Web sites suggest ways to push access boundaries

Open visiting, patient safety highlighted

Health care is evolving, and managers must evolve with it, says Karen McKinley, RN, CHAM, vice president of patient access and care management for Geisinger Health System in Danville, PA.

"As the cost of health care continues to grow, we can’t continue to do things the way we’ve always done them."

With that in mind, McKinley lists some web sites she says might suggest ways to push the boundaries of access services, as well as some Geisinger initiatives that don’t fit neatly into conventional health care boxes:


The web site of the Institute for Healthcare Improvement (IHI) contains information on a wide range of topics, including patient safety, patient flow, and a concept known as "open visiting" that is new to most organizations.

Among the offerings on open visiting is an article looking at Geisinger’s experience with allowing family members to visit loved ones in the intensive care unit "whenever they want, for as long as they want, 24/7."

The experiment came about as the result of a challenge issued by Donald Berwick, IHI’s president and CEO, to the hospitals enrolled in the Critical Care Settings domain of IHI’s IMPACT network. IMPACT is described as "a community of change-oriented health care organizations working together to achieve new levels of quality."

In response to Berwick’s plea that "at least some member hospitals execute a two-month trial of entirely open visiting in a critical care unit," Geisinger Medical Center implemented such a program cold turkey in August 2003.

The hospital agreed to let IHI report on the experiment’s progress periodically during the next year.


This site, as well as the one mentioned above, "provides a broader picture of health care improvement, and offers ideas and strategies for how to change the actual delivery of health care," says McKinley. "You find an interesting perspective on how individual work units function and their contribution to the whole macrosystem."

As defined on the web site, a microsystem in health care delivery is "a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, shared information environment, and produces performance outcomes. They evolve over time and are often embedded in larger organizations.

"As a type of complex adaptive system, they must: 1) do the work, 2) meet staff needs, and 3) maintain themselves as a clinical unit," notes McKinley. "Inpatient admitting, for example, would be a microsystem, as would emergency department registration. I think [the microsystem concept] gives a perspective that’s a little different than teams because it actively involves patients."

The model is similar to what Geisinger did in implementing its open visiting program, bringing patients and families into the discussion of how it would be done, McKinley explains. "They said, for example, that there was not enough waiting space, that they felt crowded, and that there was difficulty getting updates on their loved ones.

"What we did," she adds, "was incorporate all of those things and incorporate limits that made sense. If you need sterility, for example, family members can’t be there, so they are excused for a brief period and then allowed back in."

Stage two of the project, McKinley says, will be to involve family members in the care of the patient. "They’ll be told, These are the things your dad has to have done every day. Which would you like to do?’"


"This is a quality-measures clearinghouse," she says, "with some of the latest news on [which] measures people will have to be reporting. [The health care industry] is moving toward more public reporting of all kinds of measures, access to care, or quality indicators."

A group of Wisconsin hospitals and Dartmouth-Hitchcock Medical Center have gone public with measures from their health care delivery, McKinley notes. "This [site] is sort of a connection to what’s happening with measures, what people are going to be accountable to do. As we get more focused on delivering error-free health care, we will all be reporting in this manner."


This site deals with the story of a young child who died because of medical errors, she says, and, in part, because hospital staff didn’t listen to her mother’s concerns. "Things started to go bad, and her mother saw it," McKinley adds. "It’s about health care personnel not listening and actively involving families in care."

Such examples are helpful for access personnel, she notes, "because if we don’t listen carefully, we do things like create duplicate medical record numbers or collect the wrong information and label things incorrectly. This could result in errors."

"We’re all accountable for our piece of this complex health care puzzle," McKinley points out, "and for making sure that we pay attention to detail."

www.iom.edu and www.jcaho.org

Geisinger has made extensive use of the web sites of the Institute of Medicine (IOM) and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) in its patient safety initiatives, she says.

"They both have patient safety goals or aims, and we’re using them as a foundation to build a systemwide program," McKinley adds.

The IOM’s six aims contend that patient care should be patient-centered, safe, timely, efficient, effective, and equitable, she says, while JCAHO lists the following seven National Patient Safety Goals, approved in July 2002 by the organization’s board of directors:

  1. Improve the accuracy of patient identification.
  2. Improve the effectiveness of communication among caregivers.
  3. Improve the safety of using high-alert medications.
  4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
  5. Improve the safety of using infusion pumps.
  6. Improve the effectiveness of clinical alarm systems.
  7. Reduce the risk of health care-acquired infections.

The idea promulgated on both sites, she says, is "everybody at every level of the organization pays attention to both patient safety and staff safety."

At Geisinger, "we’re trying to create an environment that is nonpunitive, that allows us to open discussions about incidents that happen," McKinley continues.

"We find that most are a result of system problems, not individual problems, so we approach them from that perspective — looking for the root cause and trying to fix them, and not blame an individual," she adds.

"Rarely does an individual intentionally do something wrong," McKinley points out.

An example, she says, would be a case in which two patients on a nursing unit have the same name. A test is ordered on one patient, and somehow things get mixed up and the test is done on the wrong patient.

"Somebody made a mistake, but probably there was a series of events that allowed that to happen," McKinley explains. "Did anyone take time to put a middle name on the patient’s name band? Did anyone put an alert in the medical record? Did the person checking identification go through a double-check?"

"It’s like when you get on an airplane, the pilot goes through a massive series of checks," she notes. "The plane doesn’t take off until everything is perfect. Unfortunately, in health care, we don’t always apply the same rigor." n

Need more information?

  • Karen McKinley, RN, CHAM, Vice President, Patient Access and Care Management, Geisinger Health System, Danville, PA. E-mail: kmckinley@geisinger.edu.