NPSGs for 2007 are here: Here are your toughest challenges

Patient involvement is 'next wave' for safety

Asking patients if they felt unsafe at any point during their hospital stay. Actively encouraging patients to report safety concerns. Having systems in place to ensure that all patients receive a complete list of their current medications.

With the new 2007 National Patient Safety Goals (NPSGs), quality professionals agree that the Joint Commission is sending a strong message: That organizations need to find ways to involve patients in their care.

"One of the key messages that we are learning after everything that we have studied is that to be safe, health care has to be done as a team activity. And the patient is arguably the most important member of the team," says Richard J. Croteau, MD, JCAHO's executive director for strategic initiatives.

Unfortunately, the patient often is the last to know what is going on with his or her care, says Kathy Haig, director of quality resource management at OSF St. Joseph Medical Center in Bloomington, IL. "I believe this is starting to change, and the JCAHO's national patient safety goals will assist this," she says. "However, this will take time, as it is a culture change."

Staff must get used to the fact that patients have a right and a responsibility to ask questions about their safety, says Pat Wardell, vice president of quality management and patient safety officer at St. Jude Medical Center in Fullerton, CA. "I think patients are very willing to comment on things. We do get phone calls saying things like 'They went to draw my blood and I'm not sure if they washed their hands,'" she says. "I think patients are challenging the staff more than they would have 10 years ago. The patients have got to be part of the process. It's the next wave."

Each of the new NPSGs presents its own challenges, which can be quite complex, says Haig. She gives the example of an existing goal requiring a patient's medications to be reconciled, which requires you to have a system for completing the list, determine which staff member compares the lists, a process for what to do if you can't obtain a complete list, and a system for what to do if a physician is not willing to sign the reconciliation tool if he or she did not order the medication. "These are just a few of the questions that arise with that one single process," says Haig.

However, all the quality professionals interviewed by Hospital Peer Review acknowledged that the 2007 goals are heading in the right direction. "These are great goals, and we are already on target with most of them," says Alison H. Page, MSN, MHA, vice president of patient safety at Fairview Health Services.

Here are the new NPSGs and what quality managers are doing to address each:

Encourage patients to report their safety concerns.

The Joint Commission's "Speak Up" campaign is one model that organizations could adopt to provide information to patients about how to ask questions about safety. "The information itself encourages patients to do that," Croteau explains. "The organization should make sure the patients understand that their feedback is wanted if they have concerns. Organizations can develop their own ways of doing this."

The goal is not only to take action about the patient's concern, but also to provide feedback to the patient about what has been done. "This encourages them to report other safety concerns," says Croteau.

Measuring compliance

Surveyors will want to know your processes for informing patients how to report concerns, and for encouraging patients to do so. "Then the surveyors will go out and talk to front-line nurses and doctors to see if they know they are part of the process," Croteau says.

Surveyors also will be talking with patients, and may ask questions such as "What would you do if you had a question about your medication?" or "What would you do if somebody said they were taking you for a test that you didn't know anything about?"

"The patient's response will tell you a lot about whether anybody's talked to them about what to do if they have concerns," says Croteau.

An electronic error reporting system is used at Fairview Health Services, with the goal of making this available to patients directly. "Currently, if the patient identifies a concern, a staff member logs it in," says Page. "What we want to do is allow patients to do that directly, either while they are still in the hospital or afterwards on the Internet."

To measure compliance, the organization looks at how many patients actually report concerns. In addition, a customer satisfaction survey asks patients, "Did you feel safe while in the hospital?" and staff routinely ask patients if they have any concerns about their care or noticed any glitches.

At OSF St. Joseph, a video is shown to patients on admission encouraging them to watch for whether staff are washing their hands, including physicians, and if not, then to ask them to do so. When patient advocates round and visit every patient, they also remind staff of certain safety precautions, such as the importance of staff checking patients' identification before giving medication, and encouraging patients to ask about a medication if it looks unfamiliar to them.

In addition, a Family Initiated Rapid Screening Team program encourages family members to call for a rapid response team if they feel their family member's condition is changing or not improving. The family member calls the hospital switchboard operator using the emergency number 5000. The hospital switchboard operator then pages the rapid response team.

The team consists of a critical care nurse and respiratory therapist who conduct an evaluation and assessment of the patient, and work with the patient's nurse as a "second pair of eyes" to communicate with the physician, assess the patient's condition and initiate additional treatment if needed. The family members are given a brochure on admission explaining the program, which includes a phone number to call for additional questions.

Measuring patient involvement

So how do you measure the degree of patient involvement at your organization? This is a challenge for quality professionals, says Haig. She suggests tracking the number of performance improvement teams that patients are on. "We will be tracking the number of family-initiated rapid response team calls as well," she says. On patient satisfaction surveys, patients are asked whether staff checked their identification, if they washed their hands, and about their feeling of safety and security.

"In the past, we have done direct surveys of patients while they were in the hospital to determine if they had any safety concerns," says John Whittington, MD, director of knowledge management/patient safety officer at OSF Healthcare System in Peoria, IL. "Some of our hospitals have questions that they use post-hospitalization with patients to check for safety concerns. They ask patients questions related to safety, quality, and privacy."

At St. Jude Medical Center, several initiatives have been put in place to encourage patient involvement. "Part of the message to our patients is, 'We really want you to be part of your care," says Wardell. "The organization adopted many of the recommendations in the JCAHO "Speak Up" campaign, such as placing posters in patient rooms reminding patients to ask about pneumococcal pneumonia and flu vaccines.

"We have signs that ask patients to please tell us if there are problems that we haven't dealt with," says Wardell. "We will be looking at that whole process and making sure we have defined safety concerns and encourage patients to report these," says Wardell. "In our patient brochure, we invite patients to contact their patient representative if they have concerns."

Involve patients in their care.

This goal exemplifies the Wagner Chronic Care Model, which emphasizes having an informed, activated patient who is part of the health care team, says Page. "Our patients are not typically coming to us with just one thing wrong; most have chronic underlying conditions. We have to manage the entire patient, not just one acute problem," she says. "Involving individual patients and families in their care is a never-ending journey that we're on."

At Fairview Red Wing (MN) Medical Center, the case manager, hospitalist, pharmacist, therapists, and dietician go from room to room and review the care plan daily with the patient and family, says Page.

To measure patient involvement, the organization's satisfaction survey asks patients whether nurses and doctors involved them in decisions about their care. "Some of our hospitals are piloting satisfaction surveys when the patient is still in the hospital, so concerns can be addressed in real-time, such as sleep interruption or the behavior of a care provider," says Page.

Several years ago, posters were placed in patient rooms at OSF Healthcare System hospitals that encouraged patients to ask providers questions about the following: Has the provider washed his or her hands? Have they checked your wrist bracelet to identify you? Do you have any questions about medications? "In addition, we have some written material that we provide the patient about patient safety issues," says Whittington.

For example, patients receive a hand hygiene brochure about what they can do and what the staff should be doing. "They also remind them while we are rounding that even their family should be using the alcohol gel when they visit," says Whittington. "And they wear 'Ask me if I've washed my hands' buttons."

Give patients a complete list of medications.

"As part of our medication reconciliation program, we have a computerized system and electronic medical record, so for us this has not been difficult," says Wardell. "As the patient is discharged, the medication record is printed and staff go over all the medications with them."

At Fairview Lakes Medical Center in Wyoming, MN, a complete list of home medications is created upon admission, reviewed by pharmacy and medical staff, and appropriate medications for the patient during hospitalization are determined. The process is repeated at discharge. "The devil is in the details, and Fairview Lakes has nailed the details — so much so that JCAHO just highlighted their process in a training video," says Page.

Identifying safety risks in population.

Organizations should look at their own incident reporting data to identify the most common types of incidents that are placing patients at risk, says Croteau. "The other place they should look is to the literature, for the most significant risks for the type of care they provide," he adds.

For example, suicide is one of the most significant risks for behavioral health care patients. "That's why that is the first requirement under that goal," he says. "In other general care environments, an organization's data may show a lot of falls." In addition to addressing environmental risks, screening patients for fall risk is key, says Croteau.

"We assess every behavioral health patient for suicide risk," says Page. "We also evaluate every patient for risk of falling and make accommodations to prevent injury and falls." In addition, Fairview mines their data bases and patient records for safety concerns. For example, the use of Narcan, an antidote for narcotic oversedation, is monitored to identify areas where there may be opportunity to improve how narcotics are being used.

To identify safety risks, quality professionals at OSF Healthcare System use the Institute for Healthcare Improvement's Global Trigger Tool, executive safety walkarounds, incident reporting, and near-miss reporting. "We also do active computer surveillance in which we can begin to predict who is going to get sicker while hospitalized," says Whittington.

Focus groups are another way of identifying risks for specific patient populations, such as transplant patients, behavioral health patients, or pediatric patients, says Page.

Openness and sharing of information is another aspect of patient involvement, says Page. "We're moving in the direction of having the patient's health record available to the patient at all times," she says. Three health systems in Minnesota are currently working on a system to make critical patient information from the ambulatory care record easy to access in an emergency, regardless of which hospital the patient presents at, adds Page.

Assessing risks

"We have always identified safety risks through our patient safety committee, but I expect we will have to make it more formal than we have in the past," says Wardell. "It looks like there has to be an assessment made, and based on that assessment, make sure we have strategies in place."

To assess risks, the organization is looking at medication errors, patient falls, and patient complaints. "We will look at things that are truly safety issues for the patients, such as how to orient staff when we bring in new equipment, and how to prevent bedsores and pressure ulcers," says Wardell.

First, a needs assessment will be done to determine which safety issues will be evaluated. "Then we will assign priorities, assign leaders to each item, and then have the leaders determine action plans and monitor those plans to see how we are doing," says Wardell.

At OSF St. Joseph, "Safety Briefings" are used so all staff, including physicians, have a way to report concerns that could or did cause harm. "These situations are investigated for opportunities to improve care processes," says Haig.

Root cause analyses of near-miss events also are used to identify safety risks. A monthly interdisciplinary mortality and morbidity meeting includes physicians from different specialties and front-line staff from multiple disciplines involved in the case being discussed.

"The cases are selected based on problems identified, to review, discuss, and address process issues," says Haig. "For example, our last meeting involved risks involving intravenous lines. We also use equipment recalls and reported concerns to identify potential risks to patients."

[For more information, contact:

Kathy Haig, Director, Quality/Risk Management/Patient Safety Officer, OSF St. Joseph Medical Center, 2200 E. Washington Street, Bloomington, IL 61701. Telephone: (309) 662-3311, ext. 1347. E-mail: Kathy.M.Haig@osfhealthcare.org.

Alison H. Page, MSN, MHA, Vice President, Patient Safety, Fairview Health Services, 2450 Riverside Avenue - COB 1, Minneapolis, MN 55454. Telephone: (612) 672-6396. E-mail: apage1@fairview.org.

Pat Wardell, Vice President, Quality Management and Patient Safety Officer St. Jude Medical Center, 101 E. Valencia Mesa Dr., Fullerton, CA 92835. Telephone: (714) 992-3000, ext. 3763. E-mail: pat.wardell@stjoe.org.

John Whittington, MD, Director of Knowledge Management/Patient Safety Officer, OSF Healthcare System, 800 N.E. Glen Oak Ave., Peoria, IL 61603. Telephone: (309) 655 4846. E-mail: John.W.Whittington@osfhealthcare.org.]