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The Quality Colloquium at Harvard University
August 27, 2003
Patient Safety Organizational Readiness
Assessment Tool
Louis H. Diamond, MD
Vice President & Medical Director
Medstat
Beverly A. Collins, MD
Medical Director
Delmarva Foundation for Medical Care
An Agenda to Improve Patient Safety
Leadership buy-in and commitment
Conduct Organizational
Readiness Assessment*
Establish a nonblame culture
Employee survey
Make errors visible**
Disseminate and
facilitate adoption
of best practice
Conduct root cause
analysis
*Dimensions: Strategic, Cultural, etc.
**Employee reporting, patient reporting, medical record review, data mining
***Point of care and near term
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Train staff in the
safety sciences
Make tools
available
to patients
and healthcare
professionals***
Implement best practice
Crossing the Quality Chasm
Leadership
Statement of Purpose
Prioritize
Restructure Payment
Reward Improvement
Organizational
Changes
New Set
Principles
Create IT
Infrastructure
EBM
Prepare
Workforce
Ref: Adapted from IOM Report: March 01.
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Decision Support
Tool
Discussion Outline
•
Overview of the Patient Safety Organizational
Assessment Tool (PSOAT)
4
•
Conceptual Framework
•
Project Steps
•
Results of Delmarva Assessment
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Objectives of the Assessment
• Use an evidence-based process to:
– Provide gap analysis
– Highlight practices that contribute to errors
– Jump start safety programs
– Comply with regulatory requirements
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Patient Safety Organizational Assessment Tool
Description
• Content
– 100+ focused practices from the literature organized by:
• Strategic
• Structural
• Cultural
• Technical
• Medication Administration
• Patient Involvement
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Literature Sources
• National Patient Safety Foundation, Institute of Medicine
• Agency for Healthcare Research and Quality
• Literature Citation Systems
– PubMed, MEDLINE, MDConsult
• MEDSTAT internal resources
– Clinical reference database (6000+ references)
• Medical and Patient Safety web sites and listservs
• Web engines
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Description of Shortell Framework
Category
Description
Strategic
Organization articulates
what is important;
organization provides
resources and focus
Underlying beliefs, values,
norms and behaviors
Cultural
Technical
Structural
Examples
 Mission statement
 Organizational safety plan
 Executive leadership
 Board involvement
 Open non-punitive milieu
 Teamwork
 Learning from mistakes
Informational services and  Safety training programs
education
 Information systems related
to safety
 Standards
Operational structures for  Best practices sharing
organizational learning
 Electronic communication
for shared learning
 Committee structures
Shortell S. Assessing the impact of Continuous Quality Improvement on Clinical Practice: What it will take to accelerate
progress. The Milbank Quarterly, 76(4) 1998
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Impact on Quality Improvement
Strategic
Cultural
Technical
Structural
X
X
X
 No significant results
on anything really
important
X
X
 Small, temporary
effects; no lasting
impact
X
 Frustration and false
starts
X
X
X
X
X
X
X
X
X
X = fully present
X
Results
 Inability to capture the
learning and spread it
throughout the
organization
 Lasting, organizationwide impact
Shortell S. Assessing the impact of Continuous Quality Improvement on Clinical Practice: What it will take to accelerate
progress. The Milbank Quarterly, 76(4) 1998
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Impact on Safety Improvement
Strategic
•mission
•executive
leadership
Structural
•committees
•information
sharing
Patient
Safety
Cultural
•no blame
•process focused
Ref: Shortell: Milbank Quarterly, 76(4)1998
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Technical
• training
• information
systems
Value to Participating
• Avoid costs
• Focus resources/attention
• Market to community
• Increase collaboration
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Project Steps
• Delmarva and MEDSTAT partner to customize and offer tool
to MD and DC health care organizations
• Invitation to participants
• 42 organizations assigned IDs; 24 completed
• Bedsize - 8 had <150 beds; 16 had >=150 beds
• Results aggregated and analyzed
• Obtain participant feedback
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Findings
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Overview of Results: Level of Action
High
Action
Medication Administration
Structural
Strategic
Patient Involvement
Cultural
Technical
Low
Action
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Percentage Response by Section
2
37
11
10
71.0%
61.2%
No Action*
26.0%
High Action**
Patient Inv
Medication
Technical
20.3%
33.0%
49.2%
55.4%
30.4%
Cultural
20.5%
Structural
69.3%
23.5%
Strategic
23.3%
65.6%
67.2%
Response
Overall
80%
70%
60%
50%
40%
30%
20%
10%
0%
24
101
17
# of Questions
*No Action – Answered 1 or 2 on assessment tool. 1 = Not considering the practice; 2 = Discussed the practice, but no action
taken to put into place.
**High Action – Answered 4 or 5 on assessment tool. 4 = Considerable action taken to put practice into place; 5 = The practice is
fully implemented in organization.
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Difference by Bed Size: Patient Involvement
Response
70%
No Action*
60%
High Action**
65.7%
50%
52.3%
40%
30%
151+ Beds
1-150
Beds
0%
14.9%
10%
28.8%
20%
*No Action – Answered 1 or 2 on assessment tool. 1 = Not considering the practice; 2 = Discussed the practice, but no action
taken to put practice into place.
**High Action – Answered 4 or 5 on assessment tool. 4 = Considerable action taken to put practice into place; 5 = The practice is
fully implemented in organization.
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Strategic - Low vs. High Action: 17 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented or
considerable action taken
(>90% of Responses)
 Mission statement includes patient  Written patient safety plan-board
safety
reviewed
 Employee patient safety handbook  Section on safety improvement in
annual review
 Established safety program; focus
on culture
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Structural - Low vs. High Action: 24 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented or
considerable action taken
(>90% of Responses)
 Patient safety discussed at staff
meetings
 Safety reports reviewed by
multidisciplinary teams
 HR policy for avoiding potential
safety errors due to fatigue, stress
 CMS compliant restraint policy
 Fall protocol in place
 Infection control program in place
with monitors/trends
 Risk management and patient
safety program integrated
 Life safety integrated in patient
safety
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Cultural - Low vs. High Action: 10 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented
or considerable action taken
(>90% of Responses)
 Financial reward for suggested
improvement
 Encourage near miss reporting
for improvement
 Annual survey of perceptions on
culture
 Simple, confidential,
standardized reporting forms
 No ‘incident reports’ – rename
 No incident reports in personnel
files
 Use root cause analysis for
improvement
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Technical - Low vs. High Action: 11 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented or
considerable action taken
(>90% of Responses)
 Videotape procedures (e.g.
surgery) for improvement
 Voluntary, open, confidential, nonpunitive, objective error reporting
system in place
 Bar code blood transfusions
 IT for order entry
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Medication Safety - Low vs. High Action: 37 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented or
considerable action taken
(>90% of Responses)
 Electronic xmit of orders;
Information system available to all
clinical staff
 Ongoing education of drug
administration
 Bar coding at point of
administration
 Allergy info visible on patient
orders
 Lab/vital sign monitoring in place
for hazardous drugs
 All drug orders reviewed by
pharmacist before dispensing
 Lab and medical records at
bedside
 No rarely used narcotics in patient
care areas
 Morphine – limited doses, well
marked
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Medication Safety - Low vs. High Action: 37 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented or
considerable action taken
(>90% of Responses)
 No stocking or unique storage of
look-alike drugs
 Pharmacy or manufacturer
responsible for admixing or
preparing unit doses
 Antidotes for high risk drugs
widely available
 Standardized stocking of drugs on
unit
 Standardized drug admin times
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Medication Safety - Low vs. High Action: 37 Questions
Not considering or no action
taken
(>60% of Responses)
Practice fully implemented or
considerable action taken
(>90% of Responses)
 Drug information widely available
for new or unusual drugs
 IV compatibility charts on care
unit
 Alphabetic list of drugs by brand
name/generic on care unit
 24/7 Pharmacist staffing
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Recommendations Based Upon
Survey Results
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Strategic/Structural
• Incorporate patient safety into mission statement
• Improve policy and departmental standards to
incorporate safety discussion into operational
meetings
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Cultural
• Raise awareness at all levels of organization
• Reward staff for improvements; consider
alternative reward systems
• Celebrate achievements
• Gather baseline staff perceptions for both
information and awareness
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Technical
• Bar coding for patient identification, patient
tracking, CPOE
• Explore other techniques for potential error
review e.g. user centered design
• Electronic decision support for clinicians
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Medication Safety
• Standard policies in place to monitor patients on
hazardous drugs
• Availability of medication information system to all clinical
staff dealing with a patient
• Bar-coding to detect adverse drug reaction and other
administration errors at point of care
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Patient Involvement
• Educate patients and families on key safety issues regarding
their care while hospitalized
• Educate patients and families about medication safety after
discharge
• Develop safety educational programs geared towards patients
• Be mindful of following hand washing procedures
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Questions
&
Discussion
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Contacts
Louis H. Diamond
Medstat
4301 Connecticut Avenue, NW, Suite 330
Washington, DC 20008
202-719-7833
Fax: 202-719-7866
Email: [email protected]
Beverly A. Collins
Delmarva Foundation for Medical Care
7240 Parkway Drive, Suite 400
Hanover, MD 21076
410-712-7404
Fax: 410-712-4357
Email: [email protected]
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