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patient safety webinarPlease register for Strategies to Manage Hospital Acquired Conditions Reporting in an ACA World - An IC Check-Up on Sept 9th, 2014 1:00 PM CDT at: https://attendee.gotowebinar.com/register/5973501898406116610

With the August 1 Final Rule announcement by CMS, it’s time we had an Infection Control check-up from our IC expert, Brian Foy.

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Is the Answer to Enhanced Patient Safety Hiding in Plain Sight?
The Transformation of “Incident Reporting"

Is the Answer to Enhanced Patient Safety Hiding in Plain Sight? The Transformation of “Incident ReportingWe all have these systems, whether paper or electronic, that are supposed to capture incidents that can lead to and/or have resulted in patient harm. Most of these systems can do this, but many will agree that there is something missing – something important – when it comes to whether or not these systems actually enhance patient safety.

We cannot just track incidents anymore; we need to make this an organization-wide process where we build awareness, which leads to intervention, and results in changes that can be seen and monitored. In this white paper, we discuss the transformation of traditional “incident reporting” into an integrated patient safety management system and offer a path to achieve this transformation.


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Event Reporting

The Link Between Transparency and Patient Safety

Since early 2010, 13 private, acute care hospitals in Rhode Island have been collaborating in a major initiative to improve patient safety through better reporting of data on adverse and near-miss medical events. The hospitals now use the same medical event reporting technology and have standardized their reporting criteria.

November/December 2011

Event Reporting

The Link Between Transparency and Patient Safety

 

This is the third in a series of articles about Rhode Island’s statewide implementation of a standardized web-based event-reporting platform to facilitate the reduction of medical
errors. The first article, “How Rhode Island Is Leading a Revolution in Patient Safety,” is available at www.psqh.com/januaryfebruary-2011.html. The second article, “State-wide Leadership Creates a Culture of Patient Safety in Rhode Island,” is available at www.psqh.com/septemberoctober-2011.html.

Since early 2010, 13 private, acute care hospitals in Rhode Island have been collaborating in a major initiative to improve patient safety through better reporting of data on adverse and near-miss medical events. The hospitals now use the same medical event reporting technology and have standardized their reporting criteria. They also joined a patient safety organization (PSO) to have a forum for sharing knowledge and insights gained from the reported data, as well as best practices for developing a safer care environment.

In the first year since the reporting mechanisms and processes have been in place, the hospitals have made significant gains. In Kent Hospital, for example, the report rate went up on average 167% per quarter after MERS implementation, and the gain in reporting has been sustained for more than a year. This rich information provides much more content and insight for the hospital to utilize towards understanding near-misses and reducing the potential for harm.

This stands in contrast to the experience of many other hospitals. An adverse event reporting practices survey by the RAND Corporation demonstrates that although many hospitals have reporting mechanisms in place, few capitalize on the full capacity of these mechanisms to ensure proper actions take place. For example, the survey showed no improvement in distribution of adverse event reports to three key hospital departments (senior administration, nursing, and medical administration) from 2005 to 2009. In addition, fewer than half of the surveyed hospitals said that adverse event reporting led to immediate actions or to a performance initiative (Farley et al., 2010).

Cultural change may be a key difference between those hospitals and the Rhode Island group. For the Rhode Island hospitals, a critical factor in achieving positive results has been the focus on developing greater transparency about the sharing of information that affects patient safety. In this article, two thought leaders in patient safety discuss the role of transparency: Sandra Coletta, president and CEO of Kent Hospital in Warwick, Rhode Island, and David Mayer, MD, associate professor of anesthesiology for the University of Illinois at Chicago (UIC) and co-executive director for UIC’s Institute for Patient Safety Excellence.

How would you define transparency in regard to patient safety?
Mayer: Some people use the terms transparency and disclosure interchangeably. I think there’s a real difference. Disclosure is what happens after the fact. Something occurred, and now you disclose or acknowledge it. Transparency, on the other hand, is part of a hospital’s culture, meaning that every action flows from a shared belief in openness, honesty, and truth in the sharing of information.

Coletta: Transparency is about the willingness and ability of your staff to be honest with the organization about actions that may be putting patients at risk. That’s where transparency makes so much more difference in terms of preventing future events. When we share information about at-risk behaviors with one another, the whole organization becomes smarter and more compassionate. When we see someone taking a risk, the reaction is to step up and try to coach that person, rather than ignoring the behavior or judging it.

How does transparency impact the patient’s experience?
Mayer:
Transparency begins with the first conversation you have with the patient or family member. You have to understand their values, needs, preferences, and goals. You have to share all of the information you have so they can make viable choices. You have to talk about the benefits and the risks and have discussions that set correct expectations around what might happen if the procedure is performed and what happens if it isn’t. You have to continue to be transparent about what is happening throughout the care process, including end-of-life issues.

What is the relationship between transparency and event reporting?
Mayer: If we don’t know about things that are going on—not only adverse events, but also near-misses and unsafe conditions—we can’t solve the problems that already exist. Wrong-site surgery is a good example. For years, these events were under-reported. The feeling was: “Don’t say anything—just be more careful. Let’s keep it amongst ourselves.” As a result, we didn’t know how prevalent the problem was and we didn’t learn how to address it. Solutions begin with reporting, and if the culture isn’t transparent and “just,” it’s difficult for people to share the sorts of events that need to be reported.

How does event-reporting technology help?
Mayer: Electronic reporting systems make it much easier to communicate about unsafe conditions and problems. If it takes 20 minutes to fill out paperwork on a near-miss event, chances are, many people won’t do it. Computerized reporting makes it very simple for the caregivers. That’s why it’s so valuable. Another benefit is the ability to code and aggregate the data in de-identified ways so that it yields information that helps the institution focus its improvement efforts. It’s not a cure-all. You still need hotlines; you still need anonymous reporting; you still need the ability to walk into the safety-and-risk office, close the door, and say: “I need to share something with you.” Those are all elements of transparent organizations that create a culture in which people feel that they can report events.

How is Kent Hospital working to embed transparency within the organization?
Coletta: As of October 1, 2011, we eliminated our disciplinary process house-wide, and converted the entire institution to the Just Culture model. We believe the best way to make it safe for people to step forward is to apply the Just Culture methodology to all events, whether somebody punched in late to work, used the wrong recipe in the cafeteria, or violated any hospital policy. From my perspective, to apply Just Culture only to patient safety is like living in two worlds. If it applies in patient safety events, why doesn’t it apply anywhere else?

How does that work, practically?
Coletta: What is required under Just Culture is that every event be thoroughly investigated. Say, for example, a payroll error results in a check for $1 million being deposited in your account and you don’t report it. That might be grounds for automatic termination in some organizations. Upon investigation, however, we might discover that it was a direct deposit and you were unaware of it. Or that your spouse maintains the checking account and was sick at the time. Jumping to the conclusion of theft is unwarranted. So that’s the commitment we’re making—that all situations will be handled in the Just Culture context, meaning that the manager will evaluate whether an event is the result of human error, at-risk behavior, or reckless behavior.

How will that help improve patient safety?
Coletta: Knowing that the Just Culture process will be applied to every policy transgression, large or small, that occurs in this hospital will make employees more trusting that they can step forward. Our event reporting system has improved our openness and sharing significantly. We hope that making Just Culture our standard for all events will take us even further. An organization that acknowledges at-risk behaviors in a non-punitive way and seeks to prevent them in the future creates employees who will do the same for one other. We want to create a consistent culture in which everyone who works at Kent Hospital can be transparent with themselves. I have to be able to see my weaknesses and accept the fact that I have them. Only then can I be transparent with my co-workers. As a patient, I would rather be in the hands of caregivers who know their weaknesses and are addressing them than with people who are blind to their humanity and unwilling to accept the fact that they may make mistakes.

What keeps people from reporting?
Mayer: Two of the greatest obstacles are fear of retribution and apathy due to lack of feedback. If I’m a junior attending and report an event that involves a senior nurse or senior attending, I need to know that the reporting environment is safe, that no one will make my life miserable or fail to renew my contract as retribution. An organization with a transparent Just Culture rewards people for reporting rather than punishing them. Lack of feedback is another de-motivating factor. Even staff members who realize that their reports are helping to improve the hospital may get apathetic about reporting in the absence of feedback. Leaders need to find ways to thank the reporter, to share how the report helped the organization improve, and, if warranted, use each report as a teaching moment to help the reporter learn how to prevent similar events from occurring in the future.

Coletta: Recently I awarded Employee of the Month to a security guard who had violated a policy and then disclosed the violation to his boss. There was no adverse effect, and if he hadn’t spoken up, no one would have known. But the guard felt the situation was such that he should tell someone that he didn’t do what he was supposed to. I want all 2,000 of our employees to feel that way.

How do you get clinicians to automatically think, “Report first”?
Mayer: At the UIC Medical Center, our training program for residents is focused on raising awareness about the importance of reporting. We conduct educational sessions. We show residents how their reports are contributing to improvements in patient care. As a result, they become more engaged in the process. Our goal is to educate residents in such a way that when they leave here and go to other hospitals, they say “WHERE do I report?” instead of “Why do I report?”

What has been the result of your efforts?
Mayer: In the last three years, through the combination of our electronic reporting system and our educational efforts, we’ve increased from 1,500 reports a year to more than 7,000 reports a year at the University of Illinois Medical Center. Resident reports account for nearly 1,000 of that total—up from zero reports when we started the program. The vast majority of these reports are near-misses and unsafe conditions. We share the results, de-identified and aggregated, with the departments each month or quarter. We talk about what we learned and how we working to change potentially unsafe conditions. That type of feedback is a big reason why we’ve seen our reporting increase substantially.

What role does leadership play in creating a more transparent culture around patient safety?
Mayer: The vast majority of healthcare providers want to be transparent. But the culture and reporting environment in most hospitals have made that challenging. Transparency starts at the top of the organization with leaders who say, “This is what we stand for. This is how we will practice.”

Coletta: A just and transparent culture does not bubble up from the bottom. Unless there is a commitment from the very top, efforts will collapse. You need some muscle behind Just Culture. You can’t expect employees to be courageous if their leaders aren’t.

Patricia Daughenbaugh is senior manager for patient safety at GE Healthcare Performance Solutions.
Kathy Martin is director of the GE Healthcare Patient Safety Organization. She may be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. .


References
Farley, D. O., Haviland, A. M., Haas, A. C., & Pham, C. (2010 July). Adverse event reporting practices by U.S. hospitals: Survey results from 2005 and 2009. RAND Health Working Paper. Available at http://www.rand.org/content/dam/rand/pubs/working_papers/2010/RAND_WR752.pdf

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