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E-grāmata: Safer Hospital Care: Strategies for Continuous Quality Innovation, 2nd Edition

  • Formāts: 232 pages
  • Izdošanas datums: 29-May-2019
  • Izdevniecība: CRC Press
  • Valoda: eng
  • ISBN-13: 9780429609046
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Safer Hospital Care: Strategies for Continuous Quality Innovation, 2nd EditionPalielināt
  • Formāts: 232 pages
  • Izdošanas datums: 29-May-2019
  • Izdevniecība: CRC Press
  • Valoda: eng
  • ISBN-13: 9780429609046
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According to the National Patient Safety Foundation, about 440,000 deaths from hospital mistakes are expected in 2018. These mistakes are preventable, but the number of deaths has been increasing for the last two decades instead of decreasing. This book describes how to prevent deaths at very low cost and get very high return on investment (ROI).

The unique feature of this book is that it teaches the tools of innovation that anyone can master. It teaches healthcare staff how to manage innovation efficiently and quickly, because each patient life is critical. This second edition points out why the present methods are ineffective and shows how to find elegant solutions that are simple, comprehensive, and produce high return on investments.

The second edition contains all updated material with the addition of a new chapter on systems engineering for robust improvements, a practice that has been applied in most high-risk industries, such as aerospace, defense, and NASA, for years. It aims at redesigning systems to make sure right things, right coordination and right integration happens in healthcare systems.

Introduction xiii
Acknowledgment xv
Author xvii
1 The Etiologies of Unsafe Healthcare 1(12)
Introduction
1(1)
Failure Is Not an Option
2(1)
An Unconventional Way to Manage Risks
2(1)
Defining Unsafe Work
3(8)
How Unsafe Work Propagates Unknowingly
4(3)
How Does Unsafe Work Originate?
7(1)
So, Why Do We Unknowingly Sustain Unsafe Work?
8(2)
Using Best Practices Is Insufficient
10(1)
There Is Hope
10(1)
The Lessons Learned
11(1)
Summary
11(1)
References
12(1)
2 Sufficient Understanding Is a Prerequisite to Safe Care 13(10)
Introduction
13(9)
Insufficient Understanding of System Vulnerability
14(1)
Insufficient Understanding of What Is Preventable
15(1)
Insufficient Understanding from Myopia
15(2)
Insufficient Understanding of Oversights and Omissions
17(1)
Insufficient Understanding of Variation
18(1)
Some Remedies
19(3)
Summary
22(1)
References
22(1)
3 Preventing "Indifferencity" to Enhance Patient Safety 23(14)
Introduction
23(1)
Performance without Passion
23(4)
Not Learning from Mistakes
24(1)
Inattention to the Voice of the Patient
24(1)
Making Premature Judgments without Critical Thinking
25(1)
Lack of Teamwork
26(1)
Lack of Feedback and Follow-Up
27(1)
Performance without Due Concern
27(4)
Lack of Accountability
27(1)
Encouraging Substandard Work
28(1)
Reacting to Unsafe Incidences Instead of Proactively Seeking Them
28(1)
Inattention to Clinical Systems
29(1)
Difference in Mind-Set between Management and Employees
30(1)
Poor Risk Management
30(1)
Performance Diligently Done in a Substandard Manner
31(4)
Continuing to Do Substandard Work, Knowing It Is Substandard
31(1)
Ignoring Bad Behavior
31(3)
Inattention to Quality
34(1)
Summary
35(1)
References
35(2)
4 Continuous Innovation Is Better Than Continuous Improvement 37(12)
Introduction
37(1)
Why Continuous Innovation?
38(1)
Types of Innovations
39(4)
Marginal Innovation
39(1)
Incremental Innovation
40(1)
Radical Innovation
40(1)
Disruptive Innovation
41(1)
Accidental Innovation
41(1)
Strategic Innovation
41(1)
Diffusion Innovation
42(1)
Translocation Innovation
42(1)
The Foundation for the Innovation Culture
43(3)
Choice of Innovation
43(1)
Encouraging Creativity
43(3)
Structure for Sustaining Innovation
46(1)
Summary
46(1)
References
47(2)
5 Innovations Should Start with Incidence Reports 49(18)
Introduction
49(1)
The Purpose and Scope of Incidence Reports
50(1)
What to Do with Incidence Reports?
51(1)
A Sample Incidence Reporting Procedure
51(1)
A Sample Incidence Report Form
51(6)
Ideas for Innovative Solutions
57(5)
The Progress System Wide
62(3)
Summary
65(1)
References
65(2)
6 Doing More with Less Is Innovation 67(12)
Introduction
67(1)
Be Lean, Do not Be Mean
68(1)
Eliminate Waste, Do not Eliminate Value
69(1)
Do It Right the First Time-Excellence Does Matter
70(1)
Add More Right Work to Save Time and Money
71(1)
Attack Complacency
72(1)
Create a Sense of Urgency
73(1)
Establish Evidence between Lean Strategies and Patient Satisfaction
74(2)
Ideas for Lean Innovation
76(1)
Summary
76(1)
References
76(3)
7 Reinvent Quality Management 79(12)
Introduction
79(1)
A Recipe for Success
80(1)
Redefine Quality
80(2)
Conduct Negative Requirements Analysis
82(1)
Develop Strategic Plan Based on SWOT Analysis
82(3)
Consciously Manage Quality at All the Levels of an Organization
85(2)
Quality at Conformance Level
85(1)
Quality at Process Level
85(1)
Quality of Kind at Organization Level
86(1)
Architect a Patient-Centric Quality System
87(1)
Validate Interactions and Dependencies Frequently
87(1)
Incorporate Feedback Loops
88(1)
Summary
89(1)
References
90(1)
8 Reinvent Risk Management 91(14)
Introduction
91(1)
Identify Risks
92(5)
Failure Mode and Effects Analysis
92(1)
Fault Tree Analysis
93(4)
More Safety Analysis Techniques
97(2)
Mitigate Risks
99(1)
Orchestrate Risks
100(3)
Create a Sound Structure
101(1)
Integrate the Support Staff
101(1)
Conduct Risk Management Rehearsals
102(1)
Aim at High ROI without Compromising Safety
103(1)
Summary
103(1)
References
103(2)
9 Human Errors May Be Unpreventable: Preventing Harm Is an Innovation 105(12)
Introduction
105(1)
Principles of HFE
105(2)
Harm Prevention Methodologies
107(7)
Crew Resource Management
107(1)
Management Oversight and Risk Tree
108(3)
Change Analysis
111(1)
Swiss Cheese Model for Error Trapping
112(1)
Mistake Proofing
113(1)
Summary
114(1)
References
115(2)
10 Managing Safety: Lessons from Aerospace 117(6)
Introduction
117(1)
Where Does U.S. Healthcare Stand on System Safety?
118(1)
System Safety Theory of Accidents
118(2)
System Safety in Emergency Medicine
120(1)
Aerospace Hazard Analysis Techniques
120(1)
Summary
121(1)
References
121(2)
11 The Paradigm Pioneers 123(8)
Introduction
123(1)
Johns Hopkins Hospital
123(2)
Allegheny General Hospital
125(1)
Geisinger Health System
126(1)
Veterans Affairs Hospitals
127(1)
Seattle Children's Hospital
127(1)
Ideas for Future Paradigm Pioneers
128(1)
Summary
129(1)
References
129(2)
12 Protect Patients from Dangers in Medical Devices 131(8)
Introduction
131(1)
The Nature of Dangers
131(2)
Hazard Mitigation for Existing Devices
133(1)
Potential Dangers in New Devices and Technologies
134(2)
Hazard Mitigation for New Devices and Technologies
136(1)
Can We Use This Knowledge in Bedside Intelligence?
137(1)
Summary
137(1)
References
137(2)
13 Heuristics for Continuous Innovation 139(8)
Introduction
139(1)
Heuristics for Medicine
140(1)
Other Heuristics for Medicine
141(1)
Heuristics for Frontline Processes
141(3)
Stop Working on Wrong Things, and You Will Automatically Work on Right Things
141(1)
Learn to Say "No" to Yes Men
142(1)
"No Action" Is an Action
142(1)
No Control Is the Best Control
143(1)
Heuristics for Management
144(1)
If You Do not Know Where You Are Going, Any Road Will Get You There
144(1)
Convert Bad News into Good News
145(1)
As Quality Goes up, the Costs Go down
145(1)
That Which Gets Measured, Is What Gets Done
145(1)
20% of Causes Are Responsible for 80% of Effects
145(1)
Summary
145(1)
References
146(1)
14 Aequanimitas-The Best-Known Strategy for Safe Care 147(12)
Introduction
147(1)
Aequanimitas Explained
148(1)
Why Aequanimitas Is the Best-Known Strategy for Safe Care?
148(1)
The Practice of Aequanimitas
149(1)
Modern Variations of Aequanimitas
150(7)
Emotional Intelligence
150(1)
The Beginner's Mind
151(4)
Ray Brown's 31 Senses
155(2)
Summary
157(1)
References
157(2)
15 Healthcare Systems Engineering, the Powerful Quality Improvement Tool 159(10)
Introduction
159(1)
Some Progress Has Been Made
160(1)
Understanding Healthcare Systems Engineering
161(1)
Healthcare Systems Engineering at Johns Hopkins Medicine
161(4)
Healthcare Systems Engineering at Mayo Clinic
165(2)
Summary
167(1)
References
167(2)
Appendix A: The Swiss Cheese Model 169(18)
Index 187
Dev Raheja, MS, CSP, is an international risk management and quality assurance consultant for the healthcare, medical device, and aerospace industry for more than 25 years. He trains and shows how to come up with elegant design solutions using creativity and innovation. He served as Associate Professor at University of Maryland for its graduate degree program in Reliability Engineering. he currently serves as Adjunct Professor for it Mechanical Engineering Department. Prior to becoming a consultant in 1982, he worked at GE Healthcare as supervisor of quality assurance and manager of manufacturing, and at Booz-Allen & Hamilton as risk management consultant for nuclear and mass transportation industry. He has done consulting and training for the Army, Navy, Air Force, NASA, Boeing, Lockheed, BAE Aerospace, and commercial industries in over 20 countries including Australia, Japan, UK, France, Germany, Turkey, Finland, Norway and Brazil.
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