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  1. 1. International Journal for Quality in Health Care 2003; Volume 15, Supplement 1: pp. i31–i40 10.1093/intqhc/mzg075 Improving patient safety across a large integrated health care delivery system ALLAN FRANKEL1, TEJAL K. GANDHI2 AND DAVID W. BATES1,2 1 Partners HealthCare System, Boston, MA, 2Brigham and Women’s Hospital, Boston, MA, USA Abstract Objective. Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare system, a large, integrated, non-proWt health care delivery system in the United States. Design. Partners identiWed a central Patient Safety OfWcer, who then formed a Patient Safety Advisory Group with local expert members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implemen- tation. There was broad consensus that interventions should include the areas of culture change, process change, and process measurement. Setting. A large, integrated health care delivery system in the Boston, Massachusetts, area. Results. Key milestones to date include implementation of Executive WalkRounds, development of accountability principles, agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physi- cian order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network. Most inXuenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient safety initiatives. Conclusions. This loosely integrated delivery system represents a daunting landscape for the development and institution of patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for signiW- cant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging. Moreover, with many potential interventions, and limited resources, prioritization and selection is difWcult. Nonetheless, con- sensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the net result will be substantial improvement in patient safety. Keywords: culture, patient safety, quality improvement Safety in health care has received substantial attention in the be possible even without changing technology [3]. The ultimate US since the 1999 Institute of Medicine report, To Err Is goal in culture change is system transparency, deWned as a will- Human [1]. While that report described the magnitude of the ingness of providers and patients to openly and comfortably problem in some detail, it provided only a high-level view of express their concerns about the delivery of care in a manner how organizations might change in order to improve the care that identiWes Xaws and leads to their elimination, mitigation, or they provide. In the 4 years since that report, organizations appropriate management. Culture change, and the subsequent have struggled to develop coherent programs for improving increase in event identiWcation that it promotes, are essential in safety, and these programs have varied substantially. order to then be able to identify and improve systems of care We believe that patient safety programs should include at such as medication delivery. Leadership understanding of least three areas of focus: culture change, process change, and safety concepts represents an essential component for this cul- process measurement. Changing culture is a new watchword in ture change [4–7]. Yet it is far from clear how best to build a patient safety. There is a growing realization that the beneWts of culture of safety, especially across a large entity, or to know technological advances will be optimized only if health care whether one has been achieved. providers approach delivery of care from the appropriate Processes need to be standardized and variation reduced to perspective [2], and that substantial improvement in safety may improve the quality of care and reduce error rates. In some Address reprint requests to David Bates, Brigham and Women’s Hospital, BC3, 1620 Tremont St, Boston, MA 02120, USA. E-mail: dbates@partners.org International Journal for Quality in Health Care vol. 15 Supplement 1 © International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved i31
  2. 2. A. Frankel et al. instances, this may involve implementation of technology, for safety made identifying the participants for this group while in others it may not. Process and outcomes must be straightforward, as all the institutions had clearly delineated measured to know whether care has ultimately been who was responsible for their patient safety efforts. Members improved. The objective of this paper is to delineate the com- of this group include physicians, nurses, and risk managers. ponents of a patient safety strategy, developed and imple- Initially, the Patient Safety Leaders Group was most pow- mented in one large integrated delivery system, to improve erful in educating its members about the good ideas and best safety by catalyzing safety-based cultural changes, changing practices of each institution. As the group has become more processes, and measuring outcomes. cohesive, over a period of 1 year, the members are beginning to think collaboratively about goals for the integrated delivery system in addition to each individual’s speciWc hospital goals. Study design To develop the camaraderie necessary to achieve this, the group has met face-to-face for over a year. Because the inte- Study site grated delivery system is spread across much of eastern Massachusetts, initial attempts to convene this group were Partners HealthCare is the largest integrated delivery system done virtually—usually by telephone conference calls. It in the north-eastern United States. It was founded in 1994 by became apparent after a few months that the group was not Brigham and Women’s Hospital and Massachusetts General functioning effectively, so face-to-face meetings were sched- Hospital, and has grown to include primary care and specialty uled. The improvement in collaboration, camaraderie and Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 physicians, community hospitals, the two founding academic congeniality was apparent within a few sessions. As a com- medical centers, specialty facilities, community health centers, promise, the meetings are scheduled monthly, alternating and other health-related entities. While researchers within between virtual and face-to-face formats. Partners have long been leaders in patient safety research [8–13], The group is beginning to tackle a variety of system-wide Partners did not have a coherent, network-wide approach to projects, some aimed at cultural change, such as promulgating patient safety before the Institute of Medicine’s report. the acceptance of executive WalkRounds to discuss safety issues and system-wide accountability principles. Others are process-speciWc, such as managing anticoagulation, improv- Partners patient safety program structure ing the safety of central line insertions, and ensuring wide- In 2000, Partners Chief Medical OfWcer and Partners Chief spread implementation of computerized physician order Executive OfWcer decided to create the position of Partners entry. These projects were chosen because they address high- Patient Safety OfWcer. The main task of the position was to risk processes and could be used as paradigms for future devise strategies to reduce error in care delivery. A signiWcant projects relating to both medication delivery and invasive component of medical error reduction up to that point had procedures in other areas. been directed towards measurement and process change, par- In addition to the clinical care provided by Partners and ticularly in terms of medication safety [11,14,15]. However, non-Partners Harvard-afWliated organizations, these institu- experiences in attempting to improve safety across a broad tions have been leaders in patient safety research, and the array of institutions suggested that combined tools that research groups interact closely with the operational entities. addressed cultural change and leadership as well as speciWc The intent is to have the organizations serve as laboratories components of care delivery would be most successful [5]. for improvement in patient safety, and in addition to rapidly The goals delineated for the Partners Patient Safety OfWcer disseminate beneWcial changes throughout the organization. position included speciWc efforts to change the culture of our hospitals—especially by educating hospital leadership—and to revise the hospitals’ methods of analyzing adverse events so that they measure and delineate system and process prob- Results lems, pinpoint longstanding unsafe traditions, and delineate Patient safety initiatives across an integrated actions to address them. health care system Two groups were developed to support the Partners patient safety effort. A Partners Patient Safety Advisory Integrated delivery system executive-level patient safety goals Group was convened to meet two times per year to advise the differ somewhat from those established at a hospital-based Patient Safety OfWcer of national trends and to evaluate the patient safety level. Projects that target transitions from one efforts underway in the integrated delivery system. The indi- institution to another or require consensus across organiza- viduals in the advisory group were chosen based on their tional boundaries will beneWt from oversight at a high level. work in areas related to patient safety, their knowledge of the Coordinated anticoagulation management is an example. By national environment, and their stature within the Partners contrast, initiatives that are wholly hospital based or con- HealthCare System. In addition, a Partners Patient Safety tained within one organization or one administrative structure Leaders Group was convened, made up of the individuals in can be piloted and proven locally. Then other hospitals may each institution with the responsibility for patient safety. The beneWt from the learning. However, hospital-based patient Joint Commission on Accreditation of Healthcare Organiza- safety personnel tend to be, appropriately, inwardly focused tions’ mandate that hospitals identify a locus of responsibility and their time is Wlled with responsibilities from within their i32
  3. 3. Improving patient safety own organization. As a result, the opportunity to learn from organization created to help lead the improvement of health other organizations is limited to literature and an occasional care systems and to promote continuous increase of their national conference. Lack of collaboration across and within quality and value [17]. The IHI has conducted many year-long institutions is common. The strength of an integrated system multi-hospital collaboratives to develop and spread best prac- is that its leaders can develop a framework for constant col- tices. In these collaboratives, up to 140 hospitals over a period laboration to occur. The Patient Safety Leaders Group has of 1 year undertake similar projects aimed at improving health been an example of this. The relationships developed have care, and convene periodically to discuss and compare their facilitated large-scale projects as well as fostering numerous progress. The WalkRound™ tool was designed to connect collegial interactions about smaller problems. Safety requires senior leadership to patient safety and to inculcate a culture of collaboration amongst clinical groups and should be a goal of safety into the health care system. It was also postulated that all those responsible for patient safety. the information elicited during the WalkRounds™, if effec- The aim of the new Partners-wide safety goals was to achieve tively analyzed, might be used to drive safety-based changes a culture change, and to revise the hospitals’ methods of analyz- by creating a cycle of information–analysis–action–feedback. ing adverse events to include process change and process meas- The end result would be a self-sustaining process that would urement. To accomplish these goals, our approach has been continue to engage leadership, educate clinicians and mana- initially to pilot an intervention at one institution with the goal of gers, and lead to continuous improvement. eventual rollout across the entire delivery system. The interven- The WalkRounds™ were initiated with the following object- tions that have been piloted and/or implemented in the system ives: (i) to increase awareness of safety issues by all clinicians; Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 have included executive WalkRounds™, the development of (ii) to make safety a high priority for senior leadership; (iii) to accountability principles, Web-based reporting systems, and educate staff about patient safety concepts such as non-puni- process-speciWc initiatives. Separately, they are modestly useful. tive reporting; and (iv) to obtain and act upon information Combined, however, these initiatives are a signiWcant force. elicited from staff about safety problems or issues. Table 1 outlines some of our current and potential patient safety WalkRounds™ was piloted at one hospital in January 2001. initiatives; the challenge is determining the priority for implemen- The Chief Executive OfWcer, Chief Operating OfWcer, Chief tation of each of these initiatives. Medical OfWcer, and Chief Nursing OfWcer agreed to partici- pate in weekly safety walk rounds. Other participants in the WalkRounds™ include the patient safety director, patient Culture change: executive WalkRounds™ safety manager, and research assistant. WalkRounds™ are Executive WalkRounds™ were conceptualized initially in the held weekly and visit different areas of the hospital, including Idealized Design of Medications Systems Design Group at the medical/surgical/obstetrical wards, emergency room, phar- the Institute of Healthcare Improvement in 1999 [16]. The macy, and operating suites. During the WalkRounds™, Institute for Healthcare Improvement (IHI) is a not-for-proWt speciWc questions are asked of the staff nurses, residents, and staff pharmacists on duty, such as ‘Were you able to care for your patients this week as safely as possible? If not, why not?’ Table 1 Partners current and potential patient safety initiatives and ‘What could this unit do on a regular basis to improve safety?’ (Figure 1). At the end of the rounds those who were Culture change questioned are educated about patient safety concepts such as Executive WalkRounds™ the importance of reporting near misses and how thinking Accountability principles or commitments about human factors can inXuence decision making. These Education: orientation, competencies, credentialing participants are e-mailed a transcript of the conversation later Safety brieWngs that day to thank them for their participation and so that they Core process may review their comments. Events that are captured in these Intelligent Information Technology: computerized rounds are put into a database and classiWed according to the physician order entry, electronic medical records, contributing factors that inXuenced the event. Each event is computerized medication administration records, assigned a score based on its severity or its potential for bar-coding patient harm. Simulation: teamwork and communication The list of events requiring active response is prioritized by Flow: unit-based assessment level of severity and brought to the responsible leadership, Protocols: clinical practice guidelines by evidence and and ownership of the issues is assigned. Each quarter, consensus the leadership provides updates to those who participated in Hardware standardization the rounds on progress towards resolution or a statement of the rationale for not taking action. Informing them of the Measurement actions taken closes the communication loop with the Reporting systems Pharmacy interventions WalkRound™ participants. We have informally surveyed Computerized monitoring for adverse events staff and leadership about these walk rounds. Leadership have been extremely engaged and feel the rounds have great value. Protocols and clinical practice guidelines The staff overall have been pleased to see leadership commit- Attitudinal surveys (clinician and patient) ment to safety with these rounds, and have been pleased with i33
  4. 4. A. Frankel et al. Sample questions: 1. Have you been able to care for patients as safely as possible. If not, why? Weekly 2. Have there been any near misses that almost caused WalkRounds patient harm? with 3. Can you describe the unit's ability to work as a leadership team? and staff 4. When you make an error or intercept an error, do you always report it? If not, why? 5. Have you discussed patient safety issues with Monthy your patients or their family members? reports prioritized by severity of patient impact Feedback to the Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 reporter Responsible clinical manager and leadership review No Decision for action Yes Assignment of ownership Action completed Figure 1 WalkRounds™ Xow diagram. the follow-up actions they see based on their comments. Reporting System (ASRS) is an example of this successful Since the initial pilot, WalkRounds™ have been successfully approach applied to the airline industry [18]. implemented at four additional Partners institutions. The plan Currently, reporting of adverse events frequently does not for further spread to other institutions is under discussion, as occur, at least in part because individuals believe that they will is a standardized analysis of the impact of the WalkRounds™. be blamed or sanctioned (regardless of whether the individual In addition, a study is underway to evaluate the WalkRounds or the system is at fault) [19]. Most blame-free policies in 10 other Massachusetts hospitals over the next 2 years. attempt to balance the desire to increase reporting with the desire not to limit sanctions. This is usually done by promis- ing protection to those who report in a timely fashion and Culture change: accountability principles exempting cases of misconduct. Many are fashioned from the Accountability principles or commitments to safety derive ASRS reporting procedures that have for over 25 years from attempts to clearly enunciate a non-punitive or blame- offered immunity if reports are obtained within 5 days of the free reporting policy towards health care providers who event, exempted criminal actions, and afforded the reporter report adverse events or episodes of patient harm. The pur- conWdentiality, followed 30 days later by anonymity. The pose of improving reporting is to elucidate Xaws in the health ASRS system works on a national scale, but does not offer to care delivery system that may then lead to the development the individual airlines an analysis of airline-speciWc problems. and implementation of system remedies. The Aviation Safety To address this, airlines have built Aviation Safety Action i34
  5. 5. Improving patient safety Plans that tend to offer conWdentiality but not anonymity and attitude and unsafe Xying conditions. These surveys have that facilitate in-depth root-cause analysis. been modiWed for use in health care and there are clear Anonymity and conWdentiality in a hospital or health care indications that provider attitude may be correlated with system is much harder, sometimes impossible, to achieve. patient morbidity and mortality [25,26]. We are planning to Rather than simply address the protection afforded to individ- use these types of surveys to measure the cultural impact of uals for reporting, a set of principles that outlines expectations WalkRounds™ and Safety BrieWngs. of all the stakeholders regarding system-versus-individual responsibility may be what is needed. If written intelligently, Process change: high risk processes a set of principles or policies about reporting harm does not require health care institutions to compromise their ability to Standardization and simpliWcation of care through intelligent police employees or appropriately prosecute misconduct. protocols and clinical practice guidelines has been a staple of The Partners Healthcare System has been developing this quality improvement for a few decades in health care [5], but set of principles with the hope that every member institution has had variable and often poor penetration. The relationship supports them and fosters a similar attitude regarding culture, between complexity and error, delineated in human factors reporting, and accountability. The Partners Patient Safety research in many industries, has led to increased vigor on the OfWcer and Patient Safety Leaders Group initially drafted the part of health care safety advocates to implement process accountability principles by performing a search of the litera- standardization, including through the use of protocols. The ture to Wnd non-punitive policies currently in use in health major efforts of the Partners Patient Safety OfWcer have tar- Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 care. ‘Whistle-blower’ statutes were reviewed and state- geted anticoagulation management, the placement of central speciWc issues about peer review protection identiWed. The venous catheters, and computerization of physician ordering Patient Safety Leaders Group reviewed the principles, followed in the in-patient setting. by risk management and human resources representatives from each Partners institution as well as by Chief Medical and Anticoagulation Chief Nursing OfWcers. In addition, hospital lawyers and human resource departments piloted the initial drafts by Perhaps the most compelling evidence supporting the impor- applying them to selected cases to ensure that they did not tance of protocols is in the management of anticoagulants, conXict with appropriate hospital actions. Newer drafts were especially heparin and warfarin [27]. All of the Partners hospi- evaluated in a similar way. An appendix to this paper shows tals currently use some form of a heparin weight-based proto- the version of the principles approved by all the Partners col for at least some patients and we have numerous warfarin institutions. clinics within our loosely integrated delivery system. How- ever, many patients on warfarin are not managed in a clinic setting, and a system-wide program for warfarin management Culture change: future initiatives has been lacking. Systematic warfarin management is neces- The Executive WalkRounds™ and accountability principles sary to provide effective care to patients during transitions represent the foundation for cultural change. Educational from one level of care to another. modules about safety, ‘Safety BrieWngs’, and attitudinal To improve these processes, we convened a group of inter- surveys are other building blocks under consideration for ested individuals and experts including physicians, nurses, implementation. Safety BrieWngs involve frontline staff, and pharmacists, information technology specialists, in-patient are simple and brief interchanges usually conducted during discharge planners, home care specialists, ofWce business transitions in care—either as patients are transferred or as managers and outpatient anticoagulation service providers. health care providers change shifts. These brieWngs identify The mission of this group is to: (i) centralize information speciWc areas of risk at the time of the brieWng and should be about patients and their anticoagulation status while support- conducted in a relaxed but formalized fashion. ing local control and management; and (ii) decrease the The educational component of culture change occurs dur- number of steps necessary to manage anticoagulation, thereby ing orientation of new employees, and during re-credentialing decreasing the likelihood of error. To accomplish these goals, and competency training of all health care providers. The the group is currently designing software to serve a dual pur- education will include: (i) human factors—how humans inter- pose: to assist large warfarin clinics that primarily manage lab- act with their environment [20]; (ii) cognitive psychology— oratory data and drug dosages, and also to support small how humans think and how we make errors [20,21]; (iii) how ofWce-based clinics who see patients face-to-face. The needs innovative ideas diffuse [22]; and (iv) ethics and accounta- of these two types of clinics differ, but they have a common bility—the logic in making complex systems transparent [23]. requirement: anticoagulation information should be readily We are currently planning a curriculum for all new employees available from anywhere in the delivery system. (in particular clinicians) to focus on these issues. The second goal, to decrease the steps in management, Attitudinal surveys offer another opportunity to measure may be accomplished by using point-of-care blood testing the degree of transparency and open communication being devices to measure the international normalized ratio (INR) fostered by patient safety projects in an institution. Surveys rather than the standard mechanism, i.e. obtaining a vial of used in this fashion are commonplace in the airline industry blood and sending it to a laboratory for INR analysis. The [24,25]. They have shown a direct relationship between pilot group is also evaluating supports for physicians and patients i35
  6. 6. A. Frankel et al. who are not attached to current ofWce and hospital anti- Safety Leaders Group will be an important entity for sharing coagulation clinics. A model for geographically diverse care information about successes and barriers as CPOE moves that manages patient transitions well is the visiting nurse forward. association (VNA). Partners HealthCare system is looking to these groups to develop ambulatory clinic-based models Process change: future initiatives to manage anticoagulation using point-of-care testing devices. Core process changes include the intelligent structuring of Measurement of current effectiveness is underway, with information technologies, simulation, standardization, and sim- plans to audit process measures (percent of patients with pliWcation of care delivery through protocols and clinical prac- therapeutic INRs) and outcome measures (bleeding- and tice guidelines, streamlined patient Xow with fewer delays, and clot-related complications). Independent physician groups hardware standardization. Into this Wnal category falls CPOE, are particularly difWcult to monitor as each maintains its own standardizing warfarin management during transitions of care, databases, often on paper, and they have not been required and protocols for safe central venous catheter placement. to collect or maintain this information. A one-time audit sug- Other projects in this category are also being evaluated. gested that the percentage of patients maintained in thera- Boston has been a stronghold of simulation research spear- peutic INRs by the groups ranged from 45 to 75%. We headed by the Center for Medical Simulation. In the simula- believe that 75% of patients in therapeutic INR is an appro- tor, models of patients’ rooms or invasive suites and priate goal for each physician group; our plan is to ask each operating rooms are combined with computer-driven moni- Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 group to collect the information in the manner easiest for them. tors and manikins to simulate real-life problems. Students have the opportunity to learn and test their skills in a safe environment where patients cannot be harmed and actions Central venous catheter insertion can be critiqued. Simulators are available relatively inexpen- sively for placement in every hospital, and have the potential Evaluation and spread of best practices in central venous to dramatically improve teamwork, open communication and catheter (CVC) insertions is a system-wide project under- provider education. Partners and the Center for Medical Sim- taken by the Partners epidemiology leaders, the goal of ulation are embarking on many projects that will impact each which is to decrease complications, especially CVC-associ- institution. For example, anesthesia residents are all undergo- ated blood stream infections. Practice around CVC insertion ing simulation training in return for which their malpractice varies widely from one intensive care unit to another, even insurance premiums have been reduced. Under discussion is though physicians rotate through the entire delivery system. further development of in-hospital simulators for use in During CVC insertions, having in attendance an un- teamwork and skill-based training. scrubbed assistant and an experienced attendant or fellow In addition to CPOE, information technologies such as has been historically difWcult to institute. Epidemiologists electronic medical records, automated medication administra- and intensivists have instituted and spread best practices tion records and bar coding are all currently in use in some using education, protocols, and audits. The focusing of Partners settings and are becoming more widespread attention combined with the pilot study facilitated spread of throughout Partners Healthcare System. However, having a the best practices with excellent results. One organization logical strategy for implementation is the key to acceptance of with incomplete penetration of the suggested practices, after these new technologies, and Partners Information Systems is fully adopting these practices, decreased the central line putting signiWcant effort into creating a common information blood stream infection (BSI) rate over a 12-month period technology structure for the entire network. from 162 to 120, yielding a calculated saving of $2.5 million. Patient Xow is another possible area of intervention. Given The rates placed the institution in the top quartile of organi- our current nursing and pharmacist shortage, empowering zations compared with the Centers for Disease Control and nurse managers and frontline nurses to control patient Xow Prevention benchmark rates. based on safety is imperative. This may be accomplished using innovative strategies such as the unit assessment tool used by Luther Middlefort Hospital in Eau Claire Wisconsin, in which Computerized physician order entry frontline nurses use a trafWc light concept to delineate the state Computerized physician order entry (CPOE) has been found of safety on their unit. Hospital workers use red, green, and to substantially decrease the rate of serious medication errors yellow colors to identify the level of risk they perceive in their [14,15], and appears to be one of the most potent technolog- area based on parameters such as nurse:patient ratios and ical changes for improving patient safety [28]. While CPOE patient acuity. The colors are broadcast through the institution is in place in the two large teaching hospitals in the Partners as the screen-saver on the hospital computers and determine network, it has not yet been implemented in the smaller hos- where patients are admitted and transferred. Resources are pitals. Because of the recommendations of the Partners diverted to aid those areas in the ‘red’ zones [29]. Patient Safety Advisory Group regarding the substantial Finally, standards are necessary that direct hardware pur- safety beneWts of CPOE, the Partners leadership has made a chases based on safety. Medication infusion pumps are a sen- commitment to the implementation of CPOE in all in- tinel example in this category. Testing for human factor patient institutions over the next few years. The Patient problems should determine the choice of pumps, favoring i36
  7. 7. Improving patient safety those that have ‘intelligent’ but simple redundancies to alert Process measurement: adverse drug event the care provider. There are currently numerous pilot tests monitor underway in the Partners Healthcare System to evaluate and Patient safety will be improved further by the implementa- standardize these technologies. tion of routine measurement across a variety of domains. The common reporting system will be a vital tool in this Outcome measurement: a common reporting regard. However, spontaneous reporting detects only a small system minority of events [32,33], and we believe that automated detection methods will be useful in improving routine detec- Another key to a culture of safety is having an easily availa- tion of safety issues [34–36]. A computerized Adverse Drug ble and simple way for health care workers and patients to Event Monitor that searches for signs of an adverse event report adverse events. Critical components of a safety and sends this information to a pharmacist for follow-up is improvement program in a large delivery system are the now in routine use at one hospital [37]. The monitor is a pro- adoption of a common language for reporting errors and gram (consisting of > 30 triggers) that searches the patient’s near misses, and an ability among hospital staff members to computerized medication and laboratory test proWles for evi- learn from each other. The goal of Partners is to create a dence of adverse drug events and generates alerts. An exam- common reporting system for all member institutions, so ple of an alert would be a patient whose creatinine is rising that information can be rendered anonymous and shared taking an aminoglycoside. The monitor generates a daily list conWdentially to promote measurement, learning, and Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 of these alerts and the hospital pharmacists review the alerts benchmarking. To accomplish this, Partners has opted to for their patients and make interventions. Most interventions promote the use of a Web-based reporting system, and has involve calling the physician to discontinue or change the been evaluating those commercially available [30]. The use- dosage of a medication; the goal is to intervene before the fulness of these kinds of systems relies on the simplicity of adverse drug event becomes serious or prolonged. This also the data entry method, the system’s ability to receive and promotes a culture of safety within pharmacy by actively store a large volume of data in a secure environment, and involving the pharmacists in event prevention. The Adverse the breadth of analysis and ad hoc reporting available to the Drug Event Monitor won the Institute for Safe Medication site manager [31]. Practices Cheers Award in 2002 for its excellence in proac- Our main criteria for application selection are security, tively identifying potential adverse drug events. These kinds ease of use, and speed, since these are major barriers to of proactive monitoring will eventually be used at other insti- staff reporting. We are evaluating the breadth of scope of tutions within the network to supplement spontaneous the product (Does it include near misses? Does it include reporting. ambulatory care? Does it have detailed modules for more than just medications and slips/falls?). In addition, we are evaluating the coding taxonomy to make sure it would col- Process measurement: future initiatives lect enough systems-related information. We require a fol- low-up module where the appropriate leaders could edit/ Vital components of safety measurement include ascertain- modify the report once follow-up was complete. We ing provider willingness to report problems and conducting require an ability to integrate into our network e-mail sys- audits looking for adverse events and near misses. Surveying tem so that appropriate leadership would get e-mail notiWca- provider attitude and tracking the use of spontaneous tion of the Wling of the report. We are looking at the reporting systems will elucidate whether willingness to system’s capacity to generate reports or export data into report events improves. Web-based reporting systems will databases for our own report generation. Finally, adequate improve our ability to evaluate both of these. Adverse customer support is essential. A system is currently in a events and near misses can be monitored in many ways. For pilot phase and nursing staff have been very pleased with example, in one of our hospitals, pharmacy interventions are the speed and ease of use. We have seen increases in report- used to identify areas of knowledge deWciency on the part of ing in the pilot areas, particularly in areas that had house staff, and a medication competency exam has been extremely low reporting rates previously. In addition, we developed based on these interventions. The exam is given have seen increases in reports from physicians, which we to incoming interns and then again as their internship ends. attribute to the speed of the system. The exam results are monitored to evaluate how effective The Patient Safety Leaders Group is given regular pharmacy education has been during the year. The compe- updates on experience with the pilot and the impact of this tency exam is modiWed each year based on the previous on a plan for larger rollout. The ultimate goal is for all the year’s pharmacy interventions. Partners institutions to use this common reporting system As noted earlier, another hospital has implemented a com- so that hospitals can then share information about certain puterized monitoring program in which an event monitor common event types and learn from each other about screens the computerized database and sends alerts daily to systems improvements. Issues such as medication errors and pharmacists who can then review them and make interven- adverse drug events can be discussed using common termi- tions. This generic approach will likely eventually be suitable nology, and rare but serious events can be measured jointly so for screening other sources (such as discharge summaries) for that hospitals can learn from the experiences of others. adverse events [38]. i37
  8. 8. A. Frankel et al. Conclusions and the Institute for Safe Medication Practices for executive level and middle management patient-safety positions. These As the concepts underlying patient safety mature, it is becom- positions must be empowered to integrate safety, quality, and ing possible to develop a cohesive and broad patient-safety risk management departments, and to base actions on promot- strategy. We have described the path we have taken, although ing transparency and open communication [39,40]. other alternatives might have been chosen, and in addition to In conclusion, developing and implementing a strategy for the efforts described, each hospital has numerous individual improving patient safety within this large, loosely integrated projects underway. A broad patient-safety strategy may be delivery system has been challenging but exciting. Initial divided into three categories: cultural change, core process efforts have focused on cultural change, process change, and change, and process measurement. Our initial efforts across process measurement, and many other projects in these areas the Partners integrated health care system include initiatives are being evaluated and considered for pilot testing. Clearly, in each of these areas. We have many additional projects that there is no right answer as to which projects an integrated we are considering in each category, including both technology- delivery system or hospital should undertake, and there are related and non-technology-related interventions. numerous possibilities from which to choose. Some of the strategies involve technology but many do not. Decisions need to be based on measured need, leadership support, inter- Conceptual models for the future est, and resources. However, we feel that an emphasis on culture, process, and measurement makes the most sense Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 Theoretical concepts determined the initial framework for for both short-term and long-term safety improvements. our patient safety strategy. Further construction was based on hospital interests and the efforts of those invested in each project. Two years later, collaborative efforts by all have Acknowledgements helped reWne patient safety theory. Hospitals and integrated delivery systems just beginning to formulate a patient safety We acknowledge support from Partners HealthCare (see plan can build on work done and may develop a more solid page i40). framework for themselves. 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