Transcript powerpoint - Virginians Improving Patient Care and Safety

Nurses Make the LEAP: Improving Patient
Safety at Hospital X
Let’s
Evaluate
&
Assess
Process
Jeanne Poindexter, BSN, MSA, CPHRM, CPHQ
May 2003
VCU Patient Safety Fellowship
Dr. Swisher
Purpose
To improve critical thinking in nurses in Hospital
X by giving insight into what critical thinking is,
providing instruction, feedback and practice to
improve clinical decision-making while
describing the relationship between the quality
(safety) of patient care and the critical thinking
and judgment ability of the nurses providing that
care.
Background
• IOM: To Err is Human: Building a Safer
Health System - 1999
• IOM: Crossing the Quality Chasm: A new
Health System for the 21st Century - 2000
• Board of Directors Retreat – Fall 2000
The Beginnings
• Multidisciplinary design group
• Physician champion
• Facility-wide focus on reduction of
medication events
• Medication Safety Plan
2001
• Plan for Patient Safety
– Encourages recognition & acknowledgement of risk
to patient safety & medical errors
– Initiates actions to reduce these risks
– Encourages internal reporting
– Focuses on processes and systems
– Minimizes blame or retribution for involvement
– Encourages organizational learning and supports
sharing of knowledge
– Challenges leaders to be responsible for fostering safe
environment
Focus on Key Areas
• Culture and reporting
• Medication practices
• Staff skill & knowledge
Next Steps
• Created P&P related to:
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Nursing practice
Peer review
Medication practices
Communication
Monitoring, reporting, & measuring
• Created tools for communication,
educational sessions, other materials
What was missing?
Before any of this would work, we
had to improve error detection,
analysis, and increase reporting of
errors, near misses, and other safety
issues and then reporting results or
actions taken back to staff.
How did we do this?
• Hospital-wide education
• Implementation of computerized occurrence
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reporting system
Standardization of event codes
Risk management and CQI team reports
Newsletter spotlights, staff meetings
Poster presentations, etc.
Scope of Problem
• Hospital X
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Analysis of occurrence reports
Claims analysis
Patient complaints
Intensive investigation of sentinel events and
near misses
What was our goal?
• To increase the effectiveness of health care
team collaboration by improving
communication and improve quality of care
provided thereby reducing risk exposure
and loss.
Related Research
• IOM reports, QuIC
• Critical thinking—Benner, NLN, Nurse
Educator
• Reporting of errors—Medicare,
underreporting, near miss reporting,
reporting systems
• Organizational culture—Beyond Blame,
• Patient satisfaction with healthcare—The
Commonwealth Fund Survey
Objectives
• Objectives
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Critical thinking
Professional development
Improved quality of care
Increased competence
• Measurement
– Decrease patient events
– Decrease claims
– Decrease patient complaints
Table 1
Patient Safety Activities
Objective
To form a “culture of
safety”.
To provide for staff
competence.
Improvement of
infrastructure, processes
and systems.
Action Tasks
Fully implement computerized occurrence reporting system.
Adapt reporting system and change policy to include “near misses”, patient safety concerns, patient
complaints/concerns.
q
Conduct intensive analysis of patient events and near misses to identify underlying systems issues.
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Provide feedback on sentinel event alerts, response to issues and lessons learned.
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Re-structure Patient Safety Committee to be more inclusive and organizational structure for reporting.
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Provide patient safety education for all new and existing employees.
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“LEAP” –ongoing recognition of safety and quality innovations.
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Create non-punitive environment and open discussion of errors.
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Leadership leads the way with commitment to informing the patient of errors and providing public
education.
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Rejuvenate and revise preceptor and mentor programs to allow for education and guidance through
orientation and beyond.
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Support education and quality activities with Education coordinator and Outcomes Manager.
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Provide continuing education through regularly scheduled in-services, staff meetings, closed claim and
case study reviews, poster presentations and newsletter articles.
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Supplement educational activities with critical thinking vignettes via electronic mailings, “grand rounds”,
and development of cognitive aids.
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Provide quick reference materials – handbook targeting high priority or problem prone patient safety
issues.
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Identified patient safety coordinator, developed role and responsibilities.
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Revised role and membership of Patient Safety Committee.
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Developed Nurse Practice Council and charter.
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Medical Care Evaluation Committee-- Restructure medical staff peer review.
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Developed policy and procedure and implemented process for Nurse Peer Review.
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Developed clinical protocols for at-risk patient populations.
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Preparing for implementation of electronic Medication Administration Record with go-live date in Oct
2003.
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De-centralized pharmacy staff.
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Developed or revised policies and procedures for high-risk medications and procedures.
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Actions
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No quick fix
Multidimensional solution to complex problem
Start at the top
Leadership commitment—manpower, resources
Modeling—non-punitive attitudes, patientcenteredness
• Proactive vs. reactive; prevention vs.
punishment
• Active participation
Improved reporting, what’s next?
• Creating a culture of safety
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Report near misses, concerns, complaints
Intensive analysis
Provide FEEDBACK
Patient Safety Committee & Nurse Practice
Council
House-wide safety education
LEAP Risk & Quality join forces
Non-punitive, open discussion
Informing the patient
JOHN RANDOLPH MEDICAL CENTER
BOARD OF TRUSTEES
MEDICAL EXECUTIVE COMMITTEE
QUALITY COUNCIL
MEDICAL STAFF DEPARTMENTS
ORYX/CORE
MEASURES
NRCPR
NRMI 2
HOSPITAL-WIDE
QI ACTIVITIES
CUSTOMER
SATISFACTION
FUNCTIONAL
TEAMS
PHYSICIAN
DMRI
CHOIS
STANDING
COMMITTEES
NDNQI
VHQC
QUALITY AND SAFETY MANAGEMENT REPORTING
4/03
BOARD OF DIRECTORS
MEDICAL EXECUTIVE COMMITTEE
QUALITY COUNCIL
MEDICAL STAFF DEPARTMENTS
NURSE PRACTICE COUNCIL
PATIENT SAFETY COMMITTEE
CORE MEASURES
CUSTOMER SERVICE
FALLS
MEDICATION SAFETY
RESUSCITATION
OUTCOMES
PERC
RESTRAINTS
IOP
NDNQI
MR REVIEW
COMMITTEE
MEDICAL ALARMS
INFECTION
CONTROL
UTILIZATION
REVIEW
PAIN TEAM
PATIENT
OCCURRENCES
EXECUTIVE
SAFETY
MORTALITY
ICU/CCU
RCA/SENTINEL
EVENTS
FMECA
COMPLICATIONS
NURSE PEER
REVIEW
STAFFING
EFFECTIVENESS
STAFF OPINIONS
NRMI
HIGH RISK
POPULATION CARE
RISK MANAGEMENT REPORT
REGULATORY &
COMPLIANCE AUDIT
RESULTS
PI TEAMS
MR REVIEW
COMMITTEE
MEDICAL CARE EVALUATION
What’s after culture?
• Staff competence
– Preceptor & mentor programs
– Educational activities—regularly from
educational services, risk and quality
management
– Closed claim reviews, case study, critical
thinking vignettes, cognitive aids
– Quick reference materials—handbook of
problem prone patient safety issues
Last but not least…
• Infrastructure, processes and systems
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Patient safety coordinator
Revised Patient Safety Committee
Developed Nurse Practice Council, Nurse Peer Review
Restructured Medical Staff peer review—Medical Care
Evaluation Committee
Clinical protocols
Preparing for E-MAR
De-centralized pharmacy staff
Review and revision of policies for high risk medications
and processes
Leadership involvement
Methodology
Population
• All nurses practicing at Hospital X in
patient care areas. Nurses vary according to
experience, position/status, and educational
background
Design
• Evaluation study
• What is the effect of a multifaceted program
to teach critical thinking to staff nurses on
patient safety as evidenced by risk exposure
and patient satisfaction?
Measurement & Sampling
• Measurement – patient occurrences, patient
complaints, malpractice claims
• Baseline data Jan-Dec 2001
• Retrospective analysis by location and risk
issue
• Note: the number and value of claims will
most likely change over time to reflect
reserve changes, final losses, and is limited
in some cases as claims are reported later in
the reporting period.
Results
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Events reported to RM
1999 = 511
2000 = 930
2001 = 1213
2002 = 1421
Reflects > 17% in reporting 2001-2002 and
is sustained with 341 reports 1st Qtr. 2003
• Medication events + Falls = 57% in 2001,
44% at present.
High Frequency Areas?
• Med/Surg – 100% incurred loss 2000
• Med/Surg Units – 74% of reports 2001
• Claims also increased in 2001 by more than
20% in M/S
• Percentage of claims in M/S decreased by
6.41% to date
Other Problems?
• Treatment Injuries, Monitoring Related
Events, Falls = 82% events in 1999, 25%
2002-2003 to date.
• 39% decrease in Monitoring Related claims
Conclusions &
Recommendations
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Improvement in reporting 17%
Improvement in reduction of errors 15%
Improvement in reduction of claims 67%
Improvement in reduction of complaints 10%
New question? Can we sustain in light of
nursing shortage, turnover, use of agency
personnel, regulatory and budgetary pressures,
etc?
We have to keep leaping over the
potholes or we could end up on
the bottom.
Limitations
• Based on assumption that lower the adverse event
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rate, higher the quality of care
Will not identify cause and effect relationships
Assumption that adverse events/quality of care is
directly impacted by critical thinking ability of
nursing staff
Assumption that programs designed will have
effect on that ability
Does not control other independent variables (staff
mix or care hours, turnover, changes in leadership,
acuity, reporting habits, education/experience etc.
Additional Limitations
• Prone to false relational patterns
• Inferences about relationship arbitrary and
ambiguous
• Little or no reliability or validity
• Encourages shotgun approach to research
REFERENCES
Barach, Paul & Small, Stephen. Reporting and preventing medical mishaps: lessons from
non-medical near miss reporting. BMJ 2000; 18(320): 759-763.
Benner, Patricia. (1984). From novice to expert: Excellence and power in clinical nursing
practice. Menlo Park, CA: Addison-Wesley.
Davis, K., Schoenbaum, S., Collins, K., Tenney, K., Hughes, D., Audet, A. Room for
improvement: patients report on the quality of their healthcare. (New York: The
Commonwealth Fund, April 2001).
Institute of Medicine (IOM), Crossing the Quality Chasm: A new health system for the 21st
century. (Washington, D.C.: National Academy
Press, 2001).
Institute of Medicine (IOM), To Err is Human: Building a safer health system. (Washington,
D.C.: National Academy Press, 1999).
Marshall, B., Jones, S., Snyder, G. A program design to promote clinical judgment. Journal
for Nurses in Staff Development. 2001; 17(2): 78-84.
Medicare Keynotes. Issue No. 645. January 29, 2003. CHCA Management Services, LP
Nashville, TN, 2003.
National League for Nursing (NLN). Criteria and guidelines for the evaluation of
baccalaureate and higher degree programs in nursing. New York: Author; 1996.
National Research Council, Assembly of Engineering, Committee on Flight Airworthiness
Certification Procedure. Improving aircraft safety: FAA certification of commercial
passenger aircraft. Washington, D.C.: National Academy of Sciences, 1980.
Shell, R. Perceived barriers to teaching for critical thinking by BSN nursing faculty,
Nursing Health Care Perspectives. 2001; 22(16): 286-291.
Voelker, Rebecca. Hospital collaborative creates tools to help reduces medication errors.
JAMA 2001; 286(24): 3067-3069.
Wolf, Z., Serembus, J., & Beitz, J., Clinical inference of nursing students concerning
harmful outcomes after medication errors. Nurse Educator. 2001; 26(6): 268-270.
Youngblood, N. & Beitz, J., Developing critical thinking with active learning strategies.
Nurse Educator. 2001; 26(1): 39-42.
The End!
Questions???