Best Practices Awards: Big winner from the smallest state
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The group’s prize-winning achievement, good for $500, involved tapping into the expertise of a range of departments and individuals so as to establish and sustain, in the words of the entry, a “culture of safety.” At the project’s outset, with safety issues abounding, the hurdles appeared formidable—yet the process of attacking the troubles head-on ended up transforming the reputation and, indeed, the very identity of the department within Lifespan, the Brown University-affiliated health system of which 719-bed RIH is the flagship facility.
With our congratulations to all at RIH who participated in implementing the best practice or preparing the contest entry—or both—we present the winning entry in its entirety, lightly edited for clarity and conciseness:
Background
In March of 2009, upon reviewing the R.I Department of Health reportable errors (events), RIH’s Department of Diagnostic Imaging (DI) identified pervasive safety concerns. Data collected for events from 2007 to 2009 showed an average 17 events per year. Simultaneously, to identify and track trends, the department was collecting data for near misses. Analysis of this data identified significant problems with accuracy of orders for exams and discovered that these errors had been generated at all points of the process, from beginning to end.
Our conclusion after this exhaustive review led us to decide that the DI department needed to transform itself through a specific focus on the process of ordering and executing exams. Accomplishing this successfully would require the involvement and engagement of physicians and allied health professionals, as well as clinical and operational support staff.
Leadership of the DI department requested the assistance of Lifespan Learning Institute (LLI) to evaluate existing practices and identify areas of improvement. In March and April of 2009, the director of LLI interviewed section coordinators, staff members and the attending radiologists from each modality.
DI leadership then appointed six members to our Culture of Safety Task Force, whose goal was to review the findings from the LLI director’s assessment, identify areas of improvement, and provide recommendations to the department’s Patient Care and Oversight Committee. Members of the task force include the former and present director of DI, the programs administrator for RIH’s School of Diagnostic Imaging, the radiology section coordinator, the CT scan section coordinator, the DI nurse manager and the DI quality assurance and research coordinator, along with the LLI director.
The Culture of Safety Task Force identified three opportunities for improvement: physician engagement and collaboration, root-cause analysis (RCA), and education, communication and training of staff on policies and procedures.
Objectives
Data collected from 2007 to 2009 showed that the average 17 events per year spread out evenly throughout the year. In March of 2009, five reportable errors occurred. Leadership decided to investigate the psychological factors behind the errors, enlisting the help of LLI. The director of LLI’s goal was to identify the current culture of patient safety and identify any underlying causal concerns.
During the staff interviews, recurrent themes and conclusions emerged, including:
- The importance of safety: Errors can lead to adverse outcomes and undermine satisfaction and confidence of patients and families.
- Alignment and engagement: Physicians, allied health professionals and clinical and operational supportive staff across all sections of DI is critical to fostering a culture of safety.
- Response to errors: It is imperative to be ready with an array of responses (consoling, coaching, educating, counseling); to improve communication and training on policies and procedures; and to apply corrective actions consistent and fairly.
- Compliance: Staff must have a clear understanding of their duties, supported by reviews of systems and behaviors.
From these interviews, a process map was developed to summarize the findings.
- A review of near-miss data revealed a disproportionate number of near misses (60 percent) compared with overall exams in two other high-volume, highly complex clinical areas;
- One-third of the near misses generated were from 12 of 141 referral sources;
- The number of near misses reported increased 315 percent from January to September 2009;
- Wrong-side orders accounted for more than 60 percent of near misses, with nearly a third of these generated by nine referrals; and
- In one clinic area, near misses were double what would have been predicted if near misses were distributed according to percentage of overall exams.
The near-miss data pointed to the need to sustain a continuous process of collecting and reporting in order to bring about a pervasive culture of safety.
Also, seeking to understand the necessary steps in performing a DI exam consistent with a culture of safety, the Culture of Safety Task Force observed the process in several DI clinic areas. These direct observations revealed that several steps in performing DI exams, involving numerous staff members, introduced the potential for many events to occur throughout the process.
The task force was assigned the task of changing the department to embrace a culture of safety. Task force members reviewed the process map and set three main goals: improving physician engagement and collaboration, improving the RCA process, and improving communications and training.
Steps
Physician engagement and collaboration. The activities of the task force and implementation of its recommendations are now reported to and guided by the Lifespan Imaging Patient Care and Oversight Committee, which is co-chaired by the radiologist who serves as DI quality officer and Lifespan’s administrative director of medical imaging. The DI quality officer and section chief radiologist participate in the RCA process, along with a physician from the hospital department involved in any event. Leadership has met with physicians from high-volume, highly complex clinical areas to discuss the results of data analysis and the importance of placing correct orders. Staff was educated on the compliance issue of performing an exam with a complete correct order including a physician-legible signature through mandatory staff meetings.
Improve the RCA process. The DI quality-assurance (QA) coordinators work with section coordinators to ensure that all relevant staff involved in the RCA process, including risk management and quality management, are present. The DI QA coordinators contact staff involved in advance to discuss the event. With the implementation of a medical-event reporting system (MERS) and deployment of the RCA process, the facilitator is enabled to focus on the root cause of the event rather than completing paperwork during an RCA meeting. Participants are asked open-ended questions as a way to fully engage everyone. Participants are also required to summarize a learning experience as a result of the event. Section coordinators now utilize the patient safety algorithm to respond to events separate from the RCA process.
Improve communications and training. To improve communication, task force members implemented and expanded the near-miss initiative department-wide. A process for identifying, tracking and responding to near miss occurrences has been developed, and near misses are rewarded and recognized in a monthly email to all staff. Task force members provide DI leadership with a monthly report identifying where and how potential events were generated.
Improvements were also made in the way support-service departments participate in the safety process. For example, DI and hospital patient-registration leadership worked together to add additional registrars, retraining and supervisor coaching was provided to staff with data verification responsibilities, and the volunteer office added an information person to minimize distractions to staff in the area.
Task force members reviewed current department policies, procedures and guidelines, then established the top ten policies, procedures and guidelines that are most important to a culture of safety. From this online learning modules were developed.
Results
The department-wide initiative to adopt a pervasive culture of safety has been recognized through the multiple improvements outlined above. Staff are catching and reporting all types of adverse and potential safety-risk events. Near misses are now monitored during daily departmental operations. From 2007 to the present, staff has caught nearly 1,700 near misses, all of which are now documented utilizing the MERS system.
Using a mapping process, we discovered that there are approximately 25 steps involved in performing a DI exam from start to finish. This results in approximately 25,000 steps per day, creating multiple opportunities for events. The radiology-patient engagement process guideline ensures that staff members follow the same process each time they perform an exam.
Many near misses are now being caught at the registration step (beginning step) instead of the technologist step (end step). We have seen a 54 percent improvement in ED ordering, a 91 percent improvement in the ED registration process and 100 percent improvement in the main-floor registration process.
Process improvements continue with outside ordering physician groups and pediatrics, where we have seen a recent increase in reporting.
At RCA meetings, DI quality-assurance coordinators have found staff to be engaged in helping to determine the root cause of events. In some instances, staff provided valuable suggestions and solutions for process improvements. While we have not seen a significant reduction in the number of reportable events, we remain encouraged and believe that, through consistency, education and improvements, staff will continue to work together as a team to ensure our patients remain safe at all times.
The task force demonstrated to staff that each person plays a major role in the patient experience and quality of care. Task force members designed an 11-modle Net Learning course that reviewed core policies, procedures and guidelines for staff. The modules were assigned to staff according to job code. In January 2011, the Net Learning course was assigned to staff to complete within the first month. On a continuous basis, staff will be required to complete this Net Learning course as part of their annual re-training on standard expectations. It is the responsibility of section coordinators to ensure that staff completes the course as part of the annual review process.
Impact
Since its inception, our Culture of Safety Task Force has been on a journey to discover, design and develop a road map to reach a common goal—to adopt a pervasive culture of safety. This initiative has raised staff awareness of reporting all near misses and events. Staff is engaged and continues to work diligently to prevent these near misses from reaching the patient. By identifying areas of improvement through the reporting of these events in MERS, the task force continues to work with departments throughout Lifespan to improve the quality of care we deliver to our patients.
Task force findings, recommendations and results are shared each month with DI leadership and quality-assurance staff from Lifespan affiliates at a meeting of Lifespan’s Imaging Patient Care and Oversight Committee.
While it may be difficult to accurately measure the culture of safety in numbers or data within an organization, it is apparent that RIH’s diagnostic image department has created a culture whereby physicians, allied health professionals and clerical and operational support staff are engaged. The quality and safety of the care delivered to our patients is exceptional, and we continue to work to improve the patient experience in all that we do.
Editor’s note: This entry was submitted by Cindy Cobb, RIH’s manager of diagnostic imaging quality & safety.
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.