AHRQ: Patient Safety Councils

July / August 2009


Patient Safety Councils:
A New Tool for Patient Safety

Nearly 10 years after the Institute of Medicine’s To Err Is Human report (2000) galvanized the national patient safety movement, healthcare providers and organizations have re-tooled many of their inpatient processes, systems, and training programs as they aim to deliver safer medical care.

These efforts have been given further impetus by the Joint Commission’s National Patient Safety Goals and by a recent policy decision by Medicare to reduce payments for serious hospital-acquired conditions (CMS, 2008). Under this policy, hospitals no longer receive additional Medicare payments for certain conditions that were not present when the patient was admitted.

Despite these developments, efforts to involve patients in addressing healthcare policies, including patient safety, have not progressed at the same pace. There are some notable exceptions, of course. Organizations including the Dana-Farber Cancer Institute, Boston, Massachusetts; Cincinnati Children’s Hospital, Cincinnati, Ohio; and Children’s Hospitals and Clinics, Minneapolis-St. Paul, Minnesota; have earned recognition for involving patients on councils, teams, and boards. Efforts to involve patients in safety issues also have gained momentum across the globe. In 2004, the World Health Organization and its partners launched the World Alliance for Patient Safety to involve patients in reducing the incidence of illness, injuries, and death (WHO, 2009).

But for too many healthcare organizations, the patient point of view tends to be regarded more as a customer satisfaction metric than as an integral part of healthcare. Processes that require patients’ active understanding, such as outpatient medication management, are often designed to accommodate the needs of doctors, nurses, pharmacists—everyone except the patient.

The result is an unacceptable rate of medication errors that too often leads to adverse events ranging from lost productivity to injury and death. More than 500,000 medication errors occur each year in outpatient clinics among Medicare patients alone, an estimate that is probably conservative, according to the Institute of Medicine (2007).

A Community-Based Patient Safety Council
Concerns about how to reduce medication errors in its 100 outpatient clinics prompted Aurora Health Care, an integrated delivery system based in Milwaukee, Wisconsin, to develop a community-based patient safety council. While general information about using patient advisory councils to address safety issues in the inpatient setting was available, few resources addressed how to involve patients in outpatient care safety, according to Kathryn Leonhardt, MD, MPH, medical director of care management at Aurora Health Care.

Beginning in 2005 with a grant from the Agency for Healthcare Research and Quality (AHRQ), Aurora Health Care launched its community-based patient safety council. Its intent was to foster an environment that allowed patients and health providers to openly discuss the barriers and opportunities for medication safety.

A kick-off meeting to inaugurate Aurora’s council included the participation of Consumers Advancing Patient Safety (CAPS), a consumer-led advocacy group, and Midwest Airlines, a Milwaukee-based regional air carrier known for its customer service. The groups helped participants recognize the value of each party’s point of view while reaching consensus on the council’s key objectives, according to Dr. Leonhardt.

As part of that process, patient and health provider representatives shared anecdotes that revealed significant gaps in communication and understanding on both sides, she noted. For example, provider representatives at the meeting voiced frustration that patients seemed to be uninformed about their medications. However, a patient representative, who also was a caregiver for his wife, presented a complete list of her medications, which he always carried to medical appointments. Despite this patient’s level of involvement, some patients make the mistaken assumption that they don’t need to worry about their medications, Dr. Leonhardt said, because “my doctor has a list” (Leonhardt, 2006).

Creating Your Own Patient Safety Advisory Council
Noting that the first steps in building a patient advisory council can be the hardest, Dr. Leonhardt and her colleagues at Aurora Health Care outlined the key steps involved in creating a council in the Guide for Developing a Community-based Patient Safety Advisory Council (AHRQ, 2008).

According to the guide, the steps a healthcare organization should consider to create a successful patient safety advisory council include:

  • Determining the council’s scope. This involves defining the council’s goals and objectives, which can vary depending on the size of the organization and its history in involving patients in decisionmaking. Specifically, organizations should select a specific process or aspect of care, identify primary safety concerns of patients and providers, and select a topic the organization has addressed but not successfully resolved.
  • Selecting the council’s members. The council’s members are critical to building a partnership between providers and patients, and roles and responsibilities should be clearly defined. Patient members provide the consumer perspective and should have first-hand knowledge of patient safety issues in addition to an ability to collaborate with a diverse group of participants.

    Depending on the project’s scope, health providers can include doctors, nurses, pharmacists, and social workers. Provider representatives must be willing to work with patients and with other practitioners. Finally, the project lead serves as the council’s “coach” and should serve in a leadership position within the organization and possess the relevant expertise, time, and communications skills to work effectively among a diverse group of individuals.

  • Determining a budget. Establishing a patient safety council does not require a substantial budget. Small projects can be completed with a minimal investment of time by staff and volunteers. Projects that are larger in scope can require additional resources; suggested annual budgets are provided in the guide.
  • Conducting regular council meetings. Organization, planning, and preparation are key elements of effective council meetings. Some ground rules that can promote open communication include speaking in non-medical terminology and agreeing to address all council members in the same manner (by first name, for example) to avoid authority differences between patients and health providers.
  • Sustaining the partnership model. The initial excitement generated by a successful patient safety council can diminish once the project is under way. To sustain the momentum for patient involvement, organizations can consider steps such as including one or more patient representatives on different projects or sharing the experience with other health providers at meetings and conferences.

Evaluating Outpatient Medication Safety
Based on input from its patient safety council, Aurora Health Care developed and distributed personal medication lists and bags to patients and encouraged patients to bring their medicines to clinic appointments to verify them with their medical records. A public education program was launched to address medication safety, and health providers distributed the bags to patients who took five or more medications. To support providers’ work flow, a medication reconciliation process was developed at Aurora’s five participating clinics, and education and training was conducted to encourage patients’ understanding of their medications.

To evaluate the impact of the outpatient medication safety program, all scheduled patients of Aurora Health Care’s primary care providers are contacted once a year prior to medical appointments and reminded to bring their medication lists with them. During these appointments, providers compare patients’ medication lists to what is documented in their clinic’s medication list.

The AHRQ project revealed:

  • More accurate medication lists for older patients. The accuracy of medication lists among patients 55 and older improved from 55% before the education campaign to 72% afterward. The use of any medication list by patients seen in the five clinics increased from 51% at baseline to 61% after the campaign.
  • High levels of patient engagement. More than three-quarters (76%) of patients 55 and older had documented their medications on the list they received, while 73% brought the list to their physician appointment.
  • High levels of provider engagement. Surveys found that 85% of physicians, nurses, and pharmacists agreed or strongly agreed that having patients bring in their medication list enhanced the accuracy of the medication list
    on file.
  • Broad reach throughout the county. As a result of the medication safety program, 8,000 bags and 16,000 medication lists were distributed during approximately 100 community presentations. Additionally, a telephone survey revealed that 13% of local residents who were not Aurora patients also received the medication lists.

Healthcare providers may be a highly diverse group, but they are motivated by a common goal: to maintain patients’ health and well-being. As we aspire to transform our healthcare system into one that truly puts the patient at the center, we need guidance on how to translate that vision into reality.

The patient safety advisory council is a useful, practical tool that can help us achieve the important goals of improving patient safety in a variety of healthcare settings and involving patients in a meaningful way in that process.

Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at George Washington School of Medicine in Washington, D.C. She may be contacted at carolyn.clancy@ahrq.hhs.gov.

Agency for Healthcare Research and Quality, Innovations Exchange. Community collaboration improves accuracy of medication lists for elderly patients in outpatient clinic setting. Available at: http://www.innovations.ahrq.gov/content.aspx?id=1766. Accessed May 1, 2009.

Centers for Medicare and Medicaid Services. (n.d.). Hospital-acquired conditions (Present on admission), Overview. Available at: http://www.cms.hhs.gov/HospitalAcqCond/. Accessed May 4, 2009.

Institute of Medicine. Committee on Identifying and Preventing Medication Errors, Board on Health Care Services. (2007). Quality chasm series: Preventing medication errors. P. Aspden, J. Wolcott, J. L. Bootman, & L. R. Cronenwett (Eds.). Washington, DC: National Academies Press.

Institute of Medicine. Committee on Health Care in America. (2000.) To err is human: Building a safer health care system. L. T. Kohn, J. M. Corrigan, M. S. Donaldson, (Eds.). Washington, DC: National Academies Press. Accessed May 11, 2009 at: http://www.nap.edu/catalog.php?record_id=9728

Joint Commission. 2009 National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed May 4, 2009.

Leonhardt, K., Bonin, D., & Pagel, P. (2008, April). Guide for developing a community-based patient safety advisory council. Prepared by Aurora Health Care, Wisconsin. AHRQ Publication No. 08-0048. Rockville, MD: Agency for Healthcare Research and Quality.

Leonhardt, K., Bonin, D., & Pagel, P. (2006). Partners in safety: Implementing a community-based patient safety council. Wisconsin Medical Journal 105(8), 54-59.

World Health Organization, World Alliance for Patient Safety, Patients for Patient Safety. Available at: http://www.who.int/patientsafety/patients_for_patient/en/index.html/. Accessed May 20, 2009.