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Desenvolvimento da cultura de
qualidade em uma grande corporação da indústria da Saúde.
Quem somos!
Americas Serviços MédicosCearáFortaleza• Hospital Monte Klinikum
Rio Grande do NorteNatal• Hospital Promater
PernambucoRecife• Hospital Santa Joana Recife
Rio de JaneiroRio de Janeiro - Capital• Hospital e Maternidade Santa Lúcia• Hospital Pró-Cardíaco• Hospital Samaritano – Botafogo
• Americas Medical City (Samaritano Barra e Vitória Barra
• Americas Centro de Oncologia Integrada
Distrito FederalBrasília• Hospital Alvorada da Brasília
São PauloSão Paulo - Capital• Hospital Samaritano Higienópolis• Hospital Vitória Anália Franco• Hospital Alvorada• Hospital e Maternidade Metropolitano• Hospital Paulistano• Hospital TotalCor• Lotten EyesMogi das Cruzes• Hospital IpirangaGuarulhos• Hospital Carlos Chagas
Caieiras• Hospital de Clínica
CaieirasArujá• Hospital e Maternidade
Ipiranga ArujáSantos• Hospital Vitória SantosCampinas• Hospital e Maternidade
Madre Theodora
2.781leitos
17.368 colaboradores
704 leitos de UTI
145 Salas cirúrgicas
126.762cirurgias/ano
220.258internações/ano
3.661.635exames/ano
2.097.764Atendimentos emPronto-socorro/ano
01Experiência do Paciente
04
Bem estar da equipe de cuidado
02Saúde da
população
03
Eficiência nos custos
Quality and Patient Safety Pillars(2018-2023)
Safety Culture Clinical Governance Patient ExperienceHigh Reliability
Organization
• Mutual Trust
• Clear communication
• Detection and reduction of risk
• Incident recovery
• Confidence in the measures
implemented
• Professional responsibility
• Fair culture
• Resilience
• Effectiveness of clinical
intervention
• Clinical audit
• Efficient risk management
• Education and training of
professionals
• Evidence-Based Practice
• Transparency in all processes
and interpersonal relationships
• Accountability
• Team Engagement
• Value in care
• Eliminate waste and care
uselessness
• Patient activation
• Clinical outcome
• Customer satisfaction
• Respect the patient's
preferences
• Full attention
• Sensitivity to operations
• Concern about failures
• Continuous improvement
• Reluctance to simplify
• Commitment to service delivery
• Empowering professionals
• Deference to expertise
• Resilience
• Perception of culture survey
• Data validation
• Clinical audit
• Accountability Matrix
• Definition of roles and
responsibilities
• Clinical audit
• Risk management
• Focus on the patient
• Professional development
• Patient involvement
• Evidence-based assistance
• NPS
• HCAHPS
• What matters to you
• Person
• Impressions
• Processes
• Local
• Definition of roles and
responsibilities
• "Zero Harm"
• Assessment of high leadership
• Learning from mistakes
• Proactive Assessment
• Crew Resource Management
• Previously designed processes
• Accountability
Tools Tools Tools Tools
1 morte/783 internações
National QPS (quarterly)
learning sessions
KPIs QPS in Friday Meeting (monthly)
Regional QPS (monthly)
Nursing managers / General wards / Operation rooms /Emergency Department / ICU/ NICU/
PICU/ Infection Control /Pharmacy Clinic /Patient Quality and Safety
Local QPS (monthly)
Incidents (including Infection control)
Care Risks
KPIs departments
Coverage and profiles of QPS
Main Achievements
All hospitals assessed
UHG Essential Standards
Created and structured at corporative level
QPS & Care Practice Teams
Adequacy to categorize Adverse Events
WHO Taxonomy
Published to guideQuality and Patient Safety in
healthcare practice
QPS Guidelines
Implemented in all hospitals 74.663 notifications by
Dec,18
Notification System
Established to manage critical events with permanent
harm/ death or institutional image risk.
Crisis Committee
Standardized, collected and reported to monitor and
compare
KPIs and QPS metrics
Established to evaluate cases treated by crisis committee
when necessary
2nd Opinion Committee
Dec, 18Jul, 17
Daily huddle focused in safety1.581 interventions
Success rate 83%
Safety Huddle
Hospital Accreditation
International Quality Program
Accredited Accredited diagnosis
National Quality Program
Accredited Accredited diagnosis
• Alvorada Moema• Paulistano• Samaritano Higienópolis• TotalCor• Pró-Cardíaco Botafogo• Samaritano Botafogo• Centro de Oncologia Integrado RJ• Santa Joana
• Vitória Analia Franco• Américas Medical City• Monte Klinikum• Alvorada Brasília
• Caieiras• Carlos Chagas• Ipiranga Mogi• Madre Theodora• Metropolitano Lapa• Santa Lucia• Alvorada Brasília
• Ipiranga Arujá• Santa Lucia
Resilience
Corporate supportCrisis Committee
Identificationrisks
• Care
• Image
• Legal
• Media
• Human Capital
InitialMitigation
Support
Disclousure • Validation
Root cause analysis
•Care•Image
•Legal•Media
•Human Capital
Corporate supportTechnical camera
Identificationrisks / Trigger
Specializedsupport
Care planvalidation
Second opinionor telemedicine
Example
•ED
•ICU
•Pediatric
•CoEs
FOCUS:
• Support specialists for conduct cases
• Protection of those involved
• Group learning
• Corporate Uniformity • Triple aim
Corporate supportSafety Huddle
FOCUS:
• Individual action: mitigation action / caresupport. Ex: Error in administration ofchemotherapy
• Action prevalence: corporate actions tosupport the process. Ex: suicidal ideation
IncidentsReport (24h)
•Average 300 incidents / day
Validation of critical
incidents
SafetyHuddle
Local Prioritization
•Average 20 incidents / day
• Support decision
• Support Regional QPS
Safety Huddle
344
252
158
362
465
12
11
3
9
19
0 100 200 300 400 500 600
NE - DF
RJ
Samaritano Higienópolis
SP 1
SP 2
Incidence of notification with intervention for resilience (AGO18-Jan19)
Interventions Deaths
Analysis of 2018 Severe Adverse Events
Total
Reported
759
NUMBER OF CASES
IN SAMPLE
Source: Sample from Notification System – EPIMED, 2018.
DISTRIBUTION BY SEVERITY (%)
NOTIFIER´S PROFESSIONAL
CATEGORY (%)
BRONCHOASPIRATION
ERRORS AND DELAYS IN MEDICAL CARE
INCIDENTS BY TYPE
12%
19%402
Incident analysis flow
Proactive analysis
Care team / Team patient safety
Londol ProtocolPrevalence analysis
Corporate support
Riskcircumsta
nceNear miss
Incidentnoneharm
MildHarm
Adverse Event
Adverse event
moderatedamage
Adverse eventsevere
damage
Death Crisis
Safety Huddle
83%
17%
Success in resilience level 2 Death
1581 interventions (Ago 18 – Jan19)
The Incident Decision Tree
2
1
The Incident Decision Tree
2
2
1 Sabotage, intended harm etc
2 Substance abuse without mitigation
3 Substance abuse with mitigation
4 Possible reckless violation
5 System-induced violation
6 Possible negligent error
7 Guiltless error but advice is needed
8 System-induced error
9 Blameless error
Obrigado!
Dario Fortes [email protected]