The Push for Patient Safety

In recent years, an increasingly bright spotlight has been cast on the effort to promote patient safety throughout all healthcare environments. Many effective programs and initiatives, both national and local, have advanced the safety dialogue, and have aided many facilities in dramatically improving outcomes. Moving into the 21st century, the bar will continue to be raised by organizations committed to exploring innovative ways in which to protect patients.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHOs) National Patient Safety Goals (NPSGs) are designed to highlight problematic areas in healthcare and describe expert-based solutions to them. The basic principle behind the Safety Goals and this goes back to when the concept was first approved by the board of commissioners is to focus on a relatively small number of topics, with specific requirements, and work with organizations on those topics before moving on to other things, expanding the list and so on, explains Richard Croteau, MD, executive director for patient safety initiatives, Joint Commission International Center for Patient Safety. The mandate we have is to annually review the National Patient Safety Goals and make recommendations to our board, whether to keep what we have, add to it, move certain things out of the safety goals, perhaps into the standards. To do that, we have a panel of experts on patient safety, systems engineering, etc.; thats the group that we refer to as the Sentinel Event Advisory Group (SEAG).

This group meets several times annually to review and prioritize the list of topics and decide what should even be considered in terms of new topics and requirements. Any additions then go up for field review. We post that information, potential goals and requirements, on our Web site, available to anyone who wants to comment on it, Croteau continues. What were looking for, specifically, is information on what the impact would be if a particular requirement were implemented; whether its seen as cost effective, what the impact would be, what the burden would be, and how practical it would be for the different types of organizations we accredit. We bring that information back to the Advisory Group and they formulate their recommendations which then go to our board for their review and modification, if they wish to, and approval. Our track record on limiting expansion of the goals and requirements is fairly good, but there have been new goals added each year. There have been some that have been retired, and theres a constant tension between wanting to add everything that we recognize as a safe practice vs. keeping the focus, which was the original intent.

NPSG 8 focuses on accurately and completely reconciling medications across the continuum of care.¹ This involves implementation of a standardized method for creating an accurate list of medications when patients enter a facility. The medication list should be communicated between service providers within the facility and checked for accuracy. Croteau notes that this goal continues to be an issue for many facilities. The principle is pretty straightforward; when youre ordering medications for a patient, you should know what theyve been taking up to that point, he says. Most people would agree with that in principle, so the challenge then is implementing a process to gather the information about what a patient has been taking, and doing it consistently. When we first started talking about this as a safety goal, the feeling was that we could go ahead and establish it as an expectation and it would happen. We were advised by some people who were working on this for a few years that it really wasnt all that simple, so we took the unusual step of introducing it a year and a half before it was due for full implementation, building in a full year for developing the process and testing it. Even with that, a significant percentage of hospitals that we survey now are still not fully in compliance with the requirement.

Croteau explains that there seems to be a typical sequence in which hospitals implement this goal. They generally start out looking just at inpatients and they will put a process in place to gather information about the medications that a patient has been taking when he or she is admitted to the hospital, he says. The next step is to start using that information as they go through different transitions in care during the hospitalization; moving from one unit to another, going to surgery, and so on. Then finally, using that information at the point of discharge to be able to instruct the patient on what to do about medications when they go home or wherever theyre going after discharge, and provide a new list of the patients medications that will be taken following discharge. All of that, though, has to do with inpatients; the requirement is broader than that its for all settings of care. Where organizations most often are not in compliance when we do our surveys now are in the ambulatory services associated with the hospital, as well as the emergency department.

Facilities that excel in terms of patient safety must have support at all levels. It all comes down to the culture of the organization, Croteau says. We recognize that different organizations have different cultures, and its heavily dependent on the leadership and the message thats sent, and how patient safety is seen in the context of all of the operations. What were looking for are organizations in which safety is the primary consideration in everything thats done; its not seen as someones job to do patient safety, but rather thats what the organization focuses on in everything it does.

Croteau notes that this effort involves constant vigilance and awareness that adverse events may happen at any time. Looking for what can go wrong, trying to anticipate it and head it off before it happens, and always looking to protect the patients from the inevitable mistakes that will be made, because people are people; we all make mistakes. Its the culture, its the attitudes, and its the behaviors of people that act out on that culture. Weve been studying this very closely as we study adverse events that are reported to us, and that continues to come through as kind of the bottom line, the ultimate root cause of all of this, and so were going to be addressing that in our standards; there will be more in our standards relating to the culture of the organization how to measure it, how to improve it, what the different attributes of a safe culture are.

Safety at the Organizational Level

Safety-conscious hospitals frequently employ a variety of means to promote safety. Support from high-level administration is a must in such cases. You need to heighten the awareness; it needs to be obvious to the employees that this is important from the very top of the organization down, says Stephen Smith, MD, chief medical officer of The Nebraska Medical Center. Safety is the first item on our board of directors meeting agenda, and the employees are aware that the board wants to know whats going on with safety and quality first. Our CEO is a strong advocate for investing in and participating in safety projects, so employees know that the CEO takes this very seriously as well.

Probably the most important thing that has occurred in our institution has been the development of champions for our patient safety initiative, says Barry Evans, RN, MSN, adult critical care data coordinator/project manager at the University of Rochester Medical Center. This is at all levels, and we look at our hospital administrators as our No. 1 champions; without their support, this wouldnt be occurring. They truly do champion the work that is being done on the floors and in the ICUs. Its kind of been a revelation to watch this evolve over the last few years. Care has really taken such a significant stride in the right direction and outcomes are just fabulous. Staff members are really proud of what theyre doing, and if we didnt have the support of administration I dont think we would have been so successful in achieving what weve been able to do here.

Evans cites the importance of monthly senior leadership rounds, called safety rounds, in which staff members sit with hospital leaders such as the director of nursing, chief financial officer, chief safety officer, and director of ICU. They come and address issues that the staff members feel are important to patient safety, she explains. This can be anything from pharmacy issues to equipment; we discuss a lot around things such as rapid response teams, and the staff really like it and feel that their concerns are valued by leadership. Things are acted upon and improvements are made that impact staff as well as patient safety issues, so thats been a very positive thing that weve been doing.

Patient safety rounds have been important development at Nebraska Medical Center as well. Smith explains that members of the administration regularly attend staff meetings in different areas in order to address safety concerns. Its not just patient care areas, but we go to radiology, pharmacy, IT, and everywhere else, he says. The whole purpose of the conversation is, What are the issues youre facing that are unsafe? What did you have to do yesterday as far as a work-around because something wasnt safe? Where is the next mistake going to occur on this floor? We talk about things like that and we have a conversation on a regular basis with the employees.

Smith adds that this effort is key in establishing relationships between clinicians and administration. I always leave those meetings saying Ill be back in a few months, but I ask them to call me at any time if they have an issue. Then we take that information back and enter it into a database so that it gets tracked; we assign accountability and resolve the issue, then we follow up with the floor and let them know who is going to take care of the issue. Then we follow up and make sure that weve got those things taken care of. Our last inventory was more than 1,000 issues, and we had resolved more than 90 percent of those in a very short time. We speak about it in the employee forums, articles appear in our newsletter on a regular basis, so we do whatever we can to constantly remind individuals that this is an important topic.

Evans facility has successfully committed to several of the Institute for Healthcare Improvement (IHIs) 100,000 Lives Campaign initiatives. In fact, the American Association of Critical-Care Nurses (AACN) recently named Strong Memorial Hospitals Medical Intensive Care Unit team a winner of the Baxter Excellence in Patient Safety Award for implementing a program to reduce the cases of ventilator-associated pneumonia (VAP). Weve used a lot of the principles of IHI, and its just spread throughout the whole institution - it started in a very small area for us, critical care, and weve been able to carry it through, she says. Were open to new and innovative things, and I think thats been critical to our success the ability to forge forward and incorporate innovative aspects of care and just see what we can come up with and what our results are. Weve been very fortunate in that our results have been dramatic. Change is never easy; you have to be patient and you have to continue moving forward.

The team is probably the key component in keeping us going, Evans continues. We have the adult critical care medical director, he is over all of the ICUs, and we have an associate director of the ICUs who is in charge of nursing. We have structured meetings, and these are open to all four of our ICUs; they all send someone to these meetings. All of our ICU attendings are involved, and everyone has really bought into it and has invested in what were doing, so we come to the meetings, and we bring our results and initiatives; its turned into a huge multidisciplinary approach to patient safety. We do have some great leadership here; not just our hospital administrators, but our ICU administrators as well.

Effective communication is another vital component of a safe environment. Smiths facility has recently instituted crew resource management (CRM) techniques similar to those used in the aviation industry. Beginning in February, OR teams from orthopedic, cardiovascular, and oral and maxillofacial surgery received CRM training. We decided the first place where we should roll this out was surgery, because the culture in an OR is not that dissimilar from that in a cockpit, so we started there, Smith says. We picked those groups because we actually just opened up a new building in January for surgery, and the surgical suites are kind of arranged in pods, so we picked that pod because the nursing staff that works in that area will be fairly consistently working with those physicians. We finished the training in February, and once you finish the training and do a risk assessment, then you custom-fit specific tools to address those issues and hard-wire them so that becomes the way of doing business. Those tools have been selected, and were in the process of implementing them in those three areas.

The people who went through the training were pretty skeptical to start out, but we told them it was important to the organization, Smith continues. Virtually every one of them came back and said they had learned a lot and agreed with the importance of this effort. They learned about communication, teamwork, checklists, how to function in the OR, and so on. Part of that is the development of measurement systems that will document our outcomes, so weve identified the areas that we specifically want to measure.

In terms of incorporating national standards such as the NPSGs, Smith says keeping a focus on innovative approaches to patient safety can make compliance easier. We try to stay fairly proactive with these kinds of things, so a lot of things they bring up, weve fortunately already identified as issues, and have been working on, which is gratifying to us in trying to stay ahead of the curve, he notes. For example, one item on the draft list for 2007 is how to address fatigue; how do you educate your employees about fatigue, how do they manage it, and so on. Thats a significant piece of the crew resource management effort. The training that were doing has already heightened the awareness of fatigue issues on our campus. Its just a small area, but surgery is an important area, and well eventually roll this out to the rest of the campus. 

Reference:

1. Joint Commission 2006 National Patient Safety Goals Implementation Expectations. http://www.jcaho.org/NR/rdonlyres/DDE15942-8A19-4674-9F3B-C6AE2477072A/0/06_NPSG_IE.pdf