Organization: Sinai Hospital of Baltimore Solution Title: Increased Awareness of Patient Safety and Quality Improvement Principles with the Implementation of a Hospital-Wide Patient Safety and Quality Improvement Curriciulum Program/Project Description, Including Goals: Quality improvement and patient safety are key tenants of the ACGME (Accreditation Council on Graduate Medical Education) core principles of resident education and training. Despite the requirement for all residents to receive some education in PS/QI, the implementation of GME-wide education programs is poorly reported. Some residency programs have documented PS/QI programs that are specific to a particular specialty, but not a general education of patient safety and quality improvement. The office of Graduate Medical Education at Sinai has made educating all the residents of Lifebridge Health in patient safety and quality improvement a priority. Collaboration with the Josie King Foundation has brought the Duke University/Josie King Foundation Patient Safety curriculum to Lifebridge, and this curriculum is being implemented in the mandatory noon conferences that are held monthly for all residents. All staff in the institution is invited to attend the programs, and continuing education credits are offered to physicians, nurses and other allied health professionals. Over the course of the academic year, participants receive an education on the principles of patient safety, just culture, reporting of risk occurrences and errors, and ways to strengthen the systems in which they work. This creates a culture of safety and improvement at Lifebridge. Through a series of focus groups with participants, questionnaires distributed during monthly lectures, and anonymous email-based surveys, this project is documenting the change in the organizational culture. The information gained through these various modalities is used to assess and qualify the organizational culture of Lifebridge Health, as it pertains to awareness and pervasiveness of quality improvement and patient safety principles. The goals of this project are to show an overall increase in knowledge and daily recognition of the core principles of patient safety and an increase in the number of risk occurrences reported. By developing a culture where these principles are always being addressed, patients will be afforded the safest care possible. Process: This institution-wide quality improvement and patient safety education program was developed in response to the ACGME s mandate that all residency programs educate physicians-in-training on the tenants of quality improvement and patient safety. Beginning in 2012, the GME office at Sinai Hospital of Baltimore (part of Lifebridge Health)
implemented a quality improvement project that cumulated in an annual competition between resident led teams. This program was developed using the PDSA (Plan-Do-Study-Act) methodology, where competitors were tasked with identifying an area of improvement, implementing a change in the process, studying the effects of the program, and acting further upon those effects. While this program created interest in quality improvement among a select few, there still remain a great number who lack the basic understanding and knowledge of quality improvement and patient safety principles that are necessary for working with patients in today s clinical environment. Having identified this problem, the GME office reached out to the Josie King Foundation (based locally in Baltimore, MD) for assistance in implementing an education program. Utilizing the Josie King Foundation/Duke University curriculum in patient safety and quality improvement, monthly, mandatory resident meetings were changed into a Patient Safety Grand Rounds program. This protected resident education time is open to any members of the Lifebridge community (attending physicians, midlevels, RNs, SW/CM, etc.) who wish to attend. Solution: The Patient Safety Grand Rounds is a multi-year program that began in January 2015. The Grand Rounds sessions begin in July and proceed through May (the academic year runs July 1 through June 30). Speakers are chosen from the faculty, staff and housestaff at Sinai Hospital. These speakers have identified themselves as having both an interest in patient safety and quality improvement and are knowledgeable of the topic at hand. Following the sessions, questionnaires are distributed to evaluate the participants understanding of and insight on the validity of the topic presented. Additionally, anonymous surveys and focus groups have been created to measure participants perceptions of the effects of the program, and how the program has affected the individual participants knowledge and perceptions of patient safety and quality improvement. We began the series with presentations by Sorrel King, co-founder and president of The Josie King Foundation on January 2015. Sorrel made three one-hour presentations entitled Josie s Story to over a total of 400 hundred staff members. Over the next eight sessions average attendance was 103 participants per Patient Safety Grand Rounds session. Measurable Outcomes: One of the aims of this qualitative study aims to document an increase in the perceived knowledge of patient safety and quality improvement throughout the hospital environment. By making patient safety and quality improvement a major focus of GME education efforts, this program aims to show a definitive increase in the implementation and usage of patient safety and quality improvement principles throughout the participants daily work. In addition, the project aims to increase the number of occurrences report to Quality and Risk Management and to this end a number of changes in reporting avenues have been implemented (e.g. dedicated hot line for reporting (2-SAFE/2-DRUG), a link in CERNER (the health system s electronic medical record), relocation of the reporting link on the hospital intranet). We have been able to document an increase in reporting since the
beginning of this project. Whereas before all reports were completed via the online reporting system, there are now three to five additional occurrences reported per day to the 2-SAFE hotline. Surveys and focus groups, focused tracking safety event reporting, increased quality metric compliance, and increased participation in and development of patient safety and quality improvement projects provide qualitative and quantitative proof of the culture change at Lifebridge Health and Sinai Hospital. These quality metric reports are provided to the entirety of the medical staff (attending physicians, resident physicians, nursing staff, etc.) to allow for complete disclosure and frontline staff ownership of institutional progress. Figure 1 presents the percentage of participants by role in the hospital. Residents (49%) are required to attend these sessions and constitute the largest percentage of participants followed by Nurses (20%), Others (10%) and physician (8%). The other category contained staff from all areas (e.g. pharmacy, clinical labs, technicians, administration, etc.). The format for the Patient Safety Grand Rounds of theory bursts followed by small group discussion encourages exchanges across the hospital between specialties. In the past, patient safety education and training tended to be organized into siloes and did not cross specialties and disciplines. The first three Patient Safety Grand Rounds were introductions to patient safety. The topics covered were Josie s Story (raising awareness), the history of patient safety in the United Stated, defining terms (medical errors/adverse outcomes) and the reasons for focusing on patient safety. Subsequent session topics included organizational culture, just culture, medical jurisprudence, and disclosure. Participants rating of their knowledge prior to and following each session on a four point (none to extensive) Likert scale reflects their belief that they increased their knowledge. The table 1 lists the average mean scores across the first eight sessions. Sustainability: The mission of LifeBridge Health (LBH) is to provide high quality and safe patient care. The mission and vision is integral to the sustainability of a culture of safety across the system. The leaders at LBH believe this solution is contributing to the strength of patient safety and quality outcomes, and they have committed the resources necessary to ensure this program continues and affects the maximum change possible. Additionally, as the presenters are selected from the faculty and staff of LifeBridge Health, there is a frontline staff buy-in that promotes the principles of the PSGR. Presenters choose topics and example scenarios; this allows for first hand knowledge of and experience with the concepts being taught. This ensures that PSGR participants are able to find topics relatable in both the realms of their personal and professional lives. Role of Collaboration and Leadership: This program was developed through collaboration between the Sinai Hospital departments of Graduate Medical Education, Performance Improvement and Risk Management/Patient
Safety, and the Josie King Foundation. The executive leadership team at Sinai (VP for Quality and Safety, Chief Quality Officer, Chief Nursing Officer) has committed resources in the form of both time and monetary support to continue this program, and it has become a leadership priority within the various departments in the hospital and healthcare system. While the program is directed by the GME office, a multidisciplinary team is assembled for each session and topic. Individuals with explicit knowledge of the topics (nurses, physicians, lawyers, quality regulators) are invited to participate and lead discussions and give presentations. This program has removed the traditional silos that develop in patient safety, and has allowed for a frank and open discussion of safety and quality topics throughout the hospital and health system. Innovation: Education and reinforcement of patient safety and quality improvement principles is essential to changing the culture of an institution. While the ACGME requires resident education on safety and quality, there is no curriculum defined by the organization as a means to that end. By creating a multidisciplinary approach to educating the providers and staff at Sinai Hospital, the culture of the organization has shifted to be generative and quality and safetydriven. Reporting is fundamental to detecting patient safety issues. However, on its own it can be self-limiting. The multidisciplinary patient safety and quality improvement curriculum and the associated Patient Safety Grand Rounds (PSGR) program suggest that patient safety experience and learning can be used locally, and nationally, as an effective patient safety initiative, that can be measured in terms of harm prevented and lives saved. This reality is our vison not just for Lifebridge Health, but for all patients in the US. Related Tools and Resources: Josie s Story-Victoria S. Kaprielian, MD, FAAP, Dori T. Sullivan, PhD, RN, NE-BC, CPHQ, FAAN National Patient Safety Foundation tools and resources Consumers Advancing Patient Safety The Joint Commission: Transforming Patient Safety Centers for Disease Control and Prevention Safe Care Campaign The Empowered Patient Coalition Patient Safety and Quality Improvement Act of 2005 AHRQ-Common Formats for Patient Safety Organizations (PSO) on reporting patient safety incidents National critical incident reporting: Improving patient safety. British Journal of Anesthesia 2009; 103 Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care 2008; 17:416-423
Contact Person: Diane Maloney-Krichmar, PhD Title: Director, Graduate Medical Education Email: dkrichma@lifebridgehealth.org Phone: 410-601-9720 Contact Person: Daniel Galante, DO Title: Resident, Department of Surgery Email: dgalante@lifebridgehealth.org Phone: 410-601-9720 Contact Person: Tina Gionet, RN, BS, MS Title: Patient Safety Officer Email: tgionet@lifebridgehealth.org Phone: 410-601-5793
Physical Therapists 1% Risk/Quality Staff 2% PAs/NPs 5% Medical Students 5% Physicians 8% Other 10% Residents 49% Nurses 20% Figure 1: Percentage of Participants by role in the 2015 Patient Safety Grand Rounds Knowledge Prior to Presentation Knowledge following Presentation Sessions 1-3: Introductory to 2.99 3.79 Patient Safety Session 4: Anatomy of an Error 2.74 3.49 Session 5: Culture of Safety 3.03 3.54 Session 6: Just Culture ad Safe 2.95 3.43 Choices Session 7: Reporting Medical 2.84 3.50 Errors Session 8: Disclosure of Medical Errors 2.93 3.46 Table 1: Participant-Assessed PSGR Topic Knowledge