ED Accreditation Update: Safety and 'silos' don't mix, asserts The Joint Commission in new Alert
ED Accreditation Update
Safety and 'silos' don't mix, asserts The Joint Commission in new Alert
Successful programs involve nurse, physician, administration collaboration
"No unit is an island" might be the theme of a new Sentinel Event Alert from The Joint Commission (TJC).
"Health care leaders can . . . break down the barriers between clinical, operational and financial 'silos' by developing and recruiting leaders who understand the importance of all three areas working closely together in order to create safety," says TJC in its Alert. (To access the complete Alert, go to www.jointcommission.org. Under "Sentinel Event," click on "Sentinel Event Alert," then "Issue 43: Leadership committed to safety.")
ED managers agree that such silos, whether between different areas of the hospital or different disciplines within the department, are barriers to the successful creation of a safety culture. "You have to have representatives [from every unit] at each other's meetings, as well as a [hospitalwide] quality meeting that focuses on safety every month," says Kevin Klauer, DO, FACEP, director of quality and clinical education for Emergency Medicine Physicians, Canton, OH, and a staff emergency physician at Barberton Citizens Hospital and Lodi Community Hospital, both in the Akron/Canton area. "You've got to make sure safety is institutionalized into one system design — not 30 different ideas of what it is and what it means."
India Owens, RN, director of emergency services at Clarian West Hospital in Indianapolis, says, "I think that most of the things we do, most of the processes we use, cross every one of our disciplines. This central approach is important because more often than not what you have difficulty with, I have difficulty with."
Accordingly, while there are corporate goals around safety, each department keeps a "scorecard" of its performance, and every department has its own goals to feed into the overall corporate goals, Owens says. The system is totally transparent, so the ED can view the scorecards of all the other departments in the hospital. "If I have a goal to reduce labeling errors and I wonder what kind of approaches should be used, I can go and look at what other units have done," she explains. "If another unit has a higher score in this area, I can review and discuss their tactics with them."
Methodist Hospital in Sacramento, CA, held collaborative meetings between the physician staff and nursing. "You need the support of both to be effective," says Cindy Myas, RN, MSN, director of emergency services. At Methodist, the triage process recently was overhauled to enhance patient safety. The triage nurse was put in the waiting room to serve as the "greeter." She quickly determines if a patient should go home; requires further diagnostics and should be placed in the waiting room; or if they require an ED bed.
"If we were not all working in the same direction, this would not have worked," Myas says.
During a series of meetings, both groups voiced their concerns, and everyone had to agree on the new processes, she says. "Our motto was, 'If you come to the meetings, you get to make the decisions,'" Myas shares.
Administration also was a critical element, she says. "They had to be supportive," Myas says. "They actually needed to sign on to what the leadership in the ED recommended because this hit our bottom line." More staff were required to make the new process work, she explains. Administration approved the addition of two RNs to each shift, a midlevel physician's assistant, and another physician for the busiest times in the ED.
Joint Commission Sentinel Event Alert
Source: The Joint Commission. Sentinel Event Alert, Aug. 27, 2009. (Revised Sept. 8, 2009.)
Multidisciplined group provides 'safe passage'
At Clarian West Hospital in Indianapolis, the ED participates in a multidisciplinary group that processes all safety issues. Called the Safe Passage Committee, it is led by the vice president of quality and safety.
"Frontline staff [members] attend the meetings and report back to leadership," notes India Owens, RN, director of emergency services. Issues can be brought forward by staff or leadership. They are discussed, and an approach is decided upon. Meeting minutes are distributed throughout hospital and also are available to any staff member online.
Many times, she notes, the decisions involve changing or creating a policy. At Clarian West, however, processes are part of the safety policies. "For example, in the ED, we have a policy for determining if a pregnant patient who presents should be sent to OB or stay in the ED," Owens explains. "We have an algorithm embedded in the policy that outlines the steps a staff member goes through to make that determination — the key decision points." The advantage to this approach is that ED staff members don't have to go to two places (policies and processes) to find out what to do, she says.
Having all safety issues go through the committee ensures that safety practices unfold the same way in the ED as they do in other departments, Owens notes. Consider a hypothetical example in which there are three needlesticks in the ED related to a new product, she says. "It would go to that committee, and the vice president of quality and safety could make the decision to pull the product and communicate it to the entire hospital," Owens says. "The product would be pulled, and we'd revert to a prior product."
However, she adds, the process doesn't stop there. At the next committee meeting the group would discuss whether this was truly a product failure or whether there was another factor involved. "Even if the product was pulled, we'd to try to figure out the root cause," Owens explains. "Maybe we did not educate the nurses well enough, or maybe the nurses were not used to the way the product was designed. We never just pull a product."
A safety culture key to reducing errors
ED leaders agree that creating a safety culture that reaches across all hospital departments is the key to improving safety in any department. Kevin Klauer, DO, FACEP, director of quality and clinical education for Emergency Medicine Physicians, Canton, OH, and a staff emergency physician at Barberton Citizens Hospital and Lodi Community Hospital, both in the Akron/Canton area, has identified several key elements of such a culture.
"Everyone talks about safety, but people do not always do what they say," he says. "The organizational values are not matched by the operation of the institution." Patient safety should be the first priority, Klauer adds. "The translation is, it has to be an agenda item on everyone's meetings."
What's more, he adds, "Your culture has to be blameless — and not just for doctors or nurses. Errors are going to happen." Those errors do not make someone a bad doctor or a bad nurse, Klauer adds. "It's how we handle them that make us different," he says.
So, as an ED manager, the approach to staff who commit errors is to tell them you know they are committed to doing their best, and it is important to examine the incident to learn how to prevent it from happening again. That attitude must be reflected by upper management as well, Klauer says. "Your administrator has to say that 'we understand there is rarely an error made that is one-dimensional — that they are multifactorial,'" he says.
The final element — a patient-centered culture — is closely linked to having a consistent approach to safety throughout the institution. For example, notes Klauer, procedural sedation is an important issue for The Joint Commission. "My understanding is that they are concerned that it may be occurring in environments made unsafe by providers who are not properly trained," he says.
So, for example, procedural sedation is part of an ED physician's training, board certification, and standard of care. However, for some other departments, "It is a good idea to make sure the staff are trained and credentialed properly, so if you are going to do an endoscopy, you will not have a bad outcome," says Klauer.
That's where a single hospitalwide approach becomes critical, he says. "If you have 15 departments saying they do not need oversight, you can have a huge breakdown, which can result in bad patient care," says Klauer. "Some patients may be getting a shoulder reduced without sedation in some institutions. You can't have 15 different definitions of what quality and safety are."
Joint Commission suggests patient safety actions
The following are some of the actions suggested by The Joint Commission directed to senior leadership: the governing body, the chief executive, senior managers, and medical and clinical staff leaders:
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