Nurses Make the LEAP: Improving Patient Safety at Hospital X

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Nurses Make the LEAP Improving Patient Safety at
Hospital X    
Lets Evaluate Assess Process  
         
Jeanne Poindexter, BSN, MSA, CPHRM, CPHQ May
2003 VCU Patient Safety Fellowship Dr. Swisher
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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.

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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

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The Beginnings

• Multidisciplinary design group
• Physician champion
• Facility-wide focus on reduction of medication
  events
• Medication Safety Plan

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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

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Focus on Key Areas

• Culture and reporting
• Medication practices
• Staff skill knowledge

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Next Steps

• Created PP related to
• Nursing practice
• Peer review
• Medication practices
• Communication
• Monitoring, reporting, measuring
• Created tools for communication, educational
  sessions, other materials

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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.

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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.

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Scope of Problem

• Hospital X
• Analysis of occurrence reports
• Claims analysis
• Patient complaints
• Intensive investigation of sentinel events and
  near misses

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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.

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Related Research

• IOM reports, QuIC
• Critical thinkingBenner, NLN, Nurse Educator
• Reporting of errorsMedicare, underreporting,
  near miss reporting, reporting systems
• Organizational cultureBeyond Blame,
• Patient satisfaction with healthcareThe
  Commonwealth Fund Survey

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Objectives

• Objectives
• Critical thinking
• Professional development
• Improved quality of care
• Increased competence
• Measurement
• Decrease patient events
• Decrease claims
• Decrease patient complaints

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Actions

• No quick fix
• Multidimensional solution to complex problem
• Start at the top
• Leadership commitmentmanpower, resources
• Modelingnon-punitive attitudes,
  patient-centeredness
• Proactive vs. reactive prevention vs. punishment
• Active participation

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Improved reporting, whats 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

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JOHN RANDOLPH MEDICAL CENTER  
 
BOARD OF TRUSTEES
MEDICAL EXECUTIVE COMMITTEE
QUALITY COUNCIL
MEDICAL STAFF DEPARTMENTS
ORYX/CORE MEASURES
HOSPITAL-WIDE QI ACTIVITIES
CUSTOMER SATISFACTION
NRCPR
NRMI 2
FUNCTIONAL TEAMS
PHYSICIAN DMRI
CHOIS
STANDING COMMITTEES
NDNQI
VHQC
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4/03
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Whats after culture?

• Staff competence
• Preceptor mentor programs
• Educational activitiesregularly from educational
  services, risk and quality management
• Closed claim reviews, case study, critical
  thinking vignettes, cognitive aids
• Quick reference materialshandbook of problem
  prone patient safety issues

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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 reviewMedical
  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

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Methodology
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Population

• All nurses practicing at Hospital X in patient
  care areas. Nurses vary according to experience,
  position/status, and educational background

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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?

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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.

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Results

• Events reported to RM
• 1999 511
• 2000 930
• 2001 1213
• 2002 1421
• Reflects gt 17 in reporting 2001-2002 and is
  sustained with 341 reports 1st Qtr. 2003
• Medication events Falls 57 in 2001, 44 at
  present.

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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

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Other Problems?

• Treatment Injuries, Monitoring Related Events,
  Falls 82 events in 1999, 25 2002-2003 to
  date.
• 39 decrease in Monitoring Related claims

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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?

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We have to keep leaping over the potholes or we
could end up on the bottom.
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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.

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Additional Limitations

• Prone to false relational patterns
• Inferences about relationship arbitrary and
  ambiguous
• Little or no reliability or validity
• Encourages shotgun approach to research

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Reporting and preventing medical mishaps lessons
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From novice to expert Excellence and power in
clinical nursing practice. Menlo Park, CA
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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,
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judgment. Journal for Nurses in Staff
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Medicare Keynotes. Issue No. 645. January 29,
2003. CHCA Management Services, LP Nashville, TN,
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Criteria and guidelines for the evaluation of
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The End!

• Questions???