Patient Safety Rounds Jennifer N. Edwards, Dr.P.H. Manager, Patient Safety Program Memorial Sloan Kettering Cancer Center July 17, 2007
The Patient Safety Program PS Rounds Voluntary reporting system (RISQ) Unit-based safety teams PS Newsletter PS Steering Committee Teamwork Training Just Culture work Rapid Response Team Links to Quality of Care Initiative and PI projects Page 2
Goals of PS Rounds Solve Problems Empower departments to address local safety problems (sometimes with additional help) Escalate systemic problems Create Safer Environment Raise staff awareness about the importance of patient safety and the existence of the Patient Safety Program Educate staff about safety concepts Demonstrate leadership support for safety improvement Encourage near miss reporting Page 3
The Way Rounds Work 2 Hospital Leaders one clinical and one administrative, Program manager, Scribe 2 hours with staff of one unit Open-ended questions Every concern recorded; some discussion about solutions tried Solicit highest priorities Page 4
During the Round Did anything happen this week that you think interfered with your ability to provide safe care for a patient? What keeps you awake at night (regarding the safety of your patients)? Can you think of any events in the past day or few days that have resulted in prolonged hospitalization for a patient? Have there been any near misses that almost caused patient harm but did not? If you perceive that a plan or situation is unsafe, do you feel comfortable raising your concerns with other members of the team? If you had a million dollars or a magic wand, how would you fix this problem? What would make this Patient Safety Rounds more effective? Page 5
After the PS Round Return to unit in 4 Months with information On what s been addressed Analyze the information Leaders assign followup responsibility Discuss with leaders Page 6
Definitions of Contributory Factors Work environment, e.g., staffing; education and training; physical environment; equipment and supplies available; time factors Team Components: clear definitions of leadership and responsibility; effective written and verbal communication; Task Components: staff had appropriate decision making aids; test results available and accurate Organization and Management: policy, standards and goals needed Individual components: physical and mental stressors; skills and knowledge lacking Patient Components: complex patient condition Based on Vincent C. Framework for analyzing risk and safety in clinical medicine. BMJ 316:1154-1157, 1998. Page 7
Findings from PS Rounds 28 Inpatient and Outpatient Units visited so far 340 Patient Safety Issues reported Page 8
Contributory Factors Patient Comp., 2% Org and Mgmt, 9% Task Comp, 20% Indiv. Comp., 6% Work Env, 37% Team Comp., 25% Page 9
Work Environment Components 45 40 35 4 2 30 Secondary Primary 25 20 15 10 5 0 37 37 12 27 4 13 12 1 5 1 Staffing Equip/Supplies Bldg/Design Time Educ/training Environment Administration Page 10
40 35 2 30 25 20 15 10 5 8 6 36 22 18 0 Page 11 6 1 4 3 Other Team Team Components Secondary Primary Leadership Verbal comm Written comm Congruence/Consistency
Task Components 40 35 30 14 25 16 20 Secondary Primary 15 3 10 22 17 5 12 0 Task Design Decision making aids Test results 1 Other Page 12
Organizational & Management Components 30 25 20 13 15 Secondary Primary 10 5 0 15 5 1 1 Policy, Standards, Goals Risks imported/exported Other Page 13
Individual and Patient Components 30 25 20 8 15 10 5 0 16 1 3 4 4 1 Page 14 Secondary Primary Skills & Knowledge Physical & Mental Stressors Condition/Complexity Staff/PT Relationship
Resolutions of PS Issues 45% 40% 35% 30% 25% 20% 40% 15% 10% 20% 5% 0% Solved, communicated, durable Working on the solution 6% 7% Intend to address Low priority for institution Page 15
Example of concern where we re working on the solution An inpatient unit raised a concern that the complex system of medical coverage for GI, pulmonary, and general medicine services can make it hard to find the right doctor after hours. Coded: Team component, leadership and responsibility unclear AND organization and management new policy, standard, or goal needed The Who s My Doc? Project has designed an improved identification strategy to be rolled out in the next couple of months, pending sign-off by nursing Page 16
Example of low-priority concern An outpatient facility: Sometimes a patient s family has a medical emergency in the building. The medical officer of the day must respond to these problems, yet he/she also has patients to see. Coded Individual component: physical and mental stressors. Upon review, Commack has decided this is the best policy given the constraints. Page 17
Observations What s working well: Identifying risks Escalating concerns Addressing most concerns But: Resolutions can be slow We don t have the capacity to investigate everything We ve created an expectation among staff that we re fixing everything Page 18