Richard O. Davis

Implementing and Validating a Comprehensive Unit-Based Safety Program

Background: The IOM identified patient safety as a significant problem. This paper describes the implementation and validation of a comprehensive unit-based safety program (CUSP) in intensive care settings. Methods: An 8-step safety program was implemented in the Weinberg ICU, with a second control (SICU) subsequently receiving the intervention. Unit improvement teams (physician, nurse, administrator) were identified to champion efforts between staff and Safety Committee. CUSP steps: (1) culture of safety assessment; (2) sciences of safety education; (3) staff identification of safety concerns; (4) senior executives adopt a unit; (5) improvements implemented from safety concerns; (6) efforts documented/analyzed; (7) results shared; and (8) culture reassessment. Results: Safety culture improved post versus pre-intervention (35% to 52% in WICU and 35% to 67% in SICU). Senior executive adoption led to patient transport teams and pharmacy presence in ICUs. Interventions from safety assessment included: medication reconciliation, short-term goals sheet and relabeling epidural catheters. One-year post-CUSP implementation, length of stay (LOS) decreased from 2 to 1 day in WICU and 3 to 2 days in SICU (P < 0.05 WICU and SICU). Medication errors in transfer orders were nearly eliminated, and nursing turnover decreased from 9% to 2% in WICU and 8% to 2% in SICU (neither statistically significant). Conclusions: CUSP successfully implemented in 2 ICUs. CUSP can improve patient safety and reduce medication errors, LOS, and potentially nursing turnover.

Senior Executive Adopt-a-Work Unit: A Model for Safety Improvement

BACKGROUND At The Johns Hopkins Hospital (JHH), the patient safety committee created a safety program that focused on encouraging staff in selected units to identify and eliminate potential errors in the patient care environment. As part of this program, senior hospital executives each adopted an intensive care unit and worked with the unit staff to identify issues and to empower staff to address safety issues. JHH PATIENT SAFETY PROGRAM: The program consisted of eight steps, which together require six months for implementation: (1) conduct a culture survey; (2) educate staff on the science of safety; (3) identify staff safety concerns through a staff safety survey; (4) implement the senior executive adopt-a-work unit program; (5) implement improvements; (6-7) document results, share stories, and disseminate results; and (8) resurvey staff. RESULTS The senior executive adopt-a-work unit program was successful in identifying and eliminating hazards to patient safety and in creating a culture of safety. DISCUSSION The program can be broadly implemented. The keys to program success are the active role of an executive advocate and staffs willingness to openly discuss safety issues on the units. Regular meetings between the advocates and the units have provided a forum for enhancing executive awareness, increasing staff confidence and trust in executive involvement, and swiftly and effectively addressing areas of potential patient harm.

How will we know patients are safer? An organization-wide approach to measuring and improving safety

Objective:Our institution, like many, is struggling to develop measures that answer the question, How do we know we are safer? Our objectives are to present a framework to evaluate performance in patient safety and describe how we applied this model in intensive care units. Design:We focus on measures of safety rather than broader measures of quality. The measures will allow health care organizations to evaluate whether they are safer now than in the past by answering the following questions: How often do we harm patients? How often do patients receive the appropriate interventions? How do we know we learned from defects? How well have we created a culture of safety? The first two measures are rate based, whereas the latter two are qualitative. To improve care within institutions, caregivers must be engaged, must participate in the selection and development of measures, and must receive feedback regarding their performance. The following attributes should be considered when evaluating potential safety measures: Measures must be important to the organization, must be valid (represent what they intend to measure), must be reliable (produce similar results when used repeatedly), must be feasible (affordable to collect data), must be usable for the people expected to employ the data to improve safety, and must have universal applicability within the entire institution. Setting:Health care institutions. Results:Health care currently lacks a robust safety score card. We developed four aggregate measures of patient safety and present how we applied them to intensive care units in an academic medical center. The same measures are being applied to nearly 200 intensive care units as part of ongoing collaborative projects. The measures include how often do we harm patients, how often do we do what we should (i.e., use evidence-based medicine), how do we know we learned from mistakes, and how well do we improve culture. Measures collected by different departments can then be aggregated to provide a hospital level safety score card. Conclusion:The science of measuring patient safety is immature. This article is a starting point for developing feasible and scientifically sound approaches to measure safety within an institution. Institutions will need to find a balance between measures that are scientifically sound, affordable, usable, and easily applied across the institution.

Paying the Piper: Investing in Infrastructure for Patient Safety

BACKGROUND Although the best allocation of resources is unknown, there is general agreement that improvements in safety require an organization-level safety culture, in which leadership humbly acknowledges safety shortcomings and allocates resources at the patient care and unit levels to identify and mitigate risks. Since 2001, the Johns Hopkins Hospital has increased its investment in human capital at the patient care, unit/team, and organization levels to improve patient safety. PATIENT CARE LEVEL An inadequate infrastructure, both technical and human, has prompted health care organizations to rely on nurses to help implement new safety programs and to enforce new policies because hospital leaders often have limited ability to disseminate or enforce such changes with the medical staff. UNIT OR TEAM LEVEL At the team or nursing unit level, there is little or no infrastructure to develop, implement, and monitor safety projects. There is limited unit-level support for safety projects, and the resources that are allocated come from overtaxed department budgets. ORGANIZATION LEVEL HOSPITAL LEVEL AND HEALTH SYSTEM: Infrastructure is needed to design, implement, and evaluate the following domains of work-measuring progress in patient safety, translating evidence into practice, identifying and mitigating hazards, improving culture and communication, and identifying an infrastructure in the organization for patient safety efforts. REFLECTIONS Fulfilling a commitment to safe and high-quality care will not be possible without significant investment in patient safety infrastructure. Health care organizations will need to determine the cost-benefit ratio of various investments in patient safety. Yet, predicating safety efforts on the mistaken belief in a short-term return on investments will stall patient safety efforts.

Applying Lean Sigma Solutions to Mistake-Proof the Chemotherapy Preparation Process

BACKGROUND Errors related to high-alert medications, such as chemotherapeutic agents, have resulted in serious adverse events. A fast-paced application of Lean Sigma methodology was used to safeguard the chemotherapy preparation process against errors and increase compliance with United States Pharmacopeia 797 (USP 797) regulations. WORKSHOP STRUCTURE AND PROCESS On Days 1 and 2 of a Lean Sigma workshop, frontline staff studied the chemotherapy preparation process. During Days 2 and 3, interventions were developed and implementation was started. FINDINGS AND INTERVENTIONS The workshop participants were satisfied with the speed at which improvements were put to place using the structured workshop format. The multiple opportunities for error identified related to the chemotherapy preparation process, workspace layout, distractions, increased movement around ventilated hood areas, and variation in medication processing and labeling procedures. Mistake-proofing interventions were then introduced via workspace redesign, process redesign, and development of standard operating procedures for pharmacy staff. Interventions were easy to implement and sustainable. Reported medication errors reaching patients and requiring monitoring decreased, whereas the number of reported near misses increased, suggesting improvement in identifying errors before reaching the patients. DISCUSSION Application of Lean Sigma solutions enabled the development of a series of relatively inexpensive and easy to implement mistake-proofing interventions that reduce the likelihood of chemotherapy preparation errors and increase compliance with USP 797 regulations. The findings and interventions are generalizable and can inform mistake-proofing interventions in all types of pharmacies.

Using the Online and Offline Change Model to Improve Efficiency for Fast-Track Patients in an Emergency Department

BACKGROUND In 1998 the emergency department (ED) Work Group at Johns Hopkins Bayview Medical Center (Baltimore) worked to reinvigorate the fast-track program within the ED to improve throughput for patients with minor illnesses and injuries who present for care. There had been two prior unsuccessful attempts to overhaul the fast-track process. METHODS The work group used a change model intended to improve both processes and relationships for complex organizational problems that span departments and functional units. Before the first work group meeting, the work group evaluated the institutional commitment to address the issue. The next step was to find data to fully understand the issues and establish a baseline for evaluating improvements--for example, patients with minor illnesses and injuries had excessively long total ED (registration to discharge) times: 5 hours 57 minutes on average for nonacute patients. ONLINE AND OFFLINE MEETINGS: The work group identified process problems, but relationship barriers became evident as the new processes were discussed. Yet offline work was needed to minimize the potential for online surprises. The work group leaders met separately in small groups with nursing staff, lab staff, x-ray staff, registrars, and physicians assistants to inform them of data, obtain input about process changes, and address any potential concerns. The group conducted four tests of change (using Plan-Do-Study-Act cycles) to eliminate the root causes of slow turnaround identified previously. RESULTS Total ED time decreased to an average of 1 hour 47 minutes; the practice of placing nonacute patients in fast track before all higher-acuity patients were seen gained acceptance. The percentage of higher-acuity patients sent to fast track decreased from 17% of all patients seen in fast track in January 1998 to 8.5% by February 1999. Patients with minor illnesses and injuries no longer had to wait behind higher-acuity patients just to be registered. The average wait for registration decreased from 42 minutes in January 1998 to 14 minutes in February 1999. Physicians assistant, nursing, and technician staff all report improved working relationships and feeling a team spirit. DISCUSSION The offline component of the integrated model helped to improve organizational relationships and dialogue among team members, thereby facilitating the effectiveness of online efforts to improve processes. This model has also been applied to improve patient registration (revenue recovery) and the emergency transfer and admissions process.

Self-Efficacy Estimates for Drug Use Practices Predict Risk Reduction Among Injection Drug Users

We used baseline outcome efficacy (OE) estimates for human immunodeficiency virus (HIV) risk reduction to predict subsequent risk reduction 6 months hence among 792 injection drug users in a prospective study. Declines in drug use, frequency of injection, and needle sharing were found among those with high OE scores after adjustment for baseline behavior and antecedent factors. No OE effect was found in multivariate analysis for shooting gallery attendance, a risk that substantially declined in this cohort. OE for needle disinfection was associated with reduced drug risk behaviors, but not for improved needle hygiene practices over time. The self-efficacy model is useful in understanding psychological factors in risk reduction among injection drug users.

Using online and offline change models to improve ICU access and revenues.

BACKGROUND Hospital operational problems that span departments often present formidable challenges because they involve both processes and organizational relationships. Many improvement efforts fail because of relationship issues rather than a lack of understanding of system processes. Reflection on a recent change initiative led to the development of an integrated change model that includes both online and offline components. The online component draws on performance improvement models that provide concepts and tools for use in team meetings to improve processes. The offline component borrows from an earlier tradition of change management that offers guidelines for individuals or teams desiring to be change agents. METHODS The integrated change model was applied in 1997 at The Johns Hopkins Hospital, Baltimore, to reduce ambulance bypass hours, a chronic problem resulting in

Comprehensive unit-based safety program (CUSP) to improve patient experience: How a hospital enhanced care transitions and discharge processes

6.7 million in lost revenue annually. The goal was to reduce red alert hours per month by 50%. Three Plan-Do-Study-Act (PDSA) cycles were implemented to test change concepts. RESULTS There was a significant reduction in red alert hours after the change initiative, with an estimated

Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools

6 million in additional hospital revenue. DISCUSSION The integrated change model may serve as a prototype for improving complex problems in which improving organizational relationships may be as difficult as improving processes and is likely to require a significant amount of work offline. For example, this approach may be particularly helpful for improving processes that span departments or functional units such as reducing cycle times for admissions, first-dose medications, as well as in building and improving integrated delivery systems. The model awaits further testing and evolution.