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  1. 1. 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
  2. 2. 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.
  3. 3. 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
  4. 4. The Beginnings • Multidisciplinary design group • Physician champion • Facility-wide focus on reduction of medication events • Medication Safety Plan
  5. 5. 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
  6. 6. Focus on Key Areas • Culture and reporting • Medication practices • Staff skill & knowledge
  7. 7. Next Steps • Created P&P related to: – Nursing practice – Peer review – Medication practices – Communication – Monitoring, reporting, & measuring • Created tools for communication, educational sessions, other materials
  8. 8. 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.
  9. 9. How did we do this? • Hospital-wide education • Implementation of computerized occurrence reporting system • Standardization of event codes • Risk management and CQI team reports • Newsletter spotlights, staff meetings • Poster presentations, etc.
  10. 10. Scope of Problem • Hospital X – Analysis of occurrence reports – Claims analysis – Patient complaints – Intensive investigation of sentinel events and near misses
  11. 11. 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.
  12. 12. 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
  13. 13. Objectives • Objectives – Critical thinking – Professional development – Improved quality of care – Increased competence • Measurement – Decrease patient events – Decrease claims – Decrease patient complaints
  14. 14. Table 1 Patient Safety Activities Objective Action Tasks To form a “culture of safety”.  Fully implement computerized occurrence reporting system.  Adapt reporting system and change policy to include “near misses”, patient safety concerns, patient complaints/concerns.  Conduct intensive analysis of patient events and near misses to identify underlying systems issues.  Provide feedback on sentinel event alerts, response to issues and lessons learned.  Re-structure Patient Safety Committee to be more inclusive and organizational structure for reporting.  Provide patient safety education for all new and existing employees.  “LEAP” –ongoing recognition of safety and quality innovations.  Create non-punitive environment and open discussion of errors.  Leadership leads the way with commitment to informing the patient of errors and providing public education.To provide for staff competence.  Rejuvenate and revise preceptor and mentor programs to allow for education and guidance through orientation and beyond.  Support education and quality activities with Education coordinator and Outcomes Manager.  Provide continuing education through regularly scheduled in-services, staff meetings, closed claim and case study reviews, poster presentations and newsletter articles.  Supplement educational activities with critical thinking vignettes via electronic mailings, “grand rounds”, and development of cognitive aids.  Provide quick reference materials – handbook targeting high priority or problem prone patient safety issues.Improvement of infrastructure, processes and systems.  Identified patient safety coordinator, developed role and responsibilities.  Revised role and membership of Patient Safety Committee.  Developed Nurse Practice Council and charter.  Medical Care Evaluation Committee-- Restructure medical staff peer review.  Developed policy and procedure and implemented process for Nurse Peer Review.  Developed clinical protocols for at-risk patient populations.  Preparing for implementation of electronic Medication Administration Record with go-live date in Oct 2003.  De-centralized pharmacy staff.  Developed or revised policies and procedures for high-risk medications and procedures.
  15. 15. Actions • No quick fix • Multidimensional solution to complex problem • Start at the top • Leadership commitment—manpower, resources • Modeling—non-punitive attitudes, patient- centeredness • Proactive vs. reactive; prevention vs. punishment • Active participation
  16. 16. Improved reporting, what’s next? • Creating a culture of safety – 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
  18. 18. 4/03Q U A L I T Y A N D S A F E T Y M A N A G E M E N T R E P O R T I N G C O R E M E A S U R E S C U S T O M E R S E R V I C E R E S U S C I T A T I O N O U T C O M E S P E R C N D N Q I M R R E V I E W C O M M I T T E E U T I L I Z A T I O N R E V I E W P A I N T E A M M O R T A L I T Y I C U / C C U C O M P L I C A T I O N S N U R S E P E E R R E V I E W N R M I N U R S E P R A C T I C E C O U N C I L F A L L S M E D I C A T I O N S A F E T Y R E S T R A I N T S I O P M E D I C A L A L A R M S I N F E C T I O N C O N T R O L P A T I E N T O C C U R R E N C E S E X E C U T I V E S A F E T Y R C A / S E N T I N E L E V E N T S F M E C A S T A F F I N G E F F E C T I V E N E S S S T A F F O P I N I O N S H I G H R I S K P O P U L A T I O N C A R E P A T I E N T S A F E T Y C O M M I T T E E M R R E V I E W C O M M I T T E E P I T E A M S R E G U L A T O R Y & C O M P L I A N C E A U D I T R E S U L T S R I S K M A N A G E M E N T R E P O R T Q U A L I T Y C O U N C IL M E D I C A L C A R E E V A L U A T I O N M E D I C A L S T A F F D E P A R T M E N T S M E D I C A L E X E C U T I V E C O M M I T T E E B O A R D O F D I R E C T O R S
  19. 19. 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
  20. 20. Last but not least… • Infrastructure, processes and systems – 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
  21. 21. Methodology
  22. 22. Population • All nurses practicing at Hospital X in patient care areas. Nurses vary according to experience, position/status, and educational background
  23. 23. 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?
  24. 24. 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.
  25. 25. Results • 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.
  26. 26. 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
  27. 27. Other Problems? • Treatment Injuries, Monitoring Related Events, Falls = 82% events in 1999, 25% 2002-2003 to date. • 39% decrease in Monitoring Related claims
  28. 28. Conclusions & Recommendations • 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?
  29. 29. We have to keep leaping over the potholes or we could end up on the bottom.
  30. 30. Limitations • Based on assumption that lower the adverse event 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.
  31. 31. Additional Limitations • Prone to false relational patterns • Inferences about relationship arbitrary and ambiguous • Little or no reliability or validity • Encourages shotgun approach to research
  32. 32. 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.
  33. 33. 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.
  34. 34. The End! Questions???