por:
Mejoría.
Voluntario.
Contra-Referencia.
Defunción.
También es importante mencionar que en el hospital tenemos integrados equipos multidisciplinarios en las diferentes áreas y/o servicios, los cuales están encargados de la implementación de diferentes modelos de calidad con los que contamos, los cuales describimos a continuación:
Acreditación en las siguientes carteras:
CAUSES.
Cuidados Intensivos Neonatales.
INDICAS: Medición de indicadores de la atención médica estandarizados a nivel nacional.
SESTAD: Levantamiento de encuestas para conocer la percepción de la calidad en la atención por el usuario.
SUG: Sistema unificado de gestión de quejas, felicitaciones, sugerencias y solicitudes de gestión.
MECIC: El cual nos sirve para evaluar y mejorar el expediente clínico.
SINASEP: Sistema de Notificación y Aprendizaje para la Seguridad del Paciente, plataforma que nos permite capturar, clasificar y analizar los incidentes relacionados con la seguridad del paciente ocurridos en nuestra unidad, y así realizar acciones de mejora.
Así mismo en conjunto con las Direcciones de Oficinas Centrales del estado se diseñan lineamientos, procesos y protocolos para la atención del paciente y la operación de los hospitales.
Finalmente, todos nuestros procesos y estrategias se regulan a través del Comité Hospitalario de la Calidad y Seguridad del paciente, éste permite el análisis en conjunto por todos los jefes de servicio de nuestra unidad de todos los temas y modelos antes mencionado, con la finalidad de tomar decisiones en pro de la calidad de la atención del paciente, el cual se realiza de manera mensual y nos permite tener una mejor coordinación y mejorar la comunicación entre los diferentes servicios.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Competent
What is your organization doing to sustain an organizational development approach?
De manera anual (noviembre) se realiza un cierre de actividades donde se revisan los principales indicadores en las distintas Jefaturas de Servicio del HMII. En diciembre se comienza a realizar la matriz de riesgos para el año entrante y de esta forma empezar a establecer prioridades de trabajo en la organización. A nivel directivo se analiza el comportamiento de los indicadores, riesgos, problemas y proyectos seleccionados.
De esta manera, los mandos medios y la Alta Dirección detectan las necesidades de la organización para el año siguiente y marcan las pautas de trabajo mediante el acuerdo de acciones a seguir como equipo multi e interdisciplinario. Así mismo se marcan metas e indicadores para llevar a cabo una gestión efectiva durante el ejercicio del año entrante.
Por parte del Departamento de Calidad se coordinan las acciones, planes y proyectos a seguir para alcanzar las metas y objetivos planeados encaminados a aumentar la calidad brindada en la atención hospitalaria y la cultura de seguridad (tanto para pacientes como para familiares, personal y proveedores).
El Hospital Materno Infantil Irapuato mide su desempeño a través de indicadores estratégicos definidos de manera anual en el Manual de Organización, además, cada una de las Jefaturas de Servicio reportan su desempeño a Dirección con los indicadores seleccionados para cada uno de ellos.
También es importante mencionar que de forma anual se sesiona el Consejo Hospitalario, donde se exponen los resultados obtenidos por la unidad en el año inmediato anterior. En esta sesión se dan a conocer las áreas de oportunidad que se tuvieron, esto permite establecer compromisos en conjunto con el consejo hospitalario, que nos lleven a la planeación de los proyectos del siguiente año relacionados con la calidad y seguridad del paciente. Así mismo, cada año el Hospital selecciona los nuevos integrantes y /o ratifican los líderes de cada uno de los apartados que integran los diferentes modelos de calidad, para que de éste forma se asignen responsabilidades mediante los planes de trabajo y dar cumplimiento a éstos.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Competent
Which of the following patient safety challenges is your organization planning to continue working on?
Name: Raul Rojas Hernandez
Phone: 4771018700 EXT. 1001
Email: rrojash@guanajuato.gob.mx
Position: DIRECTOR GENERAL
Organization Name: Hospital de Especialidades Pediatrico Leon
Organization Address:
Boulevard Juan Alonso de Torres 4725, Fracc. San Jose del Potrero
Leon, 37296 Mexico
Type of Facilities Run by Organization
| Type of Facilities | Number of These | Number of Beds |
|---|---|---|
| Primary Care Office/Clinic | ||
| Urgent Care/Stand Alone ED | ||
| Ambulatory Surgery Center | ||
| Stand Alone Birthing Center | ||
| Acute Care Hospital | 1 | 38 |
| Rehabilitation/Long Term Care | ||
| Home Health/Hospice |
Why is your organization committed to ZERO?
Somos un hospital que desde sus inicios esta comprometido con la calidad y seguridad en todos sus procesos de atención con la finalidad de poder brindar una atención oportuna, eficiente y efectiva a todos los usuarios que acuden a solicitar atención medica. Es por eso que nuestra organización esta en la búsqueda continua de nuevos modelos de calidad que nos permitan mejorar nuestros procesos en beneficio de nuestros pacientes.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
La organización ha implementado el Modelo de Seguridad del Paciente del Sistema Nacional de Certificación de Establecimientos de Atención Médica el cual impulsa a todos los miembros a estar comprometidos y realizar acciones que permitan mejorar nuestros procesos en beneficio de nuestros pacientes. Así mismo, contamos con protocolos y lineamientos basados en las mejores prácticas nacionales e internacionales que favorecen e impulsan una atención estandarizada, efectiva y eficiente.
A través de la DGOySP se impulsa la creación y mantenimiento de una cultura de seguridad del paciente, promoviendo el reconocimiento y notificación de las cuasifallas, eventos adversos y centinela que ocurren en el día a día durante la atención de los pacientes, con un enfoque abierto, no punitivo y voluntario.
Además, nuestro compromiso con la cultura de seguridad del paciente se ve reflejada reflejado en nuestra misión, visión y valores; los cuales se describen a continuación.
Misión:
Somos una organización de profesionales de la salud, que brinda atención humanitaria, especializada y multidisciplinaria para toda la niñez y la adolescencia del Estado de Guanajuato, comprometida con la creación de conocimiento y capital humano.
Visión:
Ser el hospital pediátrico distinguido por su compromiso y gestión de calidad, seguridad y conocimiento para atender la salud y el bienestar de la niñez y la adolescencia del Estado de Guanajuato.
Valores:
Prudencia, respeto y solidaridad por el bienestar de nuestros pacientes.
Cultura de Seguridad del Paciente
Finalmente, el hospital realiza de manera anual desde el año 2018, una evaluación de la cultura de seguridad del paciente, establecida por la DGCES, dicha encuesta detecta nuestras oportunidades de mejora para establecer acciones y estrategias encaminadas a mejorar el fomento de la cultura de seguridad al interior de nuestra unidad.
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Competent
What is your organization doing to establish a holistic, continuous improvement framework?
En el Hospital de Especialidades Pediátrico León trabajamos con un enfoque de sistema mediante la integración y desarrollo de equipos multidisciplinarios integrados por las diferentes áreas y/o servicios, los cuales están encargados de la implementación de los diferentes modelos de calidad con los que contamos, los cuales describimos a continuación.
Acreditación en las siguientes carteras:
- CAUSES.
- Enfermedades Lisosomales.
- UCIN.
- Trastornos Quirúrgicos Congénitos y Adquiridos. Aparato Digestivo.
- Trastornos Quirúrgicos Congénitos y Adquiridos. Columna Vertebral.
- Implante Coclear.
- Trastornos Quirúrgicos Congénitos y Adquiridos. Aparato Urinario.
- Trastornos Quirúrgicos Congénitos y Adquiridos. Cardiovasculares.
- Síndrome Turner.
- Trasplante Renal en Paciente Pediátrico.
Modelo de Seguridad del Paciente del Consejo de Salubridad General: en donde se obtuvo un certificado de 5 años con la calificación de 9.9
INDICAS: Medición de indicadores de la atención médica estandarizados a nivel nacional.
SESTAD: Levantamiento de encuestas para conocer la percepción de la calidad en la atención por el usuario.
SUG: Sistema unificado de gestión de quejas, felicitaciones, sugerencias y solicitudes de gestión.
MECIC: El cual nos sirve para evaluar y mejorar el expediente clínico.
SINASEP: Sistema de Notificación y Aprendizaje para la Seguridad del Paciente, plataforma que nos permite capturar, clasificar y analizar los incidentes relacionados con la seguridad del paciente ocurridos en nuestra unidad, y así realizar acciones de mejora.
Así mismo en conjunto con las Direcciones de Oficinas Centrales del estado se diseñan lineamientos, procesos y protocolos para la atención del paciente y la operación de los hospitales.
Finalmente, todos nuestros procesos y estrategias se regulan a través del Comité Hospitalario de la Calidad y Seguridad del paciente, éste permite el análisis en conjunto por todos los jefes de servicio de nuestra unidad de todos los temas y modelos antes mencionado, con la finalidad de tomar decisiones en pro de la calidad de la atención del paciente, el cual se realiza de manera mensual y nos permite tener una mejor coordinación y mejorar la comunicación entre los diferentes servicios.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Competent
What is your organization doing to sustain an organizational development approach?
De forma anual se sesiona el Consejo Hospitalario, donde se exponen los resultados obtenidos por la unidad en el año inmediato anterior. Dando a conocer las áreas de oportunidad, esto permite establecer compromisos en conjunto, que nos lleven a la planeación de los proyectos del siguiente año relacionados con la calidad y seguridad del paciente. Así mismo, cada año el Hospital selecciona los nuevos integrantes y /o ratifican los líderes de cada uno de los apartados que integran los diferentes modelos de calidad, para que de éste forma se asignen responsabilidades mediante los planes de trabajo y dar cumplimiento a éstos.
En el año 2021 el Hospital va a participar en el Premio Nacional de Calidad, el cual se un modelo de competitividad a nivel nacional y que nos ayuda a promover procesos eficaces, efectivos y eficientes.
Por parte del Departamento de calidad se coordinan las acciones, planes y proyectos a seguir para alcanzar las metas y objetivos planeados encaminados a aumentar la calidad brindada en la atención hospitalaria y la cultura de seguridad (Tanto para pacientes como a familiares, personal y proveedores).
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Competent
Which of the following patient safety challenges is your organization planning to continue working on?
Name: Saúl Aparicio Romero
Phone: 5525770567
Email: dgoysp@starmedica.com
Position: Gerente de Control Organizacional
Organization Name: Hospitales Star Médica
Organization Address:
Avenida Tres Marias
, Mexico
Why is your organization committed to ZERO?
Impulsar la creación, desarrollo y mantenimiento de una cultura de seguridad del paciente en los hospitales que integran la constelación Star Médica, reduciendo el daño innecesario o potencial relacionado con la atención de nuestros pacientes.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
Desde el 2018 se crea la Dirección de Gestión Organizacional y Seguridad del Paciente (DGOySP), la cual ha diseñado el Modelo de Gestión, Innovación y Excelencia en todos los hospitales que integran la constelación de Star Médica, la cual encamina sus esfuerzos en mejorar la seguridad del paciente y la calidad de la atención. Así mismo, toda la organización ha implementado el Modelo de Seguridad del Pacientes del Sistema Nocional de Certificación de Establecimientos de Atención Médica. Por otro lado impulsa y diseña protocolos y lineamientos basados en las mejores prácticas nacionales e internacionales.
A través de la DGOySP impulsa la creación y mantenimiento de un cultura de seguridad del paciente promoviendo el reconocimiento y notificación de las cuasifallas, eventos adversos y centinela que ocurren en el día a día durante la atención de los pacientes, con un enfoque abierto, de confianza y no punitivo para identificar los riesgos y problemas; para ello se ha diseñado un portal web en el que los colaboradores pueden realizar notificaciones de manera anónima.
Por otro lado, anualmente se
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Proficient
What is your organization doing to establish a holistic, continuous improvement framework?
El Sistema de Gestión Innovación y Excelencia se desarrolla con la integración de equipos multidisciplinarios que dirigen y/o coordinan la atención y operación de cada uno de los hospitales y conjunto con las Direcciones de Oficinas Centrales diseñando los lienamientos, procesos y protocolos para la atención del paciente y la operación de los hospitales.
Por lo anterior en Hospitales Star Médica cada Sistema Critico del Modelo de Seguridad del Paciente se integra y gestiona través de un Comité Multidisciplinario StarTeam que es liderado por el Gerente de Gestión Organizacional de cada Hospital y sesionan al menos una vez cada tres meses.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Proficient
What is your organization doing to sustain an organizational development approach?
Desde la Dirección General de Hospitales Star Médica se respaldala la seguridad del paciente al integrarlo como parte del plan estratégico anual, siendo uno de los pilares para mantener el crecimiento sostenido de la organización, generando confianza en la comunidad médica, pacientes y colaboradores.
Se impulsa la creación de una cultura de seguridad del paciente desde el ingreso de los nuevos colaboradores, incluyendo en la inducción a la organización temas relacionados a la seguridad del paciente. Así mismo, en el plan anual de capacitación, donde ademas de incluir temas que por normativa de deben otorgae, desde Oficinas Centrales se establece un programa de capacitaciones relacionadas a la Seguridad del Paciente.
Como parte de los programas de institucionales para impulsar el valor institucional de Excelencia, se encentra el Programa Reconoce, mediante el cual los colaboradores en puestos seleccionados que tienen contacto directo en la atención de los pacientes se les otorga una compensación por el apego a barreras de seguridad. Así mismo, anualmente los mandos medios y Direcciones de los Hospitales que destacan por alcanzar los objetivos institucionales, entre los que se encuentran indicadores relacionados a la seguridad del paciente se les reconoce económicamente y coaching externo y materiales de consulta que los motiven a mantener el compromiso por la seguridad del paciente.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Proficient
Which of the following patient safety challenges is your organization planning to continue working on?
Name: Robin Betts
Phone: 5102066952
Email: robin.k.betts@kp.org
Position: VP Quality, Clinical Effectiveness & Regulatory Services
Organization Name: Kaiser Permanente Northern California
Organization Address:
1950 Franklin Street
Oakland, 94612 United States
Type of Facilities Run by Organization
| Type of Facilities | Number of These | Number of Beds |
|---|---|---|
| Primary Care Office/Clinic | 262 | |
| Urgent Care/Stand Alone ED | ||
| Ambulatory Surgery Center | 3 | |
| Stand Alone Birthing Center | ||
| Acute Care Hospital | 21 | 4130 |
| Rehabilitation/Long Term Care | 2 | 195 |
| Home Health/Hospice | 12 |
Why is your organization committed to ZERO?
As a health care provider, we have a moral obligation "to do no harm." Kaiser Permanente's mission is to provide high-quality affordable care, which includes having processes and systems in place to reduce preventable harm to our patients. We demonstrate our commitment to zero through the implementation of an improvement framework that reduces harm and elevates the quality of care to those we serve. This commitment benefits our KP members as well as continuing to strengthen our role as a trusted quality and safety leader in the nation.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
Quality health care also means creating a safe environment for our members and staff. We believe that:
• patient safety comes first
• patient safety is every patient's right
• patient safety is every employee's responsibility
We are continuously developing, testing, and implementing new programs to make sure our patients receive safe, quality care. These programs address issues such as medication safety, infection prevention, and reducing the risk of surgical complications and patient falls.
Our patient safety programs also focus on clear communication and a "speak-up" culture empowering anyone to speak up especially when it relates to safety. This means providing training to support communication among members of our health care teams. It also means providing medical interpreters, multilingual member education materials, and assistive technologies to accommodate unique patient care needs.
We encourage our members to provide feedback about the quality of our care and service. We welcome comments about not only their experiences in our medical offices, but also with pharmacy and lab operations, telephone services, and access to care. We carefully review their feedback and strive to make improvements on an ongoing basis.
In 2014, Kaiser Permanente's strategic plan stated, "by understanding the member's perspective we will deliver the best care". One of the most collaborative ways of engaging patients is through the development of Patient Advisory Councils (PACs). Patient Advisory Councils are built on the principles of Patient and Family Centered Care, an approach to healthcare that emphasizes partnerships among patients, families, healthcare practitioners, and leaders. As an organizational priority, Northern California Medical Centers developed and launched Patient Advisory Councils. We continue to provide opportunities to build upon that foundation by advancing evidence-based PFCC practices. These practices will improve quality, care experience, and affordability, by realigning healthcare delivery to be with, not to members. Additionally, working with our patients/members will nourish joy and meaning in the workforce. Together with our patients/members, we build our future. We also partner with our patients in safety improvement through their participation in safety event investigations. Additionally, they hold the organization accountable through their active participation on hospital Quality and Safety Committees. We now have more than 40 councils with 79 advisors on Key committees and over 400 patient/family advisors throughout Northern California Kaiser Permanente.
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Competent
What is your organization doing to establish a holistic, continuous improvement framework?
KFHP Northern California strategic priorities are formulated from the national and regional priorities established by the KFHP Board and recommendations by Executive Leadership and the QOC. Additional goals and activities are selected based on importance and relevance to KFHP membership and linkage to KFHP’s mission. Activities reflect the needs of the membership and focus on high volume, high risk, and problem-prone areas for which quality improvement activities are likely to result in improvements in care and service, access, safety, and satisfaction.
As an integral part of the organization's Quality Program, the Risk Management and Patient Safety Program exists to ensure that Kaiser Permanente is providing patient centered care that is reliable, effective, consistent, and safe. This mission is founded on the philosophy that patient safety is every patient's right and every person’s responsibility. It is an ongoing, relentless commitment to build safer systems and to prevent harm using performance improvement methodology.
To permeate responsibility and mutual accountability for patient safety throughout our organization, Kaiser Permanente will continue to implement activities broadly aimed at becoming a high reliability organization by achieving the following six strategic themes:
Safe Care, Safe Culture, Safe Staff, Safe Patients, Safe Place and Safe Systems.
The foundational elements of all risk management and patient safety initiatives and activities at Kaiser Permanente will continue to be:
1. An understanding of human error and human factors
2. The creation and maintenance of a culture in which reporting takes place in a "Just Culture" (individuals treated fairly when error occurs)
3. Proactive and prioritized performance improvement to prevent failure, mitigate hazards, and improve systems and process reliability
4. A continuous learning organization
5. The application of reliability theory to continually improve safe practice
6. Seeking input from and collaborating with patients and families
7. Assuring compliance with all state and national regulatory standards supporting Patient Safety
8. Embrace the use of technology to solve problems
9. Ongoing identification, sharing, and appropriate implementation of successful practices from other parts of the organization, other healthcare organizations, and organizations outside of healthcare.
The framework includes the following Program Components: Risk Identification, Risk Analysis Risk/Injury Prevention, Risk/Injury Control,
Infrastructure Effectiveness and leading as a Learning Organization. Our program also instituted a sustainability framework that positions to anticipate, detect and respond to early signals of performance drift to sustain ever elevating safe care.
We engage the patient and their family, as appropriate, as a partner in safety. This includes work designed to reduce medical errors, improve systems and actively participate in their own safe care. We strive for collaborative relationships with patients/members/families in all aspects of the organization.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Proficient
What is your organization doing to sustain an organizational development approach?
The organization has a long history of investing in team training and development to enhance the culture of patient safety. Over the last decade, extensive training has been conducted both in TeamSTEPPS (AHRQ) and Patient Safety University (a program developed within the organization in 2007). In addition, the organization has invested in both Quality and Patient Safety Fellow programs for emerging leaders. Recognizing the challenges of in-person training posed by the COVID-19 pandemic, Kaiser Permanente NCAL, has recently embarked on a journey of "Achieving a High Reliability Patient Safety Culture through Virtual Training." This pilot program will promote and reinforce a culture of high reliability, safety and respect through successfully spreading evidence-based methods and a common set of behavioral expectations. In addition, the program will provide a framework to deliver innovative and engaging learning experiences in a psychologically safe manner. Local leadership accountability will be embedded to ensure sustainability.
The Curriculum will include the following topics:
Leadership Orientation to Managing Error in a Just Culture
Introduction to Patient Safety/Just Culture
Highly Reliable Organization Science
Principles of Psychological Safety
Error proofing/Peer Coaching tools:
CUS
IPASS
SBAR
Closed Loop Communication
IM SAFE
The program is being designed by a core team which is sponsored by KP senior executive leaders. The core team members include physicians, hospital and Risk Management and Patient Safety Leaders. The committee will be welcoming a Patient Advisor to join the work.
In addition to curriculum development, the committee will launch two pilot sites by the fourth quarter 2021.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Competent
Which of the following patient safety challenges is your organization planning to continue working on?
Name: Helen Macfie
Phone: (714) 580-9009
Email: hmacfie@memorialcare.org
Position: Chief Transformation Officer, MemorialCare Health System (So California)
Organization Name: Memorial Health Care System
Organization Address:
17360 Brookhurst Street
Fountain Valley, 92708 United States
Why is your organization committed to ZERO?
It takes a spark to ignite a flame. And it takes leadership to unite people, tap into their passion, and show them the way. That by working together towards a common goal, we can make a huge impact on countless lives. Thanks to the spark of Joe Kiani and the Patient Safety Movement’s leadership, thousands of hospitals, healthcare organizations and patient advocates have united to achieve a vital goal: ZERO preventable deaths. At MemorialCare, and as a prior 5* recipient, we are pleased to publicly reaffirm our commitment to saving lives and eliminating all preventable patient deaths and harm. MemorialCare is a nonprofit health system offering both adult and pediatric hospital care, as well as a growing ambulatory network with primary care, imaging, surgery centers, urgent care, breast health, dialysis and physical therapy, located throughout Orange and Los Angeles counties. Our 10,300 staff and 2,600 physicians serve more than 1.7 million patients annually, with 60,500 admitted to our hospitals last year.
Our mission is to improve the health and well-being of individuals, families and our communities. A critical component is ensuring the safety of everyone we serve. 24 years ago, we established the Physician Society, a multi-disciplinary collaboration of doctors and practitioners with the sole purpose to establish, implement and refine best practice care. Together, in 2005, we initiated our “Bold Goals” for safety. This laser focus has resulted in an 84% reduction in “Harm Across the Board”, 10% lower readmissions, 71% more people surviving sepsis, 50% fewer infections, and all three of our birthing hospitals making the California Honor Roll for reducing NTSV C-Sections.
Every year, Barry Arbuckle, MemorialCare’s CEO, announces our annual “Lives Touched” at our systemwide governance summit. In 2020, that number was 27,620 lives (now totaling 184,851 since 2007). And he reminds us that there is more harm to avoid and much more work to do.
In 2019, we learned about the Actionable Patient Safety Solutions and felt the immediate connection to our Bold Goals and beyond. I went right up to Joe and pledged for MemorialCare to join the Movement. A year later, we are humbled to be the sixth health system to have earned the 5-Star Hospital designation.
The work isn’t finished—when it comes to patient safety, it never will be. By uniting with the Movement and adopting the APSS, we are really pleased to be part of a community that is eager to embrace transparency, share best practices, and implement and evolve solutions that will save lives.
The Movement is the spark. Now MemorialCare—along with all of you—has the important obligation to keep this flame alive as we continue our journey to zero preventable patient deaths and harm. Thank you.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
We have been using the Outcome Engenuity framework for over 10 years now, and have built it into our training programs for all managers. Partnering with Quality, Risk and HR, we use the framework to assess any issues or errors and help us assure we take the best most considered path to resolving the issue using their step model. We belief if our staff and doctors can feel safe reporting errors, we then get to learn from all the treasures those reports unearth. We've also revised our reporting system to make it friendly and easier for all to submit a report as one barrier we found was the time it was taking to submit and then assess. And finally we do a survey of all staff to gain their opinions on how we are doing (we use the AHRQ survey), then generating "heat maps" by department and area to help our managers see where they can continue to improve in their leadership of the culture. This is a journey to be sure and takes constant feeding and tending as new managers come in, leadership changes and even the model itself evolves. Happy to speak more on this but these are the top level thoughts.
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Proficient
What is your organization doing to establish a holistic, continuous improvement framework?
Every year we set our Bold Goals for Quality and Safety across MemorialCare, striving for every higher benchmarks either externally or compared to our own historical best, to get to ZERO harm. These are approved by our Board and then systematically reviewed and actioned by our Quality Committee of the Board (systemwide and at each hospital and the Medical Foundation - clinics) and a system-wide leadership group called our Quality Close with our c-suite and quality leadership. We are supported by a series of clinical Best Practice Teams (15 this year - for example Emergency Medicine, Pulmonary/Critical Care, Women's Health and others - as well as our Executive Quality Leadership Value Added Team which meets monthly to keep all the moving pieces on track. This framework to plan, think and activate "across and down" helps us shepherd the many important safety initiatives forward. And then finally we have a shared dashboard (we call it the PI Radar - keeping our eye on the patterns and trends) across the system as well as for each entity so that we can track our progress and where we need to action further. Again, happy to share more.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Expert
What is your organization doing to sustain an organizational development approach?
MemorialCare has adopted Lean as our framework for Mindset, Management System and Methods. All managers are training in Lean and Facilitative Leadership - and we are revising our process for training with COVID to be more on-line and interactional, with mentors. We do a lot of "just in time" training for our teams, workshops, and rapid process improvement events, bringing in staff, doctors and patients real-time to help us co-design solutions and implementation plans. We also offer coaching support through our Lean Resource Office so that any manager or leader can get additional help to think through an issue and design the "best" approach to solving.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Expert
Which of the following patient safety challenges is your organization planning to continue working on?
Name: edwin loftin
Phone: 321-268-6120
Email: edwin.loftin@parrishmed.com
Position: SVP Integrated and Acute Care Services / CNO
Organization Name: Parrish Medical Center
Organization Address:
951 N Washington Ave
Titusville, 32796 United States
Why is your organization committed to ZERO?
Parrish Healthcare is the culmination of our vision that collaborative partnerships are the way to improve access, quality, safety, and service. Parrish Healthcare’s collaborative network of hospitals, providers, insurers, and other allied health, social, and community-based service partners are effectively removing duplication of services and applying shared evidence-based best practices to achieve real integrated healing care for patients, families and communities.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
Healing environments reflect the values, beliefs and philosophies of the people and the community they serve. The physical building, the caregivers within that building, and the services provided must all be consistent with its regional and organizational culture. The element of culture is where we are focusing all our attention as it relates to the healing environment and giving healing experiences to everyone all the time.
Culture of Choice® - Our Culture of Choice® journey began shortly after moving into the new medical center in 2002. This journey is not about “changing” our culture, but about how can we make our culture healthier. Our Culture of Choice journey includes four major crossroads: Desire, Leadership, Culture and Process Improvement.
DESIRE - Our desire is to create a uniquely PMC experience for patients, families, visitors and caregivers to effectively compete in today’s consumer-driven, highly competitive marketplace.
LEADERSHIP - We developed a multitiered leadership assessment tool to identify the leaders who would help to move the medical center forward. The assessment tool includes self-assessments, 360-degree assessments, and personal styles assessments, giving more weight to those intrinsic characteristics, such as integrity, honesty, courage, and humility, rather than to technical skills that can be more easily taught and learned.
CULTURE - Our culture is defined by our mission, vision and values—principles that we live by each day.
MISSION: Healing Experiences For Everyone All The Time®
VISION: Healing Families—Healing Communities®
VALUES:
- Safety: We are responsible for the safety of everyone—employees, patients and visitors. All accidents and incidents are promptly and completely reported. We know the policies and procedures relating to safety issues in our organization and department. We strive to prevent slips, trips and falls by keeping traffic routes free of clutter and obstacles and by wiping up spills.
- Loyalty: We demonstrate caring, concern and commitment for everyone. We put the organization’s need before our own. We demonstrate “What can I give?” behavior vs. “What can I get?” behavior for the organization.
- Integrity: We comply with our Confidentiality Policy and Code of Conduct. We operate within PMC’s policies and procedures; display proper identification; and know and conform to all applicable laws, regulations and professional standards. We strive to do the right thing, keep promises, clarify and fulfill expectations. We are respectful of those who are not present, and avoid communication that is negative. We are honest in all interactions with others.
- Compassion: We anticipate and identify the needs of our internal and external customers. We respond promptly, and display a courteous, caring, respectful and sensitive attitude to everyone.
- Excellence: Excellence is an enduring personal and team commitment to provide the best possible service. We demonstrate initiative; learn from best practices and experiences; generate fresh approaches; acquire skills; and seek feedback to assess and improve performance. We will achieve excellence by consistently exceeding expectations. Excellence is proactively and passionately helping others achieve healing of mind, body and spirit.
- Stewardship: We will act as an “owner” of the organization, and hold ourselves and others accountable for the services we provide, including addressing problems to the appropriate supervisor. We take initiative to serve on committees and projects, both within the unit and hospital wide. We follow through on assignments in a reliable and timely manner. We use PMC’s resources wisely, and look for ways to improve processes, while maintaining our quality services.
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Proficient
What is your organization doing to establish a holistic, continuous improvement framework?
Research indicates that environment plays an integral role in the healing of the mind, body and spirit. The concept of a healing environment was adopted by Parrish during the planning phases of our replacement medical center in 1996. Since then we have dedicated ourselves to providing the community we serve with more than just exceptional healthcare centers; we provide healing healthcare environments.
Healing environments:
1. Inspire hope and optimism.
2. Restore inner harmony and balance with color and light.
3. Encourage people and respect nature.
4. Provide clear direction and offers a calming experience to visitors.
5. Provide safe harbor.
6. Reflect the values, beliefs and philosophies of the people and the community they serve
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Proficient
What is your organization doing to sustain an organizational development approach?
PROCESS IMPROVEMENT - This is where our journey comes full circle. In order to be successful, we continuously look at our existing processes and use our values and mission as our guides to identify better, more efficient ways of doing things. Process Improvement following Lean and Six Sigma principles. We apply this to our Game Plan. The Game Plan is our road map to fulfilling our shared mission, vision and values on behalf of the people we have the honor to serve. It defines for us What we need to do; How to achieve results; and Why it is important. You never have to wonder about our strategic direction. It’s all there, on The Game Plan. The Game Plan was introduced in 2000 and is the organization’s strategic plan. It is the framework we use for the consistent, standardized communication of the organization’s strategic direction, goals and expectations. The Game Plan is supported and directed by our Board of Directors. Every department and individual care partner has responsibility and accountability to The Game Plan and our success. Why? Because our work is purposeful work—our work is healing work.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Proficient
Which of the following patient safety challenges is your organization planning to continue working on?
Name: Daria Terrell
Phone: 3122032776
Email: DariaBrooks@msn.com
Position: Medical Director
Organization Name: St. Bernard Hospital
Organization Address:
326 West 64th Street
Chicago, 60621 United States
Type of Facilities Run by Organization
| Type of Facilities | Number of These | Number of Beds |
|---|---|---|
| Primary Care Office/Clinic | ||
| Urgent Care/Stand Alone ED | ||
| Ambulatory Surgery Center | ||
| Stand Alone Birthing Center | 0 | |
| Acute Care Hospital | 1 | 176 |
| Rehabilitation/Long Term Care | ||
| Home Health/Hospice |
Description of Other Facility
Ambulatory Care Center
Number of Other Facility
1
Why is your organization committed to ZERO?
We are committed to providing the highest quality of care to the patients we serve, which includes providing care that is guided by a foundation of safety. We believe that establishing a culture of safety that is pervasive throughout our institution will encourage and support staff and improve the quality of care and satisfaction of our patients.
Do you commit to eliminating harm from medical error by aligning your organization with these three critical components?
Yes
What is your organization doing to establish a person-centered culture of safety?
We try to encourage all employees to be driven by the desire to help those that we serve. As an institution, we are now also planning on implementing a patient safety officer as a member of our leadership team.
Where on the continuum do you feel your organization stands in establishing a person-centered culture of safety?
Novice
What is your organization doing to establish a holistic, continuous improvement framework?
We have an existing quality improvement committee and team that work consistently to ensure that our care meets established standards of care and tries to promote exceeding those standards. We would like to have those efforts align even more with safety strategies going forward in an attempt to be more proactive in avoiding risks.
Where on the continuum do you feel your organization stands in establishing a holistic continuous improvement framework?
Advanced Beginner
What is your organization doing to sustain an organizational development approach?
We have elements of organization-wide involvement in our approach to care delivery including an active Patient Family Advisory Council, our Quality Improvement committees, Care Coordination Team and Safety Team. We would like to have a way to provide more cohesion among these different entities and initiate a system-wide safety movement that starts at the Board level and intersects at multiple levels within the organization.
Where on the continuum do you feel your organization stands in sustaining an organizational development approach?
Advanced Beginner
Which of the following patient safety challenges is your organization planning to continue working on?
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