Many health care workers shy away from reporting errors for fear of retribution. Not at Missouri Baptist Medical Center.
The hospital's long-term patient safety program, in place prior to the Institute of Medicine's 1999 report on medical errors, To Err Is Human, has created a culture of safety in which employees feel free to discuss actual and potential errors. The open environment, based on trust and understanding, is supported by a system that readily implements procedures to improve the safety and quality of care provided.
"Initially, it was difficult for some people to acknowledge that the system was broken," says Kathy Benage, director of performance improvement. "Now, all employees know our patient safety and quality improvement efforts are the right thing to do. They are not comfortable with the status quo."
Building a blame-free environment is crucial if patient safety programs are to succeed, says Max Cohen, MD, vice president and chief medical officer. That allows staff to focus on safety, help identify and report events and near misses, and promote and implement improvement processes throughout the organization. But getting there was not easy. A survey of staff and managers revealed significant confusion about what a non-punitive environment entailed. Managers had to be taught how to respond to staffers who raise safety concerns, and specific criteria were added to the non-punitive policy detailing when employees would be disciplined. "If the policy had been implemented without this understanding, it would have failed," Cohen says.
All employees receive a brochure addressing Missouri Baptist's commitment to improving patient safety and its non-punitive approach to reporting events.
"We believe we are at the beginning of the journey," Cohen says. "It's not been easy. It started out as a small group of people working in isolation and has taken several years to spread across the organization."
To oversee the process, Missouri Baptist hired a full-time patient safety specialist. The position, held by Nancy Kimmel, a clinical pharmacist, provides staff a single contact for all safety issues. Kimmel is responsible for, among other things, ensuring that the hospital incorporates and uses methods to improve all aspects of patient safety and promotes a culture that recognizes patient safety as a priority. "Employees are starting to see their efforts pay off and it provides the impetus for them to keep it up," she says. "They see they are not only creating a safer environment for patients, but also a safer work environment for themselves."
Patient safety initiatives are developed through a variety of means. Senior leaders participate in weekly walkarounds to discuss safety and quality issues with staff. In addition, employees are encouraged to speak with their managers or the patient safety specialist any time concerns arise.
Cohen says a goal is to make the reporting system easy. An employee can submit an anonymous, one-page, check-box report developed for medication-related events. A safety hotline provides another opportunity to anonymously report safety incidents, and accounts for more than 60 percent of all reports filed.
Efforts to encourage reporting appear to be working. Since the hotline was created almost two years ago, reporting has increased by more than 200 percent. Incident reports alone doubled to about 150 reports per month. The organization's goal is to double reporting again in 2002.
Leaders know that the information is valuable only if meaningful data can be extracted from the reports of errors and near misses. All reports are put into a risk master database to help identify trends and ultimately prevent their recurrence. The database, maintained by the director of risk management and shared with the patient safety specialist, is used to produce process control charts and severity indexes of errors and near-errors every month. When a trend is identified, an improvement team is assembled and its recommendations are given top priority from the performance improvement department. Copies of the information from the hotline calls and incident reports, however, are given to managers immediately so action can be taken and shared with employees.
Missouri Baptist uses assessment tools to improve processes throughout the organization; for instance, it performs the failure mode evaluation analysis on its medication dispensing system. The Root Cause Analysis is used to review sentinel events, as mandated by the Joint Commission on Accreditation of Healthcare Organizations. Missouri Baptist also uses RCA for all potentially serious adverse events, conducting 18 over the past year. "The RCA process has produced a great number of major changes throughout our medical center," Benage says. "By conducting a thorough assessment of an event, we can ensure the changes we are making are helpful and not creating problems down the line. It helps eliminate the Band-Aid approach to safety issues."
The chief medical officer and the director of risk management determine when the RCA will be conducted by the performance improvement and risk management departments. A 12-month follow-up ensures the process changes have been implemented and sustained. Other assessment tools used by Missouri Baptist include the Institute for Safe Medication Practices' assessment for medication safety and the Focus-PDCA Model.
Executive Attention
Leadership visibility and follow-through are a central element of Missouri Baptist's patient safety program. "Executive walkarounds have made a difference in staff awareness of our patient safety program and the culture we are trying to initiate in our facility," Kimmel says. During the walkarounds, executives take notes and identify actions to be taken. Feedback is shared with hospital staff through a twice-monthly newsletter, We Heard You, We Acted, from the chief medical officer.
On one walkaround, Cohen says, an employee expressed concern that patients were not receiving intravenous piggybacks because the administration times were not printed on the medication administration record. A review of the process and the data determined such failures accounted for 30 percent of MAR-related events. So, a team created to improve the IVPB process set standardized administration times similar to those already in place for oral and injectable medications. It asked the vendor for the pharmacy management system to make the changes, and followed with an extensive education campaign that included pocket cards.
Prior to the changes, Cohen says, about 10 to 15 missed medication reports were filed per month. Since the program was implemented last November, no reports have been filed.
Awarding Safety Efforts
To recognize such innovative solutions, Missouri Baptist began a Patient Safety Award program. Winners receive $100 to $5,000 toward their efforts, based on whether the proposed change's impact is unit-specific or organization wide.
Despite the successes, Cohen acknowledges that more improvements are needed, and staff members have already provided so many recommendations that they would take several years to implement. A priority, he says, is improving feedback to employees. "We need to reinforce to our staff that their input is helping us achieve our patient safety goals," he says.
"If you don't fundamentally change culture, you won't succeed," Cohen says. "Every person knows they are responsible for quality and safety and they are now comfortable with those responsibilities. Only when you reach that kind of accountability will you succeed."
Text used with permission from the American Hospital Association.
Runy LA. The American Hospital Quest for Quality Prize. Hospitals & Health Networks. 2002 Aug;76(8):49-56.
