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Nurses Make the LEAP: Improving Patient Safety at Hospital X

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To improve critical thinking in nurses in Hospital X ... ORYX/CORE MEASURES. HOSPITAL-WIDE QI ACTIVITIES. NRCPR. NRMI 2. CHOIS. NDNQI. VHQC. FUNCTIONAL TEAMS ... – PowerPoint PPT presentation

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Title: Nurses Make the LEAP: Improving Patient Safety at Hospital X


1
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
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
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
The Beginnings
  • Multidisciplinary design group
  • Physician champion
  • Facility-wide focus on reduction of medication
    events
  • Medication Safety Plan

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
Focus on Key Areas
  • Culture and reporting
  • Medication practices
  • Staff skill knowledge

7
Next Steps
  • Created PP related to
  • Nursing practice
  • Peer review
  • Medication practices
  • Communication
  • Monitoring, reporting, measuring
  • Created tools for communication, educational
    sessions, other materials

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

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
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

13
Objectives
  • Objectives
  • Critical thinking
  • Professional development
  • Improved quality of care
  • Increased competence
  • Measurement
  • Decrease patient events
  • Decrease claims
  • Decrease patient complaints

14
   
15
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

16
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

17
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
18
 
4/03
19
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

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 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

21
Methodology
22
Population
  • All nurses practicing at Hospital X in patient
    care areas. Nurses vary according to experience,
    position/status, and educational background

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
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
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.

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

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