One system’s jump-start on tackling patient safety

The first step was benchmarking other industries

At Advocate Health Care in Oak Brook, IL, a plan is in the works to begin dealing with patient safety at the level of federal directives and policies.

"In fact, we got a jump-start on this six months or so before the [Institute of Medicine] report came out," says Dan Parker, director of public affairs at Advocate. "We made an early decision last year to employ safety needles to protect patients and employees. It’s costly, but it’s actually a wash when you realize the benefits of extra precautions over the cost of handling and preventing needlesticks."

Advocate’s efforts really began in June 1999, when Marj Mauer, chair of the patient safety task force, got a call from the chief medical officer, who wanted to pull together a group of people from throughout the system to discuss patient safety.

"We started at baseline," Mauer says. "We looked at what other hospitals were doing. We defined our terms between actual medical errors and quality improvement. We looked at baseline data in the Advocate system, which includes eight hospitals in the Chicago area." (Advocate is the largest integrated health care system in the metropolitan area.) She explains that in a large system like Advocate, different cultures exist in each hospital. Blending these cultures into the system does not necessarily happen quickly.

That made it hard to get baseline data, because the hospitals’ information systems were still too diverse. "The hospitals defined things differently and collected data differently," Mauer explains. "So the first thing we had to do was come up with standardization of terms before we started collecting data."

Another thing Mauer’s team found was that there weren’t many hospitals doing this, so there was no real benchmarking to work from. "That’s when we started looking outside the hospital industry," she says. "We looked at the automotive industry, the airlines, NASA. We found unpleasant statistics, such as that chances of dying from a medical error were far greater than chances of dying in a plane crash."

Advocate’s Patient Safety Task Force was curious about how these other industries managed to control errors and safety to the degree they did. The answer was a policy called Failure Mode and Affect Analysis (FMAA). "This means that during the design process, they’d look at the chances for human error and how you can build in processes to make sure mistakes don’t happen," Mauer explains. "For instance, the auto industry designs cars so you can’t start them while they’re in reverse."

Advocate set about analyzing sentinel events. "What the team did," Mauer says, "was to brainstorm all the possible areas for errors. We prioritized them and picked the top four. We then created four subteams of people closest to those processes, e.g., staff nurses and cleaning people." Then the original Patient Safety Task Force divided up and became leaders for each of the sub-teams.

The subteams focused on:

• medication errors (the team included a pharmacist and a vice president of operations who was also an RN);

• nosocomial infections (on the team were a physician epidemiologist, a respiratory therapist, and a trauma surgeon);

• labor and delivery (the team included a vice president of risk management, a family practice doctor, and labor and delivery staff nurses);

• delayed diagnosis (this team included personnel involved with diagnoses, e.g., lab workers, imaging specialists, and others who looked at how quickly they could get diagnostic information to the physician so he or she could make an accurate diagnosis).

"We chose these four areas from what we saw in literature and in high-risk areas," Mauer explains. "After the first of the year, we did a kickoff meeting where all the subteams met — more than 80 people — to review what we’d learned. We looked at To Err Is Human: Building a Safer Health System [the November report from the Institute Of Medicine that focused attention of the issue of medical errors and patient safety]. We looked at the entire issue and what the charge was to the four teams."

Advocate brought in an outside consultant who specialized in industrial quality control. "People really responded to his presentation, probably because he was from outside the health care arena," Mauer says.

All teams were educated in the FMAA process, and they now meet every week. Their target date for final recommendations is July 2000.

"We can see now that one of the biggest things we’ll be dealing with is changing the culture," Mauer remarked. "People don’t want to come forward when they’ve messed up. It’s going to be hard to change that. The public expects quality care and zero errors, as they should. But litigation is so prevalent that it’s hard for a doctor to say, I made an error.’ One of our greatest challenges is to create communications processes and systems to make sure we’re identifying mistakes and near-misses."

The teams will be looking at what kind of information technologies Advocate needs to add and how to monitor those systems. "Do we have the right people and are they competent people? Do we need new facilities and equipment? Those are the questions we’ll pursue as we define recommendations to bring to our board of directors," says Mauer. She meets with Advocate’s chief medical officer regularly, and they say that the four subteams are just the tip of the iceberg in addressing the issue. "We’re probably going to end up with a patient safety council of advocates to watch and monitor activity across the system," she says. "The Institute of Medicine report suggests there will be mandatory regulations that require reporting."

But Mauer is pleased with Advocate’s efforts. "One thing we know," she claims. "We started early, and we’re way ahead of the eight ball."