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The document outlines seven steps that a hospital in Mojowarno, Indonesia is taking to improve patient safety and quality of care: 1) Build a safety culture, 2) Lead and support staff through professional development, 3) Integrate risk management activities, 4) Conduct clinical performance audits, 5) Involve patients and the public, 6) Learn and share safety lessons, and 7) Implement solutions to prevent harm. For each step, the document describes actions the hospital is taking at both the organizational and team levels, as well as expected outcomes. The overall goal is to reduce infections, prevent staff and patient harm, lower costs, and improve patient outcomes and quality of care.
The document outlines seven steps that a hospital in Mojowarno, Indonesia is taking to improve patient safety and quality of care: 1) Build a safety culture, 2) Lead and support staff through professional development, 3) Integrate risk management activities, 4) Conduct clinical performance audits, 5) Involve patients and the public, 6) Learn and share safety lessons, and 7) Implement solutions to prevent harm. For each step, the document describes actions the hospital is taking at both the organizational and team levels, as well as expected outcomes. The overall goal is to reduce infections, prevent staff and patient harm, lower costs, and improve patient outcomes and quality of care.
The document outlines seven steps that a hospital in Mojowarno, Indonesia is taking to improve patient safety and quality of care: 1) Build a safety culture, 2) Lead and support staff through professional development, 3) Integrate risk management activities, 4) Conduct clinical performance audits, 5) Involve patients and the public, 6) Learn and share safety lessons, and 7) Implement solutions to prevent harm. For each step, the document describes actions the hospital is taking at both the organizational and team levels, as well as expected outcomes. The overall goal is to reduce infections, prevent staff and patient harm, lower costs, and improve patient outcomes 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 Rapat Kordinasi Instalasi RSK Mojowarno
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. 1. Build a safety culture Operations Demonstrate top leadership commitment to safety
Incident Report Check list Cross / double check Update and socialize procedure Inspecting system Identification label Rapat Kordinasi Instalasi RSK Mojowarno 1. Build a safety culture Operations
Signage
Practicing standard precaution (hand hygiene practices)
Implementation for PPM (Plan Preventive Maintenance) for Bio-Medical Equipments Rapat Kordinasi Instalasi RSK Mojowarno 1. Build a safety culture Operations Staff Competency the right man for the right task Identification Label
Design & Safety Layout Alarm System Rapat Kordinasi Instalasi RSK Mojowarno 1. Build a safety culture Expected Outcomes Declining infection rate Prevent harm to staff Decreasing costs Rapat Kordinasi Instalasi RSK Mojowarno Step 2 Lead and support your staff Action points For your organisation: 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 Rapat Kordinasi Instalasi RSK Mojowarno 2. Lead and support your staff (Professional Development) Operations Staff training
Safety & quality training Appraisal system (reward & punishment) Rotation within departments Daily briefings Staff counseling Career ladder Rapat Kordinasi Instalasi RSK Mojowarno 2. Lead and support your staff (Professional Development) Expected Outcomes Clinician credentialing and re-credentialing Improved professional development and skills training for workforce Improved performance management Improved staff satisfaction Improved patient outcomes Rapat Kordinasi Instalasi RSK Mojowarno Step 3 Integrate your risk management activity Action points For your organisation: 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. 3. Integrate your risk management activity 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 Rapat Kordinasi Instalasi RSK Mojowarno 3. Integrate your risk management activity 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 Improved patient outcomes Rapat Kordinasi Instalasi RSK Mojowarno Step 4 Promote reporting Action points For your organisation: 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. Rapat Kordinasi Instalasi RSK Mojowarno 4. Clinical performance & audit 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 Rapat Kordinasi Instalasi RSK Mojowarno 4. Clinical performance & audit Agreed pathways for clinical practice Reduced variation in clinical practice Improved patient outcomes Reduced health care costs through reduced adverse event Rapat Kordinasi Instalasi RSK Mojowarno Step 5 Involve and communicate with patients and the public Action points For your organisation: 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. Rapat Kordinasi Instalasi RSK Mojowarno 5. Involve patients and the public Operations Consumer participation training
Informed consent
Complaint management
Customer information center Rapat Kordinasi Instalasi RSK Mojowarno 5. Involve patients and the public Operations Seminars for public & medical professionals Patient liaison
Parentcraft, Post natal care education
Patients gathering
Stroke club
Pastoral care
Rapat Kordinasi Instalasi RSK Mojowarno 5. Involve patients and the public Greater consumer participation in health service delivery and management Enhanced patient and consumer knowledge Improved patient outcomes Rapat Kordinasi Instalasi RSK Mojowarno Step 6 Learn and share safety lessons Action points For your organisation: 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. 6. Learn and share safety lessons
Operations Infection control nurse training Adapting overseas safety & quality policies Socializing adapted safety & quality policies Intensivist training Training for external participants
Expected Outcomes Decreasing the number of infection Improvement on safety & quality policies Improving the quality of patient care Rapat Kordinasi Instalasi RSK Mojowarno Step 7 Implement solutions to prevent harm Action points For your organisation: 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. 7. Implement solutions to prevent harm 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 Rapat Kordinasi Instalasi RSK Mojowarno 7. Implement solutions to prevent harm 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 ) Rapat Kordinasi Instalasi RSK Mojowarno Expected Outcomes 7. Implement solutions to prevent harm 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. Rapat Kordinasi Instalasi RSK Mojowarno Safety is not found in the absence of danger, but in the presence of GOD!!!