Apresentação de Derek Freeley durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil. Derek Freeley é Vice Presidente Executivo do Institute for Healthcare Improvement (IHI), tem responsabilidades executivas por conduzir estratégias do IHI em cinco áreas de atuação: desenvolvimento de habilidade; cuidado centrado no paciente e família; segurança do paciente; qualidade; custo e valor; e grande foco em populações. Antes de integrar a equipe do IHI em 2013, foi diretor geral de saúde e assistência social e diretor executivo do National Health Service (NHS) na Escócia.

1. The Global Challenge
for Patient Safety
1st Symposium IHI-Einstein: Implementation and
Scale Up of Patient Safety Programs
November 3, 2013
Sao Paulo, Brazil
Derek Feeley
Executive Vice
President

2. Our Vision
Everyone has the best care and health possible.
Who We Are
IHI is a leading innovator in health and health care
improvement worldwide, joining forces with the IHI community
to spark bold, inventive ways to improve the health of
individuals and populations.
Our Mission
To improve health and health care worldwide.

3. IHI’s Work: Five Key Areas
3

4. Patient Safety
“The magnitude of medical error is enormous.
The fault lies with poorly conceived systems
rather than irresponsible people.”
- Dr. Lucian Leape
4

5. The Situation in Health Care
“What has eluded us thus far…is maintaining a
consistently high level of safety and quality over time
and across all health care services settings.
….Along with some progress, we are experiencing an
epidemic of serious and preventable adverse events.
The concept that I believe can and should change this is:
“High Reliability.”
Dr. Mark Chassin, President, JACHO, Health Affairs, April 2011
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6. To Err is Human
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Although no single activity can
offer a total solution for dealing
with medical errors, the
combination of activities
proposed in To Err is Human
offers a roadmap toward a safer
health system. With adequate
leadership, attention, and
resources, improvements can be
made. It may be part of human
nature to err, but it is also part of
human nature to create solutions,
find better alternatives, and meet
the challenges ahead.

7. Crossing the Quality Chasm
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“Between the health care we
have and the care we could have
lies not just a gap, but a chasm.”
Health care does not yet reliably
transfer best-known science into
action, and processes frequently
fail, despite the best intentions of
a dedicated and highly skilled
workforce. Our system, which
intends to heal, too often does
just the opposite – leading to
unintended harm and
unnecessary deaths at alarming
rates.

8. No Shortage of Analysis

9. Level of Harm
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United States:
3.7% of admissions
44,000 – 98,000 deaths
United States:
3.7% of admissions
44,000 – 98,000 deaths
Australia:
16% of admissions 50,000 permanent disability
250,000 adverse events 10,000 deaths
Australia:
16% of admissions 50,000 permanent disability
250,000 adverse events 10,000 deaths
Denmark:
9% of admissions
Denmark:
9% of admissions
New Zealand:
10% of admissions
New Zealand:
10% of admissions
United Kingdom:
11% of admissions
850,000 adverse events
United Kingdom:
11% of admissions
850,000 adverse events
DoH ECRI 2002 Knox K et all

10. Global Trigger Tool Reviews
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3 Exemplar
Hospitals
(900 notes)
40 Bed rural
Hospital (300
notes)
10 Hospital
Research
Project (240
notes)
7 Hospital
System (3000
notes)
Multi-state
Tertiary
System (2000
notes)
Events/1000
Days
83 90 NA 119 86
Events/100
admissions
45 40 37 41 38
Admissions
with adverse
events
32% 30% 30% 29% 30%

11. Taking Action
The 100,000 Lives Campaign was a nation-wide initiative launched by
the Institute for Healthcare Improvement to significantly reduce
morbidity and mortality in American health care.
Building on the successful work of health care providers all over the
world, we are introducing proven best practices across the country to
help participating hospitals extend or save as many as 100,000 lives.
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12. International Reach
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13. Implementing at scale….
can it be done?
Execution
Ideas
Will

14. Our change theory
A clear and stretch goalA clear and stretch goalA clear and stretch goalA clear and stretch goal
A methodA methodA methodA method
Predictive, iterative testingPredictive, iterative testingPredictive, iterative testingPredictive, iterative testing

15. 0,8
0,9
1,0
1,1
Oct-Dec
2006
Apr-Jun
2007
Oct-Dec
2007
Apr-Jun
2008
Oct-Dec
2008
Apr-Jun
2009
Oct-Dec
2009
Apr-Jun
2010
Oct-Dec
2010
Apr-Jun
2011
Oct-Dec
2011
Apr-Jun
2012
StandardisedMortalityRatio
HSMR up to September 2012
8497 less than expected deaths
12.4% reduction

16. 60
65
70
75
80
85
90
95
100
105
110
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Baseline NHS South West median
98.05
90.90
HSMR NHS South West

17. A New Culture of Safety
Institute of Medicine Report:
• Health care organizations must develop a “culture of
safety” such that their workforce and processes are
focused on improving the reliability and safety of care for
patients.
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18. Culture: A Definition
A culture is made of shared values and beliefs that
interact within an organization in order to produce
behavioral norms, or:
“How we do things around here.”
It is determined by how individuals and teams learn
together and work together.
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19. Lessons Learned
1. Establish and Oversee Specific System-Level Aims at
the Highest Governance Level
2. Develop an Executable Strategy to achieve these Aims
3. Channel Leadership Attention to System-Level
Improvement
4. Put Patients and Families on the Improvement Team
5. Make the Chief Financial Officer a Quality Champion
6. Engage Physicians
7. Build Improvement Capability
IHI Seven Leadership Leverage Points

20. Summary
Safety is a global challenge – harm exists in every
system.
You will have great care in your hospitals but not for
every patient, every time.
Improvement is possible – lives can be saved and harm
avoided.
New systems are necessary to make care safer and
more reliable.
It takes building will, generating ideas and a method for
implementation.
Cultural issues are important – leaders set the tone.
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