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The addition of a patient safety specialist and a safety hotline for reporting potentially dangerous situations improved the quality of care dramatically at a Missouri hospital, so much so that it is the first hospital honored by the American Hospital Association with its Quest for Quality prize.
Missouri Baptist Medical Center in St. Louis recently earned the award for its leadership and innovation in patient care quality, safety, and commitment. Initiatives addressing quality and patient safety have been an important part of the hospital’s mission for years, says Mark Eustis, senior executive officer at BJC HealthCare, the hospital’s parent organization. He says he began emphasizing quality and patient safety when he first joined the system as president of Missouri Baptist Medical Center in 1996.
"The management team, including physician leaders, developed a focused management strategy to define what’s important to the organization and our patients," Eustis says. "Improving clinical outcomes and patient safety have been the foundation of this effort for more than six years. It’s gratifying to know that by clearly defining our goals, developing measures of performance and specific initiatives to improve performance, the patients of Missouri Baptist have benefited from our efforts."
Max Cohen, MD, vice president for clinical quality and effectiveness and chief medical officer at Missouri Baptist Medical Center, says the support of BJC leadership was important in the hospital’s success. Many ideas sound great until you try to implement them, he says, and top-tier support can make the difference in whether you see any real results.
"But also, this is not something that the presi-dent handed down to us and said, Do it,’" Cohen explains. "The president and vice president have taken personal responsibility to ensure that we have a blame-free culture and that safety is a priority."
Many new strategies in place for patient safety
Missouri Baptist Medical Center implemented several strategies in the last three years in an effort to improve quality and patient safety, says Carolyn Roth, RN, JD, director of risk management. She says the hospital leaders immediately realized that the patient safety effort had to include a wide range of staff members at the hospital, not just a few key leaders.
"When we first set out to make some improvements, we got feedback early on that it looked like a three-man show and that wasn’t going over well. The staff thought it was just another case of somebody telling them what they were doing wrong," she says. "So we pulled in the directors of nursing and other supervisors to show that this was a hospitalwide effort and we had commitment from the top."
Among the first tasks was the addition of the position of "patient safety specialist" in 2001. As patient safety specialist, Nancy Kimmel, RPh, has focused on developing and implementing programs such as:
In addition, unit safety briefings, during which nurses share and discuss safety concerns identified in the past eight to 12 hours, are incorporated into the beginning of every shift.
Patient safety specialist added to staff
Once Kimmel was hired as patient safety specialist, the hospital set about organizing two new teams: the Medication Safety Team and the Patient Safety Council. The hospital’s Medication Safety Team began meeting in March 2000. The group of physicians, nurses, pharmacists, risk management staff, clinical educators and performance improvement staff worked to significantly enhance the "culture of safety" and the processes used by the hospital’s employees to dispense medications to their patients. In addition, Missouri Baptist Medical Center developed the Mind Your Meds program for patients, which features a brochure with a tear-off, wallet-sized card that can be used to help keep track of their prescriptions and therefore prevent problems with drug interactions. More than 35,000 brochures have been distributed in the first 13 months of the program, which spawned similar programs at many other hospitals (including six within BJC HealthCare).
The hospital’s Patient Safety Council began meeting May 2001. This group was composed of physicians, nurses and staff from departments ranging from pharmacy to infection control to marketing. The Patient Safety Council is charged with creating a blame-free, nonpunitive culture that allows the staff to understand that, though they are accountable, many of the problems are process-related rather than entirely human error, says Kathy Benage, RN, director of performance improvement at Missouri Baptist Medical Center.
"The number of staff-reported problems has increased tenfold during the last 18 months," she reports. "We’re thrilled, and we’ve accomplished a lot, but we also realize that we have a long way to go, and we’ll continue to keep working to create an environment that is as safe for our patients as we can make it."
Roth and Benage both report directly to Cohen, which he says offers a tremendous advantage when coordinating patient safety improvements. When they hired Kimmel as patient safety specialist, they had to decide whom she should report to. The risk manager? Benage, the quality professional? Directly to Cohen?
They decided to have the patient safety specialist report directly to Benage, the director of performance improvement, largely because Kimmel’s role includes a great deal of data management, and that fits better with Benage’s department.
"She is able to access a lot of data and start working on safety issues that derive from that data. That’s a valuable part of what she does for us," Roth says. "Before this, one of our biggest concerns was medication errors and it was historically a nursing function to look at that. But Nancy put together a multidisciplinary task force to look at this problem in a more circular way, rather than just from one view point."
Trigger for concerns
Managing the patient safety hotline is an important part of Kimmel’s job, as well. When the hotline was first introduced, she received about 15 calls a month. Now that number is up to about 200 calls a month, and Benage says that’s a good thing. More calls means the staff is using a lower trigger point for reporting their concerns, which is exactly what the teams wanted. Cohen says he is "absolutely thrilled with the huge increase in hotline calls and also with total event reporting across the organization. That’s also increased about tenfold as a result of letting the staff know we’re just as interested in near misses as in errors that have reached the patient and caused harm."
The hotline started out as a way to report only medication safety issues, but it wasn’t used very much. Roth says the hospital conducted focus groups with staff and found out that they would use the hotline much more if they could report other safety concerns.
The hotline is promoted to staff in many ways, and the phone number reaches an answering machine dedicated to nothing but hotline calls. Staff are told that they can leave information anonymously if they choose, or they can leave their name for follow-up purposes.
"The anonymity was a concern of mine because I need those names in case a lawsuit comes out of the event. I need witnesses," Roth says. "I was uneasy about that, but it has turned out fine. Some calls sound much worse at first, before you investigate it. You have to be careful not to take all the calls at face value."
Kimmel monitors the hotline recordings and ensures that action is taken within 24 hours of when the call was received. That action may include a preliminary investigation and a report to other supervisors who can take action. If the hotline caller leaves his or her name, Kimmel always reports back to that person within 24 hours to explain what is being done. She puts all of the hotline calls on a spreadsheet and sends that summary to both the risk manager and the director of performance improvement. They can select out any calls for immediate action and look for trends. Data also are sent to department managers so they can be aware of concerns in their area and watch for trends.
"The information that comes in is analyzed, and we’re looking for multiple things," Kimmel says. "Did the error reach the patient? If so, that report goes right to the risk manager. If not, I look at whether there is a high risk for an adverse outcome. Those we deal with immediately with a root-cause analysis or a performance improvement team. And if it’s a problem that can be fixed right away, we do that."
She says the culture of safety has generated support from all the managers in the hospital so that when she needs expedited action on a safety issue, there usually is no grumbling or hesitation.
The hotline calls range from the obviously serious medical error to the "small things that someone has noticed for a while and then they decide to pick up the phone," Roth says. "It could be something like a door that swings back too hard and could really nail someone. It’s a real risk, and it’s so easy to fix if you know about it. But before the hotline, there wasn’t really a vehicle for reporting that kind of concern."
Roth recounts one example in which a hotline caller reported a problem with the delivery of patient specimens to the lab. Glass bottles were found broken at the lab’s receiving station, and the staff initially attributed the problem to poor packaging by those sending the specimens. But Kimmel noticed a trend in the hotline reports and investigated further. Kimmel and Roth determined that the problem was not poor packaging by the staff, it was faulty specimen containers. Their investigation actually led to a national recall of the specimen bottles by the manufacturer.
"If not for the hotline, and if we didn’t have someone who was watching for trends in the reports, that might never have been discovered. It would have been blamed on poor performance by the staff," Roth says.
Many of the patient safety improvements required significant changes in policies and procedures, but Benage says the hospital tried to implement some changes gradually so that efforts could be refined before the entire hospital was affected. They refer to the process as "small tests of change."
"We wanted to improve the process by which we reconcile the drugs a patient takes at home and their drugs on admission, so we did a small test of change to try that process on one unit," she says. "When it worked there, we spread it to other units. It’s a concept that allows us to test the idea first, learn more from it, then spread it through the system. It also allows us to take action right away instead of studying something forever."
Change can be daunting
Cohen says that gradual process was important in achieving some of the major changes that improve patient safety at the hospital. Changing any documentation, for instance, was a daunting task because changes had to be approved by the forms committee, a process that always took longer than the patient safety teams were willing to wait.
"We got the forms committee to agree that we could change it, test it and change it over and over again, then get their formal approval. We got that agreement up front that the form wasn’t really changed until we tested it to death," he says. "This whole effort at improving patient safety is a lot more difficult than it sounds. There is a tendency to be impetuous, and think one can move quickly and accomplish a lot, but huge culture changes take a lot of time. You need a lot of patience."
Other finalists for the AHA prize included Children’s Hospitals and Clinics of Minneapolis/ St. Paul and Fairview Hospital in Great Barring-ton, MA. Brigham and Women’s Hospital in Boston received a Citation of Merit. For earning the Quest for Quality Prize, Missouri Baptist Medical Center will receive $75,000 to be used toward furthering current and developing new patient safety initiatives.