Rethinking Patient Safety

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When it comes to setting patient-safety priorities, hospital executives have a lot of choices. With a multitude of initiatives promising to help hospitals meet safety goals, establishing a plan of action can be daunting.

Practices like those endorsed by the National Quality Forum focus primarily on making basic clinical changes in care delivery, but they don’t explore methodologies for changing how caregivers work together, says Suzanne Delbanco, Ph.D., CEO of The Leapfrog Group. “Certain techniques can reinforce those practices by making sure the right checks and balances are in place so that the right clinical decisions can be made,” she says.

Three patient safety innovations based on team building, improving response time and empowering patients are gaining traction in the industry and producing results for hospitals.

1. All together, now: Crew Resource Management

Since Crew Resource Management dramatically improved the aviation industry’s safety record in the late 1980s, the program has been adapted for healthcare. The skills physicians, nurses and staff gain from CRM training equip them to communicate and coordinate clinical activities more effectively. One of the program’s basic principles is to identify “small slips, trips and lapses” before they develop into serious problems, says Steve Harden, president of Memphis, Tenn.-based CRM firm LifeWings Partners LLC. Hospitals establish checklists and protocols so everyone understands what needs to be done, and clinicians are taught to speak up when they notice a potential mistake.

After University of Texas Medical Branch’s CEO and surgical chair learned of CRM’s potential, they convinced leaders to adopt it as part of the six-hospital

Galveston-based health system’s safety programming. Five CRM firms were interviewed before UTMB was sold on LifeWings’ tailored training and tools, says Jennifer Baer, R.N., director of performance improvement. In May 2005, UTMB’s leadership team attended a three-day CRM boot camp to establish policies and learn how to promote the program. Physicians, residents, nurses, techs and housekeepers subsequently underwent training.

Although UTMB is still processing the data and preparing to move CRM into labor and delivery, Baer says OR staffers already report major improvements in the communication flow during procedures. “There’s a lot of engagement,” says Karen Sexton, R.N., Ph.D., vice president and CEO of UTMB Hospitals and Clinics. “At the completion of a case, our teams talk about how they could have improved the process for that case.”

2. Think fast: Rapid Response Teams

First developed in Australia, rapid response teams focus on reacting quickly to changing patient needs. Establishing role clarity is one of RRT training’s most important elements, says Tamra Merryman, R.N., M.S.N., vice president of the Center for Quality Improvement and Innovation at the University of Pittsburgh Medical Center. The 19-hospital system implemented its first RRT in 1995, and now employs the teams systemwide. “You can have the greatest people on your team, but if you don’t have them orchestrated, then you’re just going to make noise,” Merryman says.

UPMC teams respond to “Condition C” calls placed by a clinician when a patient needs immediate attention but is not in full arrest. “It sounds silly to say, ‘Let’s call for help before the patient quits breathing instead of waiting until they stop,’ but that is the thrust of what rapid response teams are about,” Merryman says . In the past year, they’ve responded to 100 more “C” events than the year before, while instances of full arrest have declined. University of Texas Medical Branch also uses RRTs, and in the first two to three months, the number of cardiac arrest codes was cut in half, according to Baer.

Despite such successes, Merryman says many organizations struggle with implementation. Hurdles exist because some healthcare leaders remain unconvinced that it’s within their financial and staffing capabilities. “People get too hung up on how much resource is needed,” she says. Rather than being a dedicated resource, RRTs are called together at a moment’s notice. They are so short-lived and focused, says Merryman, that even large hospitals in the UPMC system with more than 500 beds use existing resources for their teams.

3. Power shift: Patient-Centered Initiatives

Groups like the Joint Commission on Accreditation of Healthcare Organizations are placing greater emphasis on patients’ view of safety. “They have good ideas, and they can help,” says JCAHO President Dennis O’Leary, M.D.

Fourteen months ago, UPMC launched an extension of its RRT called “Condition H,” for “help.” “We sit in our living rooms, and if we need emergency help, we can call 911. But when we go to a hospital, we can’t,” says Merryman. Any patient confused about treatment or troubled by a symptom can call the operator (via the same number the medical team uses to call for an RRT) and ask for a Condition H. Operators are trained to get information to ensure that a legitimate need exists, then a code is issued.

Because most of the calls have been based on what she terms a “myriad of communication failures,” Merryman says the “H” response team includes the hospital’s house physician, the administrative nursing coordinator, a representative of the patient relations staff, the unit manager and a respiratory therapist. Although no imminent medical emergency may exist, Merryman says the respiratory therapist was added to ease breathing issues caused by anxiety.

Since the program began, 33 calls have been placed, averaging about two per month. “Every one has been appropriate and thoughtful,” says Merryman. And word is getting out—UPMC has fielded calls from more than 200 hospitals asking how they can replicate the program.

Officers in the Culture Club

Patient safety initiatives are only as good as an executive team’s ability to make them part of the organizational culture. Leaders may wear several hats along the way to getting buy-in from those who will actually carry out procedures every day:

The Trendsetter: “Everybody is looking to see how important patient safety is to the person who’s running the place and to the board,” says JCAHO’s Dennis O’Leary, M.D.

The Cheerleader: On their weekly rounds, leaders of the University of Texas Medical Branch make note of employees who model what the organization is trying to achieve and send them a note of thanks.

The Reporter: Executives must make sure their institution knows how they’re performing, says Suzanne Delbanco, Ph.D., of The Leapfrog Group. “If they don’t know where they’re starting from, it’s hard to know if they’re getting somewhere.”

The Equalizer: Leadership must push standardization. “Having everybody do their own thing is a patient safety risk,” says O’Leary.

The Enforcer: Leaders set the rules and make sure they’re followed. When people don’t follow protocol and leadership tolerates it, errors continue to happen, O’Leary says.

The Marketer: Execs don’t always win over staff members’ hearts and minds in formal presentations, rounds and medical staff meetings, says Steve Harden, president of LifeWings Partners LLC. It’s all in how they “sell” the benefits and outcomes in day-to-day interactions.

Kara Olsen is a staff writer with HealthLeaders magazine and managing editor of HealthLeaders Online News. She may be reached at




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