SlideShare une entreprise Scribd logo
1  sur  10
Télécharger pour lire hors ligne
International Journal for Quality in Health Care 2003; Volume 15, Supplement 1: pp. i31–i40                                                   10.1093/intqhc/mzg075




Improving patient safety across a large
integrated health care delivery system
ALLAN FRANKEL1, TEJAL K. GANDHI2 AND DAVID W. BATES1,2
1
    Partners HealthCare System, Boston, MA, 2Brigham and Women’s Hospital, Boston, MA, USA


Abstract
Objective. Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety
across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare
system, a large, integrated, non-proWt health care delivery system in the United States.
Design. Partners identiWed a central Patient Safety OfWcer, who then formed a Patient Safety Advisory Group with local expert
members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member




                                                                                                                                                                      Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implemen-
tation. There was broad consensus that interventions should include the areas of culture change, process change, and process
measurement.
Setting. A large, integrated health care delivery system in the Boston, Massachusetts, area.
Results. Key milestones to date include implementation of Executive WalkRounds, development of accountability principles,
agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physi-
cian order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network.
Most inXuenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient
safety initiatives.
Conclusions. This loosely integrated delivery system represents a daunting landscape for the development and institution of
patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for signiW-
cant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging.
Moreover, with many potential interventions, and limited resources, prioritization and selection is difWcult. Nonetheless, con-
sensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the
net result will be substantial improvement in patient safety.
Keywords: culture, patient safety, quality improvement



Safety in health care has received substantial attention in the                               be possible even without changing technology [3]. The ultimate
US since the 1999 Institute of Medicine report, To Err Is                                     goal in culture change is system transparency, deWned as a will-
Human [1]. While that report described the magnitude of the                                   ingness of providers and patients to openly and comfortably
problem in some detail, it provided only a high-level view of                                 express their concerns about the delivery of care in a manner
how organizations might change in order to improve the care                                   that identiWes Xaws and leads to their elimination, mitigation, or
they provide. In the 4 years since that report, organizations                                 appropriate management. Culture change, and the subsequent
have struggled to develop coherent programs for improving                                     increase in event identiWcation that it promotes, are essential in
safety, and these programs have varied substantially.                                         order to then be able to identify and improve systems of care
   We believe that patient safety programs should include at                                  such as medication delivery. Leadership understanding of
least three areas of focus: culture change, process change, and                               safety concepts represents an essential component for this cul-
process measurement. Changing culture is a new watchword in                                   ture change [4–7]. Yet it is far from clear how best to build a
patient safety. There is a growing realization that the beneWts of                            culture of safety, especially across a large entity, or to know
technological advances will be optimized only if health care                                  whether one has been achieved.
providers approach delivery of care from the appropriate                                         Processes need to be standardized and variation reduced to
perspective [2], and that substantial improvement in safety may                               improve the quality of care and reduce error rates. In some


Address reprint requests to David Bates, Brigham and Women’s Hospital, BC3, 1620 Tremont St, Boston, MA 02120, USA.
E-mail: dbates@partners.org

International Journal for Quality in Health Care vol. 15 Supplement 1
© International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved                                                       i31
A. Frankel et al.


instances, this may involve implementation of technology,            for safety made identifying the participants for this group
while in others it may not. Process and outcomes must be             straightforward, as all the institutions had clearly delineated
measured to know whether care has ultimately been                    who was responsible for their patient safety efforts. Members
improved. The objective of this paper is to delineate the com-       of this group include physicians, nurses, and risk managers.
ponents of a patient safety strategy, developed and imple-              Initially, the Patient Safety Leaders Group was most pow-
mented in one large integrated delivery system, to improve           erful in educating its members about the good ideas and best
safety by catalyzing safety-based cultural changes, changing         practices of each institution. As the group has become more
processes, and measuring outcomes.                                   cohesive, over a period of 1 year, the members are beginning
                                                                     to think collaboratively about goals for the integrated delivery
                                                                     system in addition to each individual’s speciWc hospital goals.
Study design                                                         To develop the camaraderie necessary to achieve this, the
                                                                     group has met face-to-face for over a year. Because the inte-
Study site                                                           grated delivery system is spread across much of eastern
                                                                     Massachusetts, initial attempts to convene this group were
Partners HealthCare is the largest integrated delivery system        done virtually—usually by telephone conference calls. It
in the north-eastern United States. It was founded in 1994 by        became apparent after a few months that the group was not
Brigham and Women’s Hospital and Massachusetts General               functioning effectively, so face-to-face meetings were sched-
Hospital, and has grown to include primary care and specialty        uled. The improvement in collaboration, camaraderie and




                                                                                                                                        Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
physicians, community hospitals, the two founding academic           congeniality was apparent within a few sessions. As a com-
medical centers, specialty facilities, community health centers,     promise, the meetings are scheduled monthly, alternating
and other health-related entities. While researchers within          between virtual and face-to-face formats.
Partners have long been leaders in patient safety research [8–13],      The group is beginning to tackle a variety of system-wide
Partners did not have a coherent, network-wide approach to           projects, some aimed at cultural change, such as promulgating
patient safety before the Institute of Medicine’s report.            the acceptance of executive WalkRounds to discuss safety
                                                                     issues and system-wide accountability principles. Others are
                                                                     process-speciWc, such as managing anticoagulation, improv-
Partners patient safety program structure
                                                                     ing the safety of central line insertions, and ensuring wide-
In 2000, Partners Chief Medical OfWcer and Partners Chief            spread implementation of computerized physician order
Executive OfWcer decided to create the position of Partners          entry. These projects were chosen because they address high-
Patient Safety OfWcer. The main task of the position was to          risk processes and could be used as paradigms for future
devise strategies to reduce error in care delivery. A signiWcant     projects relating to both medication delivery and invasive
component of medical error reduction up to that point had            procedures in other areas.
been directed towards measurement and process change, par-              In addition to the clinical care provided by Partners and
ticularly in terms of medication safety [11,14,15]. However,         non-Partners Harvard-afWliated organizations, these institu-
experiences in attempting to improve safety across a broad           tions have been leaders in patient safety research, and the
array of institutions suggested that combined tools that             research groups interact closely with the operational entities.
addressed cultural change and leadership as well as speciWc          The intent is to have the organizations serve as laboratories
components of care delivery would be most successful [5].            for improvement in patient safety, and in addition to rapidly
The goals delineated for the Partners Patient Safety OfWcer          disseminate beneWcial changes throughout the organization.
position included speciWc efforts to change the culture of our
hospitals—especially by educating hospital leadership—and
to revise the hospitals’ methods of analyzing adverse events
so that they measure and delineate system and process prob-
                                                                     Results
lems, pinpoint longstanding unsafe traditions, and delineate
                                                                     Patient safety initiatives across an integrated
actions to address them.
                                                                     health care system
   Two groups were developed to support the Partners
patient safety effort. A Partners Patient Safety Advisory            Integrated delivery system executive-level patient safety goals
Group was convened to meet two times per year to advise the          differ somewhat from those established at a hospital-based
Patient Safety OfWcer of national trends and to evaluate the         patient safety level. Projects that target transitions from one
efforts underway in the integrated delivery system. The indi-        institution to another or require consensus across organiza-
viduals in the advisory group were chosen based on their             tional boundaries will beneWt from oversight at a high level.
work in areas related to patient safety, their knowledge of the      Coordinated anticoagulation management is an example. By
national environment, and their stature within the Partners          contrast, initiatives that are wholly hospital based or con-
HealthCare System. In addition, a Partners Patient Safety            tained within one organization or one administrative structure
Leaders Group was convened, made up of the individuals in            can be piloted and proven locally. Then other hospitals may
each institution with the responsibility for patient safety. The     beneWt from the learning. However, hospital-based patient
Joint Commission on Accreditation of Healthcare Organiza-            safety personnel tend to be, appropriately, inwardly focused
tions’ mandate that hospitals identify a locus of responsibility     and their time is Wlled with responsibilities from within their


i32
Improving patient safety


own organization. As a result, the opportunity to learn from             organization created to help lead the improvement of health
other organizations is limited to literature and an occasional           care systems and to promote continuous increase of their
national conference. Lack of collaboration across and within             quality and value [17]. The IHI has conducted many year-long
institutions is common. The strength of an integrated system             multi-hospital collaboratives to develop and spread best prac-
is that its leaders can develop a framework for constant col-            tices. In these collaboratives, up to 140 hospitals over a period
laboration to occur. The Patient Safety Leaders Group has                of 1 year undertake similar projects aimed at improving health
been an example of this. The relationships developed have                care, and convene periodically to discuss and compare their
facilitated large-scale projects as well as fostering numerous           progress. The WalkRound™ tool was designed to connect
collegial interactions about smaller problems. Safety requires           senior leadership to patient safety and to inculcate a culture of
collaboration amongst clinical groups and should be a goal of            safety into the health care system. It was also postulated that
all those responsible for patient safety.                                the information elicited during the WalkRounds™, if effec-
    The aim of the new Partners-wide safety goals was to achieve         tively analyzed, might be used to drive safety-based changes
a culture change, and to revise the hospitals’ methods of analyz-        by creating a cycle of information–analysis–action–feedback.
ing adverse events to include process change and process meas-           The end result would be a self-sustaining process that would
urement. To accomplish these goals, our approach has been                continue to engage leadership, educate clinicians and mana-
initially to pilot an intervention at one institution with the goal of   gers, and lead to continuous improvement.
eventual rollout across the entire delivery system. The interven-            The WalkRounds™ were initiated with the following object-
tions that have been piloted and/or implemented in the system            ives: (i) to increase awareness of safety issues by all clinicians;




                                                                                                                                                 Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
have included executive WalkRounds™, the development of                  (ii) to make safety a high priority for senior leadership; (iii) to
accountability principles, Web-based reporting systems, and              educate staff about patient safety concepts such as non-puni-
process-speciWc initiatives. Separately, they are modestly useful.       tive reporting; and (iv) to obtain and act upon information
Combined, however, these initiatives are a signiWcant force.             elicited from staff about safety problems or issues.
Table 1 outlines some of our current and potential patient safety            WalkRounds™ was piloted at one hospital in January 2001.
initiatives; the challenge is determining the priority for implemen-     The Chief Executive OfWcer, Chief Operating OfWcer, Chief
tation of each of these initiatives.                                     Medical OfWcer, and Chief Nursing OfWcer agreed to partici-
                                                                         pate in weekly safety walk rounds. Other participants in the
                                                                         WalkRounds™ include the patient safety director, patient
Culture change: executive WalkRounds™
                                                                         safety manager, and research assistant. WalkRounds™ are
Executive WalkRounds™ were conceptualized initially in the               held weekly and visit different areas of the hospital, including
Idealized Design of Medications Systems Design Group at                  the medical/surgical/obstetrical wards, emergency room, phar-
the Institute of Healthcare Improvement in 1999 [16]. The                macy, and operating suites. During the WalkRounds™,
Institute for Healthcare Improvement (IHI) is a not-for-proWt            speciWc questions are asked of the staff nurses, residents, and
                                                                         staff pharmacists on duty, such as ‘Were you able to care for
                                                                         your patients this week as safely as possible? If not, why not?’
Table 1 Partners current and potential patient safety initiatives        and ‘What could this unit do on a regular basis to improve
                                                                         safety?’ (Figure 1). At the end of the rounds those who were
Culture change                                                           questioned are educated about patient safety concepts such as
  Executive WalkRounds™                                                  the importance of reporting near misses and how thinking
  Accountability principles or commitments                               about human factors can inXuence decision making. These
  Education: orientation, competencies, credentialing                    participants are e-mailed a transcript of the conversation later
  Safety brieWngs                                                        that day to thank them for their participation and so that they
Core process                                                             may review their comments. Events that are captured in these
  Intelligent Information Technology: computerized                       rounds are put into a database and classiWed according to the
  physician order entry, electronic medical records,                     contributing factors that inXuenced the event. Each event is
  computerized medication administration records,                        assigned a score based on its severity or its potential for
  bar-coding                                                             patient harm.
  Simulation: teamwork and communication                                     The list of events requiring active response is prioritized by
  Flow: unit-based assessment                                            level of severity and brought to the responsible leadership,
  Protocols: clinical practice guidelines by evidence and                and ownership of the issues is assigned. Each quarter,
  consensus                                                              the leadership provides updates to those who participated in
  Hardware standardization                                               the rounds on progress towards resolution or a statement of
                                                                         the rationale for not taking action. Informing them of the
Measurement
                                                                         actions taken closes the communication loop with the
  Reporting systems
  Pharmacy interventions                                                 WalkRound™ participants. We have informally surveyed
  Computerized monitoring for adverse events                             staff and leadership about these walk rounds. Leadership have
                                                                         been extremely engaged and feel the rounds have great value.
  Protocols and clinical practice guidelines
                                                                         The staff overall have been pleased to see leadership commit-
  Attitudinal surveys (clinician and patient)
                                                                         ment to safety with these rounds, and have been pleased with


                                                                                                                                          i33
A. Frankel et al.




                                                                                            Sample questions:
                                                                                            1. Have you been able to
                                                                                            care for patients as safely
                                                                                            as possible. If not, why?
                                                                      Weekly                2. Have there been any near
                                                                                            misses that almost caused
                                                                   WalkRounds               patient harm?
                                                                       with                 3. Can you describe the
                                                                                            unit's ability to work as a
                                                                    leadership              team?
                                                                     and staff              4. When you make an error
                                                                                            or intercept an error, do you
                                                                                            always report it? If not, why?
                                                                                            5. Have you discussed
                                                                                            patient safety issues with
                                                                      Monthy                your patients or their family
                                                                                            members?
                                                                      reports
                                                                    prioritized
                                                                    by severity
                                                                     of patient
                                                                      impact
                    Feedback to the




                                                                                                                                        Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
                       reporter
                                                                    Responsible
                                                                       clinical
                                                                      manager
                                                                         and
                                                                     leadership
                                                                       review
                                                No

                                                                       Decision
                                                                      for action

                                                       Yes



                                                                   Assignment of
                                                                    ownership



                                                                       Action
                                                                     completed



Figure 1 WalkRounds™ Xow diagram.

the follow-up actions they see based on their comments.            Reporting System (ASRS) is an example of this successful
Since the initial pilot, WalkRounds™ have been successfully        approach applied to the airline industry [18].
implemented at four additional Partners institutions. The plan        Currently, reporting of adverse events frequently does not
for further spread to other institutions is under discussion, as   occur, at least in part because individuals believe that they will
is a standardized analysis of the impact of the WalkRounds™.       be blamed or sanctioned (regardless of whether the individual
In addition, a study is underway to evaluate the WalkRounds        or the system is at fault) [19]. Most blame-free policies
in 10 other Massachusetts hospitals over the next 2 years.         attempt to balance the desire to increase reporting with the
                                                                   desire not to limit sanctions. This is usually done by promis-
                                                                   ing protection to those who report in a timely fashion and
Culture change: accountability principles
                                                                   exempting cases of misconduct. Many are fashioned from the
Accountability principles or commitments to safety derive          ASRS reporting procedures that have for over 25 years
from attempts to clearly enunciate a non-punitive or blame-        offered immunity if reports are obtained within 5 days of the
free reporting policy towards health care providers who            event, exempted criminal actions, and afforded the reporter
report adverse events or episodes of patient harm. The pur-        conWdentiality, followed 30 days later by anonymity. The
pose of improving reporting is to elucidate Xaws in the health     ASRS system works on a national scale, but does not offer to
care delivery system that may then lead to the development         the individual airlines an analysis of airline-speciWc problems.
and implementation of system remedies. The Aviation Safety         To address this, airlines have built Aviation Safety Action


i34
Improving patient safety


Plans that tend to offer conWdentiality but not anonymity and        attitude and unsafe Xying conditions. These surveys have
that facilitate in-depth root-cause analysis.                        been modiWed for use in health care and there are clear
   Anonymity and conWdentiality in a hospital or health care         indications that provider attitude may be correlated with
system is much harder, sometimes impossible, to achieve.             patient morbidity and mortality [25,26]. We are planning to
Rather than simply address the protection afforded to individ-       use these types of surveys to measure the cultural impact of
uals for reporting, a set of principles that outlines expectations   WalkRounds™ and Safety BrieWngs.
of all the stakeholders regarding system-versus-individual
responsibility may be what is needed. If written intelligently,
                                                                     Process change: high risk processes
a set of principles or policies about reporting harm does not
require health care institutions to compromise their ability to      Standardization and simpliWcation of care through intelligent
police employees or appropriately prosecute misconduct.              protocols and clinical practice guidelines has been a staple of
   The Partners Healthcare System has been developing this           quality improvement for a few decades in health care [5], but
set of principles with the hope that every member institution        has had variable and often poor penetration. The relationship
supports them and fosters a similar attitude regarding culture,      between complexity and error, delineated in human factors
reporting, and accountability. The Partners Patient Safety           research in many industries, has led to increased vigor on the
OfWcer and Patient Safety Leaders Group initially drafted the        part of health care safety advocates to implement process
accountability principles by performing a search of the litera-      standardization, including through the use of protocols. The
ture to Wnd non-punitive policies currently in use in health         major efforts of the Partners Patient Safety OfWcer have tar-




                                                                                                                                           Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
care. ‘Whistle-blower’ statutes were reviewed and state-             geted anticoagulation management, the placement of central
speciWc issues about peer review protection identiWed. The           venous catheters, and computerization of physician ordering
Patient Safety Leaders Group reviewed the principles, followed       in the in-patient setting.
by risk management and human resources representatives
from each Partners institution as well as by Chief Medical and
                                                                     Anticoagulation
Chief Nursing OfWcers. In addition, hospital lawyers and
human resource departments piloted the initial drafts by             Perhaps the most compelling evidence supporting the impor-
applying them to selected cases to ensure that they did not          tance of protocols is in the management of anticoagulants,
conXict with appropriate hospital actions. Newer drafts were         especially heparin and warfarin [27]. All of the Partners hospi-
evaluated in a similar way. An appendix to this paper shows          tals currently use some form of a heparin weight-based proto-
the version of the principles approved by all the Partners           col for at least some patients and we have numerous warfarin
institutions.                                                        clinics within our loosely integrated delivery system. How-
                                                                     ever, many patients on warfarin are not managed in a clinic
                                                                     setting, and a system-wide program for warfarin management
Culture change: future initiatives
                                                                     has been lacking. Systematic warfarin management is neces-
The Executive WalkRounds™ and accountability principles              sary to provide effective care to patients during transitions
represent the foundation for cultural change. Educational            from one level of care to another.
modules about safety, ‘Safety BrieWngs’, and attitudinal                To improve these processes, we convened a group of inter-
surveys are other building blocks under consideration for            ested individuals and experts including physicians, nurses,
implementation. Safety BrieWngs involve frontline staff, and         pharmacists, information technology specialists, in-patient
are simple and brief interchanges usually conducted during           discharge planners, home care specialists, ofWce business
transitions in care—either as patients are transferred or as         managers and outpatient anticoagulation service providers.
health care providers change shifts. These brieWngs identify         The mission of this group is to: (i) centralize information
speciWc areas of risk at the time of the brieWng and should be       about patients and their anticoagulation status while support-
conducted in a relaxed but formalized fashion.                       ing local control and management; and (ii) decrease the
   The educational component of culture change occurs dur-           number of steps necessary to manage anticoagulation, thereby
ing orientation of new employees, and during re-credentialing        decreasing the likelihood of error. To accomplish these goals,
and competency training of all health care providers. The            the group is currently designing software to serve a dual pur-
education will include: (i) human factors—how humans inter-          pose: to assist large warfarin clinics that primarily manage lab-
act with their environment [20]; (ii) cognitive psychology—          oratory data and drug dosages, and also to support small
how humans think and how we make errors [20,21]; (iii) how           ofWce-based clinics who see patients face-to-face. The needs
innovative ideas diffuse [22]; and (iv) ethics and accounta-         of these two types of clinics differ, but they have a common
bility—the logic in making complex systems transparent [23].         requirement: anticoagulation information should be readily
We are currently planning a curriculum for all new employees         available from anywhere in the delivery system.
(in particular clinicians) to focus on these issues.                    The second goal, to decrease the steps in management,
   Attitudinal surveys offer another opportunity to measure          may be accomplished by using point-of-care blood testing
the degree of transparency and open communication being              devices to measure the international normalized ratio (INR)
fostered by patient safety projects in an institution. Surveys       rather than the standard mechanism, i.e. obtaining a vial of
used in this fashion are commonplace in the airline industry         blood and sending it to a laboratory for INR analysis. The
[24,25]. They have shown a direct relationship between pilot         group is also evaluating supports for physicians and patients


                                                                                                                                    i35
A. Frankel et al.


who are not attached to current ofWce and hospital anti-           Safety Leaders Group will be an important entity for sharing
coagulation clinics. A model for geographically diverse care       information about successes and barriers as CPOE moves
that manages patient transitions well is the visiting nurse        forward.
association (VNA). Partners HealthCare system is looking
to these groups to develop ambulatory clinic-based models
                                                                   Process change: future initiatives
to manage anticoagulation using point-of-care testing
devices.                                                           Core process changes include the intelligent structuring of
   Measurement of current effectiveness is underway, with          information technologies, simulation, standardization, and sim-
plans to audit process measures (percent of patients with          pliWcation of care delivery through protocols and clinical prac-
therapeutic INRs) and outcome measures (bleeding- and              tice guidelines, streamlined patient Xow with fewer delays, and
clot-related complications). Independent physician groups          hardware standardization. Into this Wnal category falls CPOE,
are particularly difWcult to monitor as each maintains its own     standardizing warfarin management during transitions of care,
databases, often on paper, and they have not been required         and protocols for safe central venous catheter placement.
to collect or maintain this information. A one-time audit sug-        Other projects in this category are also being evaluated.
gested that the percentage of patients maintained in thera-        Boston has been a stronghold of simulation research spear-
peutic INRs by the groups ranged from 45 to 75%. We                headed by the Center for Medical Simulation. In the simula-
believe that 75% of patients in therapeutic INR is an appro-       tor, models of patients’ rooms or invasive suites and
priate goal for each physician group; our plan is to ask each      operating rooms are combined with computer-driven moni-




                                                                                                                                        Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
group to collect the information in the manner easiest for them.   tors and manikins to simulate real-life problems. Students
                                                                   have the opportunity to learn and test their skills in a safe
                                                                   environment where patients cannot be harmed and actions
Central venous catheter insertion                                  can be critiqued. Simulators are available relatively inexpen-
                                                                   sively for placement in every hospital, and have the potential
Evaluation and spread of best practices in central venous
                                                                   to dramatically improve teamwork, open communication and
catheter (CVC) insertions is a system-wide project under-
                                                                   provider education. Partners and the Center for Medical Sim-
taken by the Partners epidemiology leaders, the goal of
                                                                   ulation are embarking on many projects that will impact each
which is to decrease complications, especially CVC-associ-
                                                                   institution. For example, anesthesia residents are all undergo-
ated blood stream infections. Practice around CVC insertion
                                                                   ing simulation training in return for which their malpractice
varies widely from one intensive care unit to another, even
                                                                   insurance premiums have been reduced. Under discussion is
though physicians rotate through the entire delivery system.
                                                                   further development of in-hospital simulators for use in
During CVC insertions, having in attendance an un-
                                                                   teamwork and skill-based training.
scrubbed assistant and an experienced attendant or fellow
                                                                      In addition to CPOE, information technologies such as
has been historically difWcult to institute. Epidemiologists
                                                                   electronic medical records, automated medication administra-
and intensivists have instituted and spread best practices
                                                                   tion records and bar coding are all currently in use in some
using education, protocols, and audits. The focusing of
                                                                   Partners settings and are becoming more widespread
attention combined with the pilot study facilitated spread of
                                                                   throughout Partners Healthcare System. However, having a
the best practices with excellent results. One organization
                                                                   logical strategy for implementation is the key to acceptance of
with incomplete penetration of the suggested practices, after
                                                                   these new technologies, and Partners Information Systems is
fully adopting these practices, decreased the central line
                                                                   putting signiWcant effort into creating a common information
blood stream infection (BSI) rate over a 12-month period
                                                                   technology structure for the entire network.
from 162 to 120, yielding a calculated saving of $2.5 million.
                                                                      Patient Xow is another possible area of intervention. Given
The rates placed the institution in the top quartile of organi-
                                                                   our current nursing and pharmacist shortage, empowering
zations compared with the Centers for Disease Control and
                                                                   nurse managers and frontline nurses to control patient Xow
Prevention benchmark rates.
                                                                   based on safety is imperative. This may be accomplished using
                                                                   innovative strategies such as the unit assessment tool used by
                                                                   Luther Middlefort Hospital in Eau Claire Wisconsin, in which
Computerized physician order entry
                                                                   frontline nurses use a trafWc light concept to delineate the state
Computerized physician order entry (CPOE) has been found           of safety on their unit. Hospital workers use red, green, and
to substantially decrease the rate of serious medication errors    yellow colors to identify the level of risk they perceive in their
[14,15], and appears to be one of the most potent technolog-       area based on parameters such as nurse:patient ratios and
ical changes for improving patient safety [28]. While CPOE         patient acuity. The colors are broadcast through the institution
is in place in the two large teaching hospitals in the Partners    as the screen-saver on the hospital computers and determine
network, it has not yet been implemented in the smaller hos-       where patients are admitted and transferred. Resources are
pitals. Because of the recommendations of the Partners             diverted to aid those areas in the ‘red’ zones [29].
Patient Safety Advisory Group regarding the substantial               Finally, standards are necessary that direct hardware pur-
safety beneWts of CPOE, the Partners leadership has made a         chases based on safety. Medication infusion pumps are a sen-
commitment to the implementation of CPOE in all in-                tinel example in this category. Testing for human factor
patient institutions over the next few years. The Patient          problems should determine the choice of pumps, favoring


i36
Improving patient safety


those that have ‘intelligent’ but simple redundancies to alert   Process measurement: adverse drug event
the care provider. There are currently numerous pilot tests      monitor
underway in the Partners Healthcare System to evaluate and
                                                                 Patient safety will be improved further by the implementa-
standardize these technologies.
                                                                 tion of routine measurement across a variety of domains.
                                                                 The common reporting system will be a vital tool in this
Outcome measurement: a common reporting                          regard. However, spontaneous reporting detects only a small
system                                                           minority of events [32,33], and we believe that automated
                                                                 detection methods will be useful in improving routine detec-
Another key to a culture of safety is having an easily availa-
                                                                 tion of safety issues [34–36]. A computerized Adverse Drug
ble and simple way for health care workers and patients to
                                                                 Event Monitor that searches for signs of an adverse event
report adverse events. Critical components of a safety
                                                                 and sends this information to a pharmacist for follow-up is
improvement program in a large delivery system are the
                                                                 now in routine use at one hospital [37]. The monitor is a pro-
adoption of a common language for reporting errors and
                                                                 gram (consisting of > 30 triggers) that searches the patient’s
near misses, and an ability among hospital staff members to
                                                                 computerized medication and laboratory test proWles for evi-
learn from each other. The goal of Partners is to create a
                                                                 dence of adverse drug events and generates alerts. An exam-
common reporting system for all member institutions, so
                                                                 ple of an alert would be a patient whose creatinine is rising
that information can be rendered anonymous and shared
                                                                 taking an aminoglycoside. The monitor generates a daily list
conWdentially to promote measurement, learning, and




                                                                                                                                      Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
                                                                 of these alerts and the hospital pharmacists review the alerts
benchmarking. To accomplish this, Partners has opted to
                                                                 for their patients and make interventions. Most interventions
promote the use of a Web-based reporting system, and has
                                                                 involve calling the physician to discontinue or change the
been evaluating those commercially available [30]. The use-
                                                                 dosage of a medication; the goal is to intervene before the
fulness of these kinds of systems relies on the simplicity of
                                                                 adverse drug event becomes serious or prolonged. This also
the data entry method, the system’s ability to receive and
                                                                 promotes a culture of safety within pharmacy by actively
store a large volume of data in a secure environment, and
                                                                 involving the pharmacists in event prevention. The Adverse
the breadth of analysis and ad hoc reporting available to the
                                                                 Drug Event Monitor won the Institute for Safe Medication
site manager [31].
                                                                 Practices Cheers Award in 2002 for its excellence in proac-
   Our main criteria for application selection are security,
                                                                 tively identifying potential adverse drug events. These kinds
ease of use, and speed, since these are major barriers to
                                                                 of proactive monitoring will eventually be used at other insti-
staff reporting. We are evaluating the breadth of scope of
                                                                 tutions within the network to supplement spontaneous
the product (Does it include near misses? Does it include
                                                                 reporting.
ambulatory care? Does it have detailed modules for more
than just medications and slips/falls?). In addition, we are
evaluating the coding taxonomy to make sure it would col-
                                                                 Process measurement: future initiatives
lect enough systems-related information. We require a fol-
low-up module where the appropriate leaders could edit/          Vital components of safety measurement include ascertain-
modify the report once follow-up was complete. We                ing provider willingness to report problems and conducting
require an ability to integrate into our network e-mail sys-     audits looking for adverse events and near misses. Surveying
tem so that appropriate leadership would get e-mail notiWca-     provider attitude and tracking the use of spontaneous
tion of the Wling of the report. We are looking at the           reporting systems will elucidate whether willingness to
system’s capacity to generate reports or export data into        report events improves. Web-based reporting systems will
databases for our own report generation. Finally, adequate       improve our ability to evaluate both of these. Adverse
customer support is essential. A system is currently in a        events and near misses can be monitored in many ways. For
pilot phase and nursing staff have been very pleased with        example, in one of our hospitals, pharmacy interventions are
the speed and ease of use. We have seen increases in report-     used to identify areas of knowledge deWciency on the part of
ing in the pilot areas, particularly in areas that had           house staff, and a medication competency exam has been
extremely low reporting rates previously. In addition, we        developed based on these interventions. The exam is given
have seen increases in reports from physicians, which we         to incoming interns and then again as their internship ends.
attribute to the speed of the system.                            The exam results are monitored to evaluate how effective
   The Patient Safety Leaders Group is given regular             pharmacy education has been during the year. The compe-
updates on experience with the pilot and the impact of this      tency exam is modiWed each year based on the previous
on a plan for larger rollout. The ultimate goal is for all the   year’s pharmacy interventions.
Partners institutions to use this common reporting system           As noted earlier, another hospital has implemented a com-
so that hospitals can then share information about certain       puterized monitoring program in which an event monitor
common event types and learn from each other about               screens the computerized database and sends alerts daily to
systems improvements. Issues such as medication errors and       pharmacists who can then review them and make interven-
adverse drug events can be discussed using common termi-         tions. This generic approach will likely eventually be suitable
nology, and rare but serious events can be measured jointly so   for screening other sources (such as discharge summaries) for
that hospitals can learn from the experiences of others.         adverse events [38].


                                                                                                                               i37
A. Frankel et al.


Conclusions                                                        and the Institute for Safe Medication Practices for executive
                                                                   level and middle management patient-safety positions. These
As the concepts underlying patient safety mature, it is becom-     positions must be empowered to integrate safety, quality, and
ing possible to develop a cohesive and broad patient-safety        risk management departments, and to base actions on promot-
strategy. We have described the path we have taken, although       ing transparency and open communication [39,40].
other alternatives might have been chosen, and in addition to         In conclusion, developing and implementing a strategy for
the efforts described, each hospital has numerous individual       improving patient safety within this large, loosely integrated
projects underway. A broad patient-safety strategy may be          delivery system has been challenging but exciting. Initial
divided into three categories: cultural change, core process       efforts have focused on cultural change, process change, and
change, and process measurement. Our initial efforts across        process measurement, and many other projects in these areas
the Partners integrated health care system include initiatives     are being evaluated and considered for pilot testing. Clearly,
in each of these areas. We have many additional projects that      there is no right answer as to which projects an integrated
we are considering in each category, including both technology-    delivery system or hospital should undertake, and there are
related and non-technology-related interventions.                  numerous possibilities from which to choose. Some of the
                                                                   strategies involve technology but many do not. Decisions
                                                                   need to be based on measured need, leadership support, inter-
Conceptual models for the future                                   est, and resources. However, we feel that an emphasis on
                                                                   culture, process, and measurement makes the most sense




                                                                                                                                                Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
Theoretical concepts determined the initial framework for          for both short-term and long-term safety improvements.
our patient safety strategy. Further construction was based on
hospital interests and the efforts of those invested in each
project. Two years later, collaborative efforts by all have        Acknowledgements
helped reWne patient safety theory. Hospitals and integrated
delivery systems just beginning to formulate a patient safety      We acknowledge support from Partners HealthCare (see
plan can build on work done and may develop a more solid           page i40).
framework for themselves. While still mostly theoretical and
unproven, safety in overview is becoming clearer and should
include the following: (i) leadership promotes patient safety as   References
a core value by participation in safety-based activities; (ii)
open communication and effective reporting, leading to a            1. Institute of Medicine. To Err is Human. Building a Safer Health
sense of psychological safety [4]; (iii) allocation of resources       System. Washington, DC: National Academy Press, 1999.
to support patient safety efforts is required in every budget;
                                                                    2. Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM,
(iv) training and education in patient safety concepts and             Sheridan T. Reducing the frequency of errors in medicine using
practice is part of orientation, credentialing, and competency         information technology. J Am Med Informatics Assoc 2001; 8:
evaluations; (v) the search for new knowledge in patient safety        299–308.
is a component of any research program; (vi) active projects
                                                                    3. Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation
are developed to enhance disclosure and improve public per-
                                                                       on physician rounds and adverse drug events in the intensive
ception about safety and honesty, including increasing patient         care unit. J Am Med Assoc 1999; 282: 267–270.
participation and input in hospital management; (vii) sharing
best practices and collaboration is expected of all physician       4. Carroll JS, Edmondson AC. Leading organisational learning in
specialties and hospital locations; and (viii) new measures to         health care. Qual Health Care 2002; 11: 51–56.
assess patient safety are constantly sought and tested. These       5. Leape LL, Kabcenell AI, Gandhi TK, Carver P, Nolan TW,
eight ideas should determine the array of projects undertaken          Berwick DM. Reducing adverse drug events: lessons from a
by an institution, the goal being to ensure that work is being         breakthrough series collaborative. Jt Comm J Qual Improv 2000;
performed to address all of them. In a truly robust institution,       26: 321–331.
every hospital location and each physician group or specialty       6. Pizzi LT, Goldfarb NI, Nash DB. Promoting a culture of safety.
should be able to identify its own group of safety and quality         In: Shojania KG, Duncan BW, McDonald KM, Wachter RM,
projects, also aimed at improving their environment in all             eds. Evidence Report/Technology Assessment No. 43, Making Health
eight areas.                                                           Care Safer: A Critical Analysis of Patient Safety Practices, AHRQ Pub-
   Measurement of effectiveness will exist in two categories:          lication No. 01-E058. Agency for Healthcare Research and
culture and patient outcome. Measurement of speciWc                    Quality, 2001. Available at http://www.ahrq.gov/clinic/
projects should include effectiveness and likelihood of patient        ptsafety/chap40.htm (last accessed on July 12, 2002).
harm. Institutional improvement in promoting a safety cul-          7. Rozich JD, Resar RK. Medication safety: one organization’s
ture will be apparent through workforce attitudinal surveys,           approach to the challenge. J Outcomes Manag 2001; 8: 27–34.
the willingness to report adverse events, and the speed of test-    8. Brennan TA, Leape LL, Laird N et al. Incidence of adverse
ing and implementation of worthwhile projects.                         events and negligence in hospitalized patients: results from the
   Patient safety personnel job descriptions have changed as the       Harvard Medical Practice Study I. New Engl J Med 1991; 324:
science has matured. Templates are available through Premier           370–376.



i38
Improving patient safety


 9. Leape LL, Brennan TA, Laird NM et al. The nature of adverse            27. Gandhi TK, Shojania KG, Bates DW. Protocols for high-risk
    events in hospitalized patients: results from the Harvard Medical          drugs: reducing adverse events related to anticoagulants. In:
    Practice Study II. New Engl J Med 1991; 324: 377–384.                      Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds.
                                                                               Evidence Report/Technology Assessment No. 43, Making Health Care
10. Bates DW, Cullen D, Laird N et al. Incidence of adverse drug
                                                                               Safer: A Critical Analysis of Patient Safety Practices, AHRQ Publica-
    events and potential adverse drug events: implications for pre-
                                                                               tion No. 01-E058. Agency for Healthcare Research and Quality,
    vention. J Am Med Assoc 1995; 274: 29–34.
                                                                               2001. Available at: http://www.ahrq.gov/clinic/ptsafety/chap9.htm
11. Leape LL, Bates DW, Cullen DJ et al. Systems analysis of                   (last accessed July 12, 2002).
    adverse drug events. J Am Med Assoc 1995; 274: 35–43.
                                                                           28. The Leapfrog Group. Fact Sheet: Computerized physician order entry
12. Kuperman GJ, Teich JM, Tanasijevic MJ et al. Improving                     (CPOE). November 2000. Available at: http://www.leapfrog-
    response to critical laboratory results with automation: results of        group.org/FactSheets/CPOE_FactSheet.pdf (last accessed on
    a randomized controlled trial. J Am Med Inform Assoc 1999; 6:              July 12, 2002).
    512–522.
                                                                           29. Rozich JD, Resar RK. Using a unit assessment tool to optimize
13. Gandhi TK, Burstin HR, Cook EF et al. Drug complications in                patient Xow and stafWng in a community hospital. Jt Comm J
    outpatients. J Gen Intern Med 2000; 15: 149–154.                           Qual Improv 2002; 28: 31–41.
14. Bates DW, Leape LL, Cullen DJ et al. Effect of computerized            30. DoctorQuality, Inc. Risk Prevention and Management System
    physician order entry and a team intervention on prevention                media center. Available at: http://www.doctorquality.com/
    of serious medication errors. J Am Med Assoc 1998; 280:                    www/RPM_Media/default.htm (last accessed July 12, 2002).




                                                                                                                                                       Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
    1311–1316.
                                                                           31. Joshi, MS, Anderson JF, Marwaha S. A systems approach
15. Bates DW, Teich J, Lee J et al. The impact of computerized phy-            to improving error reporting. J Healthcare Inf Manage 2002; 16:
    sician order entry on medication error prevention. J Am Med                40–45.
    Informatics Assoc 1999; 6: 313–321.
                                                                           32. Tubert P, Begaud B, Pere JC, Haramburu F, Lellouch J. Power
16. Frankel, A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M,             and weakness of spontaneous reporting: a probabilistic
    Gandhi TK. Patient Safety Leadership WalkRounds™. Jt Comm J                approach. J Clin Epidemiol 1992; 45: 283–286.
    Qual saf 2003; 29: 16–26.
                                                                           33. Dormann H, Muth-Selbach U, Krebs S et al. Incidence and costs
17. Institute for Healthcare Improvement [Internet homepage].                  of adverse drug reactions during hospitalisation: computerised
    Available at: http://www.ihi.org/ (last accessed on July 12, 2002).        monitoring versus stimulated spontaneous reporting. Drug Saf
                                                                               2000; 22: 161–168.
18. NASA. Aviation Safety Reporting System [Internet homepage].
    Available at: http://www.asrs.arc.nasa.gov/ (last accessed on          34. Jha AK, Kuperman GJ, Teich JM et al. Identifying adverse drug
    July 12, 2002).                                                            events: development of a computer-based monitor and compar-
                                                                               ison with chart review and stimulated voluntary report. J Am
19. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR,
                                                                               Med Inform Assoc 1998; 5: 305–314.
    Leape LL. The incident reporting system does not detect
    adverse drug events: a problem for quality improvement.                35. Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized
    Jt Comm J Qual Improv 1995; 21: 541–548.                                   surveillance of adverse drug events in hospital patients. J Am
                                                                               Med Assoc 1991; 266: 2847–2851.
20. Reason J. Human Error. Cambridge, UK: Cambridge University
    Press, 1990.                                                           36. Honigman B, Lee J, Rothschild J et al. Using computerized data
                                                                               to identify adverse drug events in outpatients. J Am Med Informat-
21. Rasmussen J. Human error and the problem of causality in
                                                                               ics Assoc 2001; 8: 254–266.
    analysis of accidents. Philos Trans R Soc Lond B Biol Sci 1990; 327:
    449–462.                                                               37. Silverman JB, Stapinski CD, Churchill WW, Neppl C, Bates
                                                                               DW, Gandhi TK. The adverse event prevention program
22. Ryan B, Gross N. The diffusion of hybrid seed corn in two Iowa
                                                                               (ADEPP): Putting the literature into action. Am J Health Syst
    communities. Rural Sociol 1943; 8: 15–24.
                                                                               Pharm 2003, in press.
23. Waldrop MM. Complexity: the emerging science at the edge of
                                                                           38. Murff HJ, Forster AJ, Peterson JF, Fiskio JM, Heiman HL,
    order and chaos. London: Viking, 1992.
                                                                               Bates DW. Electronically screening discharge summaries for
24. Helmreich RL, Merritt AC. Culture at work in aviation and                  adverse medical events. J Gen Intern Med 2001; 17(suppl. 1):
    medicine: national, organizational and professional inXuences.             A205.
    BrookWeld, VT: Ashgate, 1998.
                                                                           39. http://www.my.premierinc.com/all/safety/resources/patient_
25. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and team-               safety/downloads/18_Safety_Job_Description_07-09-02.DOC
    work in medicine and aviation: cross sectional surveys. Br Med
                                                                           40. http://www.ismp.org/Tools/CovenantJobDesc.html
    J 2000; 320: 745–749.
26. Shortell SM, Zimmerman JE, Rouseau DM et al. The perform-
    ance of intensive care units: does good management make a dif-
    ference? Med Care 1994; 32: 508–525.                                   Accepted for publication 21 July 2003




                                                                                                                                                i39
Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
A. Frankel et al.




                                                                                          i40

Contenu connexe

Tendances

Snap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B PracticeSnap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B Practiceprimary
 
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
 
An Evironmental Scan of Interprofessional Collaborative Practice and Education
An Evironmental Scan of Interprofessional Collaborative Practice and EducationAn Evironmental Scan of Interprofessional Collaborative Practice and Education
An Evironmental Scan of Interprofessional Collaborative Practice and EducationEvan C. Marlatt
 
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
 
The Role of Physician Specialty Board Certification Status in the Quality Mov...
The Role of Physician Specialty Board Certification Status in the Quality Mov...The Role of Physician Specialty Board Certification Status in the Quality Mov...
The Role of Physician Specialty Board Certification Status in the Quality Mov...abimorg
 
Clinical Governance: As Drive for Patient Safety in Clinical Dentistry
Clinical Governance: As Drive for Patient Safety in Clinical Dentistry Clinical Governance: As Drive for Patient Safety in Clinical Dentistry
Clinical Governance: As Drive for Patient Safety in Clinical Dentistry Ruby Med Plus
 
How Do Organizations in Healthcare Measure the Value Proposition?
How Do Organizations in Healthcare Measure the Value Proposition? How Do Organizations in Healthcare Measure the Value Proposition?
How Do Organizations in Healthcare Measure the Value Proposition? AHCPhysicians
 
Quality Improvement Summary
Quality Improvement SummaryQuality Improvement Summary
Quality Improvement Summaryjasminepaul
 
QSEN: It's not just for nursing school
QSEN:  It's not just for nursing schoolQSEN:  It's not just for nursing school
QSEN: It's not just for nursing schooltahq2012
 
Hm 2012 session ii – hospital board governance
Hm 2012 session ii – hospital board governanceHm 2012 session ii – hospital board governance
Hm 2012 session ii – hospital board governancedrbhutto
 
Evidence basednursing
Evidence basednursingEvidence basednursing
Evidence basednursingEleoisa Cruz
 
A care coordination handout
A care coordination handoutA care coordination handout
A care coordination handoutchandice2
 
Matria Newsletter Spring 2008
Matria Newsletter Spring 2008Matria Newsletter Spring 2008
Matria Newsletter Spring 2008Amy Wilson
 
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
 
Governance and management in healthcare
Governance and management in healthcareGovernance and management in healthcare
Governance and management in healthcareRick Jones
 
Rob Reid: Redesigning primary care: the Group Health journey
Rob Reid: Redesigning primary care: the Group Health journeyRob Reid: Redesigning primary care: the Group Health journey
Rob Reid: Redesigning primary care: the Group Health journeyThe King's Fund
 
Shared Governance in Nursing: A dynamic facelift for empowered practice
Shared Governance in Nursing: A dynamic facelift for empowered practiceShared Governance in Nursing: A dynamic facelift for empowered practice
Shared Governance in Nursing: A dynamic facelift for empowered practiceNashrene Ahmed Raafat El-bar
 
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
 

Tendances (20)

Snap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B PracticeSnap%2 B Framework%2 Bfor%2 B General%2 B Practice
Snap%2 B Framework%2 Bfor%2 B General%2 B Practice
 
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطار
 
An Evironmental Scan of Interprofessional Collaborative Practice and Education
An Evironmental Scan of Interprofessional Collaborative Practice and EducationAn Evironmental Scan of Interprofessional Collaborative Practice and Education
An Evironmental Scan of Interprofessional Collaborative Practice and Education
 
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطار
 
The Role of Physician Specialty Board Certification Status in the Quality Mov...
The Role of Physician Specialty Board Certification Status in the Quality Mov...The Role of Physician Specialty Board Certification Status in the Quality Mov...
The Role of Physician Specialty Board Certification Status in the Quality Mov...
 
Clinical Governance: As Drive for Patient Safety in Clinical Dentistry
Clinical Governance: As Drive for Patient Safety in Clinical Dentistry Clinical Governance: As Drive for Patient Safety in Clinical Dentistry
Clinical Governance: As Drive for Patient Safety in Clinical Dentistry
 
How Do Organizations in Healthcare Measure the Value Proposition?
How Do Organizations in Healthcare Measure the Value Proposition? How Do Organizations in Healthcare Measure the Value Proposition?
How Do Organizations in Healthcare Measure the Value Proposition?
 
Quality Improvement Summary
Quality Improvement SummaryQuality Improvement Summary
Quality Improvement Summary
 
QSEN: It's not just for nursing school
QSEN:  It's not just for nursing schoolQSEN:  It's not just for nursing school
QSEN: It's not just for nursing school
 
Hm 2012 session ii – hospital board governance
Hm 2012 session ii – hospital board governanceHm 2012 session ii – hospital board governance
Hm 2012 session ii – hospital board governance
 
Evidence basednursing
Evidence basednursingEvidence basednursing
Evidence basednursing
 
A care coordination handout
A care coordination handoutA care coordination handout
A care coordination handout
 
Shared governance
Shared governanceShared governance
Shared governance
 
Matria Newsletter Spring 2008
Matria Newsletter Spring 2008Matria Newsletter Spring 2008
Matria Newsletter Spring 2008
 
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطار
 
Governance and management in healthcare
Governance and management in healthcareGovernance and management in healthcare
Governance and management in healthcare
 
Rob Reid: Redesigning primary care: the Group Health journey
Rob Reid: Redesigning primary care: the Group Health journeyRob Reid: Redesigning primary care: the Group Health journey
Rob Reid: Redesigning primary care: the Group Health journey
 
Shared Governance in Nursing: A dynamic facelift for empowered practice
Shared Governance in Nursing: A dynamic facelift for empowered practiceShared Governance in Nursing: A dynamic facelift for empowered practice
Shared Governance in Nursing: A dynamic facelift for empowered practice
 
Healthcare Transformation 021115
Healthcare Transformation 021115Healthcare Transformation 021115
Healthcare Transformation 021115
 
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطارDrhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطار
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطار
 

En vedette

Tqm health practices and client satisfaction in a selected health facility in...
Tqm health practices and client satisfaction in a selected health facility in...Tqm health practices and client satisfaction in a selected health facility in...
Tqm health practices and client satisfaction in a selected health facility in...IAEME Publication
 
National Health Administrators’ Client Expresses Satisfaction
National Health Administrators’ Client Expresses SatisfactionNational Health Administrators’ Client Expresses Satisfaction
National Health Administrators’ Client Expresses SatisfactionJoseph Fiegoli
 
A comparative study on patients’ satisfaction in health care service
A comparative study on patients’ satisfaction in health care serviceA comparative study on patients’ satisfaction in health care service
A comparative study on patients’ satisfaction in health care serviceAlexander Decker
 
Ugandan Global Health Profile_MackenzieWright_2015
Ugandan Global Health Profile_MackenzieWright_2015Ugandan Global Health Profile_MackenzieWright_2015
Ugandan Global Health Profile_MackenzieWright_2015Mackenzie Wright
 
Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...
Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...
Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...David Meyers
 
Study of patients of outdoor department regarding their satisfaction for heal...
Study of patients of outdoor department regarding their satisfaction for heal...Study of patients of outdoor department regarding their satisfaction for heal...
Study of patients of outdoor department regarding their satisfaction for heal...IAEME Publication
 
Quality health care
Quality health careQuality health care
Quality health carePS Deb
 
1 health care quality concepts
1 health care quality concepts 1 health care quality concepts
1 health care quality concepts Olaya El Ghariny
 
Quality and reliability in health care
Quality and reliability in health careQuality and reliability in health care
Quality and reliability in health careKiran Hanjar
 
How to Implement Quality in Health Care Organizations.
How to Implement Quality in Health Care Organizations.How to Implement Quality in Health Care Organizations.
How to Implement Quality in Health Care Organizations.Healthcare consultant
 
Patient satisfaction
Patient satisfactionPatient satisfaction
Patient satisfactionNc Das
 
RESEARCH PAPER ANALYSIS
RESEARCH PAPER ANALYSIS RESEARCH PAPER ANALYSIS
RESEARCH PAPER ANALYSIS Sambit Biswal
 
ICHOM2017 Portugal_Luis R. Murillo Zamorano
ICHOM2017 Portugal_Luis R. Murillo ZamoranoICHOM2017 Portugal_Luis R. Murillo Zamorano
ICHOM2017 Portugal_Luis R. Murillo ZamoranoLuis R. Murillo-Zamorano
 

En vedette (18)

Tqm health practices and client satisfaction in a selected health facility in...
Tqm health practices and client satisfaction in a selected health facility in...Tqm health practices and client satisfaction in a selected health facility in...
Tqm health practices and client satisfaction in a selected health facility in...
 
Uganda Health Vouchers Scheme: The Results So Far
Uganda Health Vouchers Scheme: The Results So FarUganda Health Vouchers Scheme: The Results So Far
Uganda Health Vouchers Scheme: The Results So Far
 
National Health Administrators’ Client Expresses Satisfaction
National Health Administrators’ Client Expresses SatisfactionNational Health Administrators’ Client Expresses Satisfaction
National Health Administrators’ Client Expresses Satisfaction
 
A comparative study on patients’ satisfaction in health care service
A comparative study on patients’ satisfaction in health care serviceA comparative study on patients’ satisfaction in health care service
A comparative study on patients’ satisfaction in health care service
 
Ugandan Global Health Profile_MackenzieWright_2015
Ugandan Global Health Profile_MackenzieWright_2015Ugandan Global Health Profile_MackenzieWright_2015
Ugandan Global Health Profile_MackenzieWright_2015
 
Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...
Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...
Creating a Culture of Quality Health Care in Resource Limited Clinical and Co...
 
Study of patients of outdoor department regarding their satisfaction for heal...
Study of patients of outdoor department regarding their satisfaction for heal...Study of patients of outdoor department regarding their satisfaction for heal...
Study of patients of outdoor department regarding their satisfaction for heal...
 
Quality health care
Quality health careQuality health care
Quality health care
 
1 health care quality concepts
1 health care quality concepts 1 health care quality concepts
1 health care quality concepts
 
Quality and reliability in health care
Quality and reliability in health careQuality and reliability in health care
Quality and reliability in health care
 
How to Implement Quality in Health Care Organizations.
How to Implement Quality in Health Care Organizations.How to Implement Quality in Health Care Organizations.
How to Implement Quality in Health Care Organizations.
 
PBH101 (20)
PBH101 (20)PBH101 (20)
PBH101 (20)
 
Service Quality In Healthcare
Service Quality In HealthcareService Quality In Healthcare
Service Quality In Healthcare
 
Patient satisfaction
Patient satisfactionPatient satisfaction
Patient satisfaction
 
Elective 2-1 Quality health care nursing
Elective 2-1 Quality health care nursingElective 2-1 Quality health care nursing
Elective 2-1 Quality health care nursing
 
RESEARCH PAPER ANALYSIS
RESEARCH PAPER ANALYSIS RESEARCH PAPER ANALYSIS
RESEARCH PAPER ANALYSIS
 
Quality In Health Care
Quality In Health CareQuality In Health Care
Quality In Health Care
 
ICHOM2017 Portugal_Luis R. Murillo Zamorano
ICHOM2017 Portugal_Luis R. Murillo ZamoranoICHOM2017 Portugal_Luis R. Murillo Zamorano
ICHOM2017 Portugal_Luis R. Murillo Zamorano
 

Similaire à Article pp

RESEARCH ARTICLE Open AccessAn organizational perspective .docx
RESEARCH ARTICLE Open AccessAn organizational perspective .docxRESEARCH ARTICLE Open AccessAn organizational perspective .docx
RESEARCH ARTICLE Open AccessAn organizational perspective .docxronak56
 
ipc-blueprint-july-2007-en
ipc-blueprint-july-2007-enipc-blueprint-july-2007-en
ipc-blueprint-july-2007-enSophie Gravel
 
Increased Awareness Concerning Patient.docx
Increased Awareness Concerning Patient.docxIncreased Awareness Concerning Patient.docx
Increased Awareness Concerning Patient.docx4934bk
 
· Analyze how healthcare reimbursement influences your nursing pra
· Analyze how healthcare reimbursement influences your nursing pra· Analyze how healthcare reimbursement influences your nursing pra
· Analyze how healthcare reimbursement influences your nursing praLesleyWhitesidefv
 
Accomplishing Reform Successful Case Studies Drawn From The Health Systems O...
Accomplishing Reform  Successful Case Studies Drawn From The Health Systems O...Accomplishing Reform  Successful Case Studies Drawn From The Health Systems O...
Accomplishing Reform Successful Case Studies Drawn From The Health Systems O...Carrie Tran
 
Introduction Healthcare system is considered one of the busiest.pdf
Introduction Healthcare system is considered one of the busiest.pdfIntroduction Healthcare system is considered one of the busiest.pdf
Introduction Healthcare system is considered one of the busiest.pdfbkbk37
 
TransforMED_Pediatric_Care_Coordination_Case_Study
TransforMED_Pediatric_Care_Coordination_Case_StudyTransforMED_Pediatric_Care_Coordination_Case_Study
TransforMED_Pediatric_Care_Coordination_Case_StudyCecilia Saffold
 
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...Marion Sills
 
HS410 Unit 6 Quality Management - DiscussionDiscussionThi.docx
HS410 Unit 6 Quality Management - DiscussionDiscussionThi.docxHS410 Unit 6 Quality Management - DiscussionDiscussionThi.docx
HS410 Unit 6 Quality Management - DiscussionDiscussionThi.docxAlysonDuongtw
 
Chapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxChapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxspoonerneddy
 
Chapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxChapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxmccormicknadine86
 
Educational Preparedness
Educational PreparednessEducational Preparedness
Educational PreparednessSusan White
 
The National Academies Health and Medicine DivisionAbout U.docx
The National Academies Health and Medicine DivisionAbout U.docxThe National Academies Health and Medicine DivisionAbout U.docx
The National Academies Health and Medicine DivisionAbout U.docxdennisa15
 
NURS 521 Nursing Informatics And Technology.docx
NURS 521 Nursing Informatics And Technology.docxNURS 521 Nursing Informatics And Technology.docx
NURS 521 Nursing Informatics And Technology.docxstirlingvwriters
 
Business Strategies in Healthcare (1).pdf
Business Strategies in Healthcare (1).pdfBusiness Strategies in Healthcare (1).pdf
Business Strategies in Healthcare (1).pdfTEWMAGAZINE
 
DHA7002 Walden University Improving Healthcare Quality Discussion.pdf
DHA7002 Walden University Improving Healthcare Quality Discussion.pdfDHA7002 Walden University Improving Healthcare Quality Discussion.pdf
DHA7002 Walden University Improving Healthcare Quality Discussion.pdfsdfghj21
 
Organizational Culture Readiness Essay Assignment Paper.docx
Organizational Culture Readiness Essay Assignment Paper.docxOrganizational Culture Readiness Essay Assignment Paper.docx
Organizational Culture Readiness Essay Assignment Paper.docx4934bk
 

Similaire à Article pp (20)

RESEARCH ARTICLE Open AccessAn organizational perspective .docx
RESEARCH ARTICLE Open AccessAn organizational perspective .docxRESEARCH ARTICLE Open AccessAn organizational perspective .docx
RESEARCH ARTICLE Open AccessAn organizational perspective .docx
 
ipc-blueprint-july-2007-en
ipc-blueprint-july-2007-enipc-blueprint-july-2007-en
ipc-blueprint-july-2007-en
 
Free_from_Harm
Free_from_HarmFree_from_Harm
Free_from_Harm
 
Increased Awareness Concerning Patient.docx
Increased Awareness Concerning Patient.docxIncreased Awareness Concerning Patient.docx
Increased Awareness Concerning Patient.docx
 
· Analyze how healthcare reimbursement influences your nursing pra
· Analyze how healthcare reimbursement influences your nursing pra· Analyze how healthcare reimbursement influences your nursing pra
· Analyze how healthcare reimbursement influences your nursing pra
 
Laying The Foundation For Health Care Reform: Local Initiatives to Integrate ...
Laying The Foundation For Health Care Reform: Local Initiatives to Integrate ...Laying The Foundation For Health Care Reform: Local Initiatives to Integrate ...
Laying The Foundation For Health Care Reform: Local Initiatives to Integrate ...
 
Accomplishing Reform Successful Case Studies Drawn From The Health Systems O...
Accomplishing Reform  Successful Case Studies Drawn From The Health Systems O...Accomplishing Reform  Successful Case Studies Drawn From The Health Systems O...
Accomplishing Reform Successful Case Studies Drawn From The Health Systems O...
 
Introduction Healthcare system is considered one of the busiest.pdf
Introduction Healthcare system is considered one of the busiest.pdfIntroduction Healthcare system is considered one of the busiest.pdf
Introduction Healthcare system is considered one of the busiest.pdf
 
TransforMED_Pediatric_Care_Coordination_Case_Study
TransforMED_Pediatric_Care_Coordination_Case_StudyTransforMED_Pediatric_Care_Coordination_Case_Study
TransforMED_Pediatric_Care_Coordination_Case_Study
 
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...
 
HS410 Unit 6 Quality Management - DiscussionDiscussionThi.docx
HS410 Unit 6 Quality Management - DiscussionDiscussionThi.docxHS410 Unit 6 Quality Management - DiscussionDiscussionThi.docx
HS410 Unit 6 Quality Management - DiscussionDiscussionThi.docx
 
Chapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxChapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docx
 
Chapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxChapter 7. The Evidence for Evidence-Based Practice Implem.docx
Chapter 7. The Evidence for Evidence-Based Practice Implem.docx
 
Educational Preparedness
Educational PreparednessEducational Preparedness
Educational Preparedness
 
The National Academies Health and Medicine DivisionAbout U.docx
The National Academies Health and Medicine DivisionAbout U.docxThe National Academies Health and Medicine DivisionAbout U.docx
The National Academies Health and Medicine DivisionAbout U.docx
 
NURS 521 Nursing Informatics And Technology.docx
NURS 521 Nursing Informatics And Technology.docxNURS 521 Nursing Informatics And Technology.docx
NURS 521 Nursing Informatics And Technology.docx
 
Business Strategies in Healthcare (1).pdf
Business Strategies in Healthcare (1).pdfBusiness Strategies in Healthcare (1).pdf
Business Strategies in Healthcare (1).pdf
 
Linkage To Care
Linkage To CareLinkage To Care
Linkage To Care
 
DHA7002 Walden University Improving Healthcare Quality Discussion.pdf
DHA7002 Walden University Improving Healthcare Quality Discussion.pdfDHA7002 Walden University Improving Healthcare Quality Discussion.pdf
DHA7002 Walden University Improving Healthcare Quality Discussion.pdf
 
Organizational Culture Readiness Essay Assignment Paper.docx
Organizational Culture Readiness Essay Assignment Paper.docxOrganizational Culture Readiness Essay Assignment Paper.docx
Organizational Culture Readiness Essay Assignment Paper.docx
 

Plus de Terence Reeves

Toolkit for bed managers
Toolkit for bed managersToolkit for bed managers
Toolkit for bed managersTerence Reeves
 
Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113
Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113
Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113Terence Reeves
 
Qi toolbook-1201799140380428-5
Qi toolbook-1201799140380428-5Qi toolbook-1201799140380428-5
Qi toolbook-1201799140380428-5Terence Reeves
 
Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...
Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...
Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...Terence Reeves
 
Policy forthe provision of same sex accommodation final ratified version pdf...
Policy forthe provision of same sex accommodation final ratified version  pdf...Policy forthe provision of same sex accommodation final ratified version  pdf...
Policy forthe provision of same sex accommodation final ratified version pdf...Terence Reeves
 
Equality diversity and human rights strategic framework
Equality diversity and human rights strategic frameworkEquality diversity and human rights strategic framework
Equality diversity and human rights strategic frameworkTerence Reeves
 
Equality diversity and human rights scheme
Equality diversity and human rights schemeEquality diversity and human rights scheme
Equality diversity and human rights schemeTerence Reeves
 
Declaration of compliance
Declaration of complianceDeclaration of compliance
Declaration of complianceTerence Reeves
 
Bcbv for commissioners
Bcbv for commissionersBcbv for commissioners
Bcbv for commissionersTerence Reeves
 
Annualcomplaintsreport0809 final
Annualcomplaintsreport0809 finalAnnualcomplaintsreport0809 final
Annualcomplaintsreport0809 finalTerence Reeves
 
00 nsc implementation guide 2010
00 nsc implementation guide 201000 nsc implementation guide 2010
00 nsc implementation guide 2010Terence Reeves
 
Annual plan doc v28 final public version rev contents page final 30july09
Annual plan doc v28 final public version   rev contents page final   30july09Annual plan doc v28 final public version   rev contents page final   30july09
Annual plan doc v28 final public version rev contents page final 30july09Terence Reeves
 
implementation guide 2010
 implementation guide 2010 implementation guide 2010
implementation guide 2010Terence Reeves
 

Plus de Terence Reeves (18)

Utilization guide
Utilization guideUtilization guide
Utilization guide
 
Toolkit for bed managers
Toolkit for bed managersToolkit for bed managers
Toolkit for bed managers
 
Size mix
Size mixSize mix
Size mix
 
Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113
Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113
Rw3 central manchester_univ_hosps_nhs_ft_hcai_inspection_report_20100113
 
Report pp
Report ppReport pp
Report pp
 
Qi toolbook-1201799140380428-5
Qi toolbook-1201799140380428-5Qi toolbook-1201799140380428-5
Qi toolbook-1201799140380428-5
 
Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...
Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...
Privacy and dignity eliminating mixed sex accommodation improvement plan dec ...
 
Policy forthe provision of same sex accommodation final ratified version pdf...
Policy forthe provision of same sex accommodation final ratified version  pdf...Policy forthe provision of same sex accommodation final ratified version  pdf...
Policy forthe provision of same sex accommodation final ratified version pdf...
 
Ndnqi brochure
Ndnqi brochureNdnqi brochure
Ndnqi brochure
 
Examplejobdescription
ExamplejobdescriptionExamplejobdescription
Examplejobdescription
 
Equality diversity and human rights strategic framework
Equality diversity and human rights strategic frameworkEquality diversity and human rights strategic framework
Equality diversity and human rights strategic framework
 
Equality diversity and human rights scheme
Equality diversity and human rights schemeEquality diversity and human rights scheme
Equality diversity and human rights scheme
 
Declaration of compliance
Declaration of complianceDeclaration of compliance
Declaration of compliance
 
Bcbv for commissioners
Bcbv for commissionersBcbv for commissioners
Bcbv for commissioners
 
Annualcomplaintsreport0809 final
Annualcomplaintsreport0809 finalAnnualcomplaintsreport0809 final
Annualcomplaintsreport0809 final
 
00 nsc implementation guide 2010
00 nsc implementation guide 201000 nsc implementation guide 2010
00 nsc implementation guide 2010
 
Annual plan doc v28 final public version rev contents page final 30july09
Annual plan doc v28 final public version   rev contents page final   30july09Annual plan doc v28 final public version   rev contents page final   30july09
Annual plan doc v28 final public version rev contents page final 30july09
 
implementation guide 2010
 implementation guide 2010 implementation guide 2010
implementation guide 2010
 

Dernier

PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 

Dernier (20)

PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 

Article pp

  • 1. International Journal for Quality in Health Care 2003; Volume 15, Supplement 1: pp. i31–i40 10.1093/intqhc/mzg075 Improving patient safety across a large integrated health care delivery system ALLAN FRANKEL1, TEJAL K. GANDHI2 AND DAVID W. BATES1,2 1 Partners HealthCare System, Boston, MA, 2Brigham and Women’s Hospital, Boston, MA, USA Abstract Objective. Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare system, a large, integrated, non-proWt health care delivery system in the United States. Design. Partners identiWed a central Patient Safety OfWcer, who then formed a Patient Safety Advisory Group with local expert members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implemen- tation. There was broad consensus that interventions should include the areas of culture change, process change, and process measurement. Setting. A large, integrated health care delivery system in the Boston, Massachusetts, area. Results. Key milestones to date include implementation of Executive WalkRounds, development of accountability principles, agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physi- cian order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network. Most inXuenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient safety initiatives. Conclusions. This loosely integrated delivery system represents a daunting landscape for the development and institution of patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for signiW- cant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging. Moreover, with many potential interventions, and limited resources, prioritization and selection is difWcult. Nonetheless, con- sensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the net result will be substantial improvement in patient safety. Keywords: culture, patient safety, quality improvement Safety in health care has received substantial attention in the be possible even without changing technology [3]. The ultimate US since the 1999 Institute of Medicine report, To Err Is goal in culture change is system transparency, deWned as a will- Human [1]. While that report described the magnitude of the ingness of providers and patients to openly and comfortably problem in some detail, it provided only a high-level view of express their concerns about the delivery of care in a manner how organizations might change in order to improve the care that identiWes Xaws and leads to their elimination, mitigation, or they provide. In the 4 years since that report, organizations appropriate management. Culture change, and the subsequent have struggled to develop coherent programs for improving increase in event identiWcation that it promotes, are essential in safety, and these programs have varied substantially. order to then be able to identify and improve systems of care We believe that patient safety programs should include at such as medication delivery. Leadership understanding of least three areas of focus: culture change, process change, and safety concepts represents an essential component for this cul- process measurement. Changing culture is a new watchword in ture change [4–7]. Yet it is far from clear how best to build a patient safety. There is a growing realization that the beneWts of culture of safety, especially across a large entity, or to know technological advances will be optimized only if health care whether one has been achieved. providers approach delivery of care from the appropriate Processes need to be standardized and variation reduced to perspective [2], and that substantial improvement in safety may improve the quality of care and reduce error rates. In some Address reprint requests to David Bates, Brigham and Women’s Hospital, BC3, 1620 Tremont St, Boston, MA 02120, USA. E-mail: dbates@partners.org International Journal for Quality in Health Care vol. 15 Supplement 1 © International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved i31
  • 2. A. Frankel et al. instances, this may involve implementation of technology, for safety made identifying the participants for this group while in others it may not. Process and outcomes must be straightforward, as all the institutions had clearly delineated measured to know whether care has ultimately been who was responsible for their patient safety efforts. Members improved. The objective of this paper is to delineate the com- of this group include physicians, nurses, and risk managers. ponents of a patient safety strategy, developed and imple- Initially, the Patient Safety Leaders Group was most pow- mented in one large integrated delivery system, to improve erful in educating its members about the good ideas and best safety by catalyzing safety-based cultural changes, changing practices of each institution. As the group has become more processes, and measuring outcomes. cohesive, over a period of 1 year, the members are beginning to think collaboratively about goals for the integrated delivery system in addition to each individual’s speciWc hospital goals. Study design To develop the camaraderie necessary to achieve this, the group has met face-to-face for over a year. Because the inte- Study site grated delivery system is spread across much of eastern Massachusetts, initial attempts to convene this group were Partners HealthCare is the largest integrated delivery system done virtually—usually by telephone conference calls. It in the north-eastern United States. It was founded in 1994 by became apparent after a few months that the group was not Brigham and Women’s Hospital and Massachusetts General functioning effectively, so face-to-face meetings were sched- Hospital, and has grown to include primary care and specialty uled. The improvement in collaboration, camaraderie and Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 physicians, community hospitals, the two founding academic congeniality was apparent within a few sessions. As a com- medical centers, specialty facilities, community health centers, promise, the meetings are scheduled monthly, alternating and other health-related entities. While researchers within between virtual and face-to-face formats. Partners have long been leaders in patient safety research [8–13], The group is beginning to tackle a variety of system-wide Partners did not have a coherent, network-wide approach to projects, some aimed at cultural change, such as promulgating patient safety before the Institute of Medicine’s report. the acceptance of executive WalkRounds to discuss safety issues and system-wide accountability principles. Others are process-speciWc, such as managing anticoagulation, improv- Partners patient safety program structure ing the safety of central line insertions, and ensuring wide- In 2000, Partners Chief Medical OfWcer and Partners Chief spread implementation of computerized physician order Executive OfWcer decided to create the position of Partners entry. These projects were chosen because they address high- Patient Safety OfWcer. The main task of the position was to risk processes and could be used as paradigms for future devise strategies to reduce error in care delivery. A signiWcant projects relating to both medication delivery and invasive component of medical error reduction up to that point had procedures in other areas. been directed towards measurement and process change, par- In addition to the clinical care provided by Partners and ticularly in terms of medication safety [11,14,15]. However, non-Partners Harvard-afWliated organizations, these institu- experiences in attempting to improve safety across a broad tions have been leaders in patient safety research, and the array of institutions suggested that combined tools that research groups interact closely with the operational entities. addressed cultural change and leadership as well as speciWc The intent is to have the organizations serve as laboratories components of care delivery would be most successful [5]. for improvement in patient safety, and in addition to rapidly The goals delineated for the Partners Patient Safety OfWcer disseminate beneWcial changes throughout the organization. position included speciWc efforts to change the culture of our hospitals—especially by educating hospital leadership—and to revise the hospitals’ methods of analyzing adverse events so that they measure and delineate system and process prob- Results lems, pinpoint longstanding unsafe traditions, and delineate Patient safety initiatives across an integrated actions to address them. health care system Two groups were developed to support the Partners patient safety effort. A Partners Patient Safety Advisory Integrated delivery system executive-level patient safety goals Group was convened to meet two times per year to advise the differ somewhat from those established at a hospital-based Patient Safety OfWcer of national trends and to evaluate the patient safety level. Projects that target transitions from one efforts underway in the integrated delivery system. The indi- institution to another or require consensus across organiza- viduals in the advisory group were chosen based on their tional boundaries will beneWt from oversight at a high level. work in areas related to patient safety, their knowledge of the Coordinated anticoagulation management is an example. By national environment, and their stature within the Partners contrast, initiatives that are wholly hospital based or con- HealthCare System. In addition, a Partners Patient Safety tained within one organization or one administrative structure Leaders Group was convened, made up of the individuals in can be piloted and proven locally. Then other hospitals may each institution with the responsibility for patient safety. The beneWt from the learning. However, hospital-based patient Joint Commission on Accreditation of Healthcare Organiza- safety personnel tend to be, appropriately, inwardly focused tions’ mandate that hospitals identify a locus of responsibility and their time is Wlled with responsibilities from within their i32
  • 3. Improving patient safety own organization. As a result, the opportunity to learn from organization created to help lead the improvement of health other organizations is limited to literature and an occasional care systems and to promote continuous increase of their national conference. Lack of collaboration across and within quality and value [17]. The IHI has conducted many year-long institutions is common. The strength of an integrated system multi-hospital collaboratives to develop and spread best prac- is that its leaders can develop a framework for constant col- tices. In these collaboratives, up to 140 hospitals over a period laboration to occur. The Patient Safety Leaders Group has of 1 year undertake similar projects aimed at improving health been an example of this. The relationships developed have care, and convene periodically to discuss and compare their facilitated large-scale projects as well as fostering numerous progress. The WalkRound™ tool was designed to connect collegial interactions about smaller problems. Safety requires senior leadership to patient safety and to inculcate a culture of collaboration amongst clinical groups and should be a goal of safety into the health care system. It was also postulated that all those responsible for patient safety. the information elicited during the WalkRounds™, if effec- The aim of the new Partners-wide safety goals was to achieve tively analyzed, might be used to drive safety-based changes a culture change, and to revise the hospitals’ methods of analyz- by creating a cycle of information–analysis–action–feedback. ing adverse events to include process change and process meas- The end result would be a self-sustaining process that would urement. To accomplish these goals, our approach has been continue to engage leadership, educate clinicians and mana- initially to pilot an intervention at one institution with the goal of gers, and lead to continuous improvement. eventual rollout across the entire delivery system. The interven- The WalkRounds™ were initiated with the following object- tions that have been piloted and/or implemented in the system ives: (i) to increase awareness of safety issues by all clinicians; Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 have included executive WalkRounds™, the development of (ii) to make safety a high priority for senior leadership; (iii) to accountability principles, Web-based reporting systems, and educate staff about patient safety concepts such as non-puni- process-speciWc initiatives. Separately, they are modestly useful. tive reporting; and (iv) to obtain and act upon information Combined, however, these initiatives are a signiWcant force. elicited from staff about safety problems or issues. Table 1 outlines some of our current and potential patient safety WalkRounds™ was piloted at one hospital in January 2001. initiatives; the challenge is determining the priority for implemen- The Chief Executive OfWcer, Chief Operating OfWcer, Chief tation of each of these initiatives. Medical OfWcer, and Chief Nursing OfWcer agreed to partici- pate in weekly safety walk rounds. Other participants in the WalkRounds™ include the patient safety director, patient Culture change: executive WalkRounds™ safety manager, and research assistant. WalkRounds™ are Executive WalkRounds™ were conceptualized initially in the held weekly and visit different areas of the hospital, including Idealized Design of Medications Systems Design Group at the medical/surgical/obstetrical wards, emergency room, phar- the Institute of Healthcare Improvement in 1999 [16]. The macy, and operating suites. During the WalkRounds™, Institute for Healthcare Improvement (IHI) is a not-for-proWt speciWc questions are asked of the staff nurses, residents, and staff pharmacists on duty, such as ‘Were you able to care for your patients this week as safely as possible? If not, why not?’ Table 1 Partners current and potential patient safety initiatives and ‘What could this unit do on a regular basis to improve safety?’ (Figure 1). At the end of the rounds those who were Culture change questioned are educated about patient safety concepts such as Executive WalkRounds™ the importance of reporting near misses and how thinking Accountability principles or commitments about human factors can inXuence decision making. These Education: orientation, competencies, credentialing participants are e-mailed a transcript of the conversation later Safety brieWngs that day to thank them for their participation and so that they Core process may review their comments. Events that are captured in these Intelligent Information Technology: computerized rounds are put into a database and classiWed according to the physician order entry, electronic medical records, contributing factors that inXuenced the event. Each event is computerized medication administration records, assigned a score based on its severity or its potential for bar-coding patient harm. Simulation: teamwork and communication The list of events requiring active response is prioritized by Flow: unit-based assessment level of severity and brought to the responsible leadership, Protocols: clinical practice guidelines by evidence and and ownership of the issues is assigned. Each quarter, consensus the leadership provides updates to those who participated in Hardware standardization the rounds on progress towards resolution or a statement of the rationale for not taking action. Informing them of the Measurement actions taken closes the communication loop with the Reporting systems Pharmacy interventions WalkRound™ participants. We have informally surveyed Computerized monitoring for adverse events staff and leadership about these walk rounds. Leadership have been extremely engaged and feel the rounds have great value. Protocols and clinical practice guidelines The staff overall have been pleased to see leadership commit- Attitudinal surveys (clinician and patient) ment to safety with these rounds, and have been pleased with i33
  • 4. A. Frankel et al. Sample questions: 1. Have you been able to care for patients as safely as possible. If not, why? Weekly 2. Have there been any near misses that almost caused WalkRounds patient harm? with 3. Can you describe the unit's ability to work as a leadership team? and staff 4. When you make an error or intercept an error, do you always report it? If not, why? 5. Have you discussed patient safety issues with Monthy your patients or their family members? reports prioritized by severity of patient impact Feedback to the Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 reporter Responsible clinical manager and leadership review No Decision for action Yes Assignment of ownership Action completed Figure 1 WalkRounds™ Xow diagram. the follow-up actions they see based on their comments. Reporting System (ASRS) is an example of this successful Since the initial pilot, WalkRounds™ have been successfully approach applied to the airline industry [18]. implemented at four additional Partners institutions. The plan Currently, reporting of adverse events frequently does not for further spread to other institutions is under discussion, as occur, at least in part because individuals believe that they will is a standardized analysis of the impact of the WalkRounds™. be blamed or sanctioned (regardless of whether the individual In addition, a study is underway to evaluate the WalkRounds or the system is at fault) [19]. Most blame-free policies in 10 other Massachusetts hospitals over the next 2 years. attempt to balance the desire to increase reporting with the desire not to limit sanctions. This is usually done by promis- ing protection to those who report in a timely fashion and Culture change: accountability principles exempting cases of misconduct. Many are fashioned from the Accountability principles or commitments to safety derive ASRS reporting procedures that have for over 25 years from attempts to clearly enunciate a non-punitive or blame- offered immunity if reports are obtained within 5 days of the free reporting policy towards health care providers who event, exempted criminal actions, and afforded the reporter report adverse events or episodes of patient harm. The pur- conWdentiality, followed 30 days later by anonymity. The pose of improving reporting is to elucidate Xaws in the health ASRS system works on a national scale, but does not offer to care delivery system that may then lead to the development the individual airlines an analysis of airline-speciWc problems. and implementation of system remedies. The Aviation Safety To address this, airlines have built Aviation Safety Action i34
  • 5. Improving patient safety Plans that tend to offer conWdentiality but not anonymity and attitude and unsafe Xying conditions. These surveys have that facilitate in-depth root-cause analysis. been modiWed for use in health care and there are clear Anonymity and conWdentiality in a hospital or health care indications that provider attitude may be correlated with system is much harder, sometimes impossible, to achieve. patient morbidity and mortality [25,26]. We are planning to Rather than simply address the protection afforded to individ- use these types of surveys to measure the cultural impact of uals for reporting, a set of principles that outlines expectations WalkRounds™ and Safety BrieWngs. of all the stakeholders regarding system-versus-individual responsibility may be what is needed. If written intelligently, Process change: high risk processes a set of principles or policies about reporting harm does not require health care institutions to compromise their ability to Standardization and simpliWcation of care through intelligent police employees or appropriately prosecute misconduct. protocols and clinical practice guidelines has been a staple of The Partners Healthcare System has been developing this quality improvement for a few decades in health care [5], but set of principles with the hope that every member institution has had variable and often poor penetration. The relationship supports them and fosters a similar attitude regarding culture, between complexity and error, delineated in human factors reporting, and accountability. The Partners Patient Safety research in many industries, has led to increased vigor on the OfWcer and Patient Safety Leaders Group initially drafted the part of health care safety advocates to implement process accountability principles by performing a search of the litera- standardization, including through the use of protocols. The ture to Wnd non-punitive policies currently in use in health major efforts of the Partners Patient Safety OfWcer have tar- Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 care. ‘Whistle-blower’ statutes were reviewed and state- geted anticoagulation management, the placement of central speciWc issues about peer review protection identiWed. The venous catheters, and computerization of physician ordering Patient Safety Leaders Group reviewed the principles, followed in the in-patient setting. by risk management and human resources representatives from each Partners institution as well as by Chief Medical and Anticoagulation Chief Nursing OfWcers. In addition, hospital lawyers and human resource departments piloted the initial drafts by Perhaps the most compelling evidence supporting the impor- applying them to selected cases to ensure that they did not tance of protocols is in the management of anticoagulants, conXict with appropriate hospital actions. Newer drafts were especially heparin and warfarin [27]. All of the Partners hospi- evaluated in a similar way. An appendix to this paper shows tals currently use some form of a heparin weight-based proto- the version of the principles approved by all the Partners col for at least some patients and we have numerous warfarin institutions. clinics within our loosely integrated delivery system. How- ever, many patients on warfarin are not managed in a clinic setting, and a system-wide program for warfarin management Culture change: future initiatives has been lacking. Systematic warfarin management is neces- The Executive WalkRounds™ and accountability principles sary to provide effective care to patients during transitions represent the foundation for cultural change. Educational from one level of care to another. modules about safety, ‘Safety BrieWngs’, and attitudinal To improve these processes, we convened a group of inter- surveys are other building blocks under consideration for ested individuals and experts including physicians, nurses, implementation. Safety BrieWngs involve frontline staff, and pharmacists, information technology specialists, in-patient are simple and brief interchanges usually conducted during discharge planners, home care specialists, ofWce business transitions in care—either as patients are transferred or as managers and outpatient anticoagulation service providers. health care providers change shifts. These brieWngs identify The mission of this group is to: (i) centralize information speciWc areas of risk at the time of the brieWng and should be about patients and their anticoagulation status while support- conducted in a relaxed but formalized fashion. ing local control and management; and (ii) decrease the The educational component of culture change occurs dur- number of steps necessary to manage anticoagulation, thereby ing orientation of new employees, and during re-credentialing decreasing the likelihood of error. To accomplish these goals, and competency training of all health care providers. The the group is currently designing software to serve a dual pur- education will include: (i) human factors—how humans inter- pose: to assist large warfarin clinics that primarily manage lab- act with their environment [20]; (ii) cognitive psychology— oratory data and drug dosages, and also to support small how humans think and how we make errors [20,21]; (iii) how ofWce-based clinics who see patients face-to-face. The needs innovative ideas diffuse [22]; and (iv) ethics and accounta- of these two types of clinics differ, but they have a common bility—the logic in making complex systems transparent [23]. requirement: anticoagulation information should be readily We are currently planning a curriculum for all new employees available from anywhere in the delivery system. (in particular clinicians) to focus on these issues. The second goal, to decrease the steps in management, Attitudinal surveys offer another opportunity to measure may be accomplished by using point-of-care blood testing the degree of transparency and open communication being devices to measure the international normalized ratio (INR) fostered by patient safety projects in an institution. Surveys rather than the standard mechanism, i.e. obtaining a vial of used in this fashion are commonplace in the airline industry blood and sending it to a laboratory for INR analysis. The [24,25]. They have shown a direct relationship between pilot group is also evaluating supports for physicians and patients i35
  • 6. A. Frankel et al. who are not attached to current ofWce and hospital anti- Safety Leaders Group will be an important entity for sharing coagulation clinics. A model for geographically diverse care information about successes and barriers as CPOE moves that manages patient transitions well is the visiting nurse forward. association (VNA). Partners HealthCare system is looking to these groups to develop ambulatory clinic-based models Process change: future initiatives to manage anticoagulation using point-of-care testing devices. Core process changes include the intelligent structuring of Measurement of current effectiveness is underway, with information technologies, simulation, standardization, and sim- plans to audit process measures (percent of patients with pliWcation of care delivery through protocols and clinical prac- therapeutic INRs) and outcome measures (bleeding- and tice guidelines, streamlined patient Xow with fewer delays, and clot-related complications). Independent physician groups hardware standardization. Into this Wnal category falls CPOE, are particularly difWcult to monitor as each maintains its own standardizing warfarin management during transitions of care, databases, often on paper, and they have not been required and protocols for safe central venous catheter placement. to collect or maintain this information. A one-time audit sug- Other projects in this category are also being evaluated. gested that the percentage of patients maintained in thera- Boston has been a stronghold of simulation research spear- peutic INRs by the groups ranged from 45 to 75%. We headed by the Center for Medical Simulation. In the simula- believe that 75% of patients in therapeutic INR is an appro- tor, models of patients’ rooms or invasive suites and priate goal for each physician group; our plan is to ask each operating rooms are combined with computer-driven moni- Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 group to collect the information in the manner easiest for them. tors and manikins to simulate real-life problems. Students have the opportunity to learn and test their skills in a safe environment where patients cannot be harmed and actions Central venous catheter insertion can be critiqued. Simulators are available relatively inexpen- sively for placement in every hospital, and have the potential Evaluation and spread of best practices in central venous to dramatically improve teamwork, open communication and catheter (CVC) insertions is a system-wide project under- provider education. Partners and the Center for Medical Sim- taken by the Partners epidemiology leaders, the goal of ulation are embarking on many projects that will impact each which is to decrease complications, especially CVC-associ- institution. For example, anesthesia residents are all undergo- ated blood stream infections. Practice around CVC insertion ing simulation training in return for which their malpractice varies widely from one intensive care unit to another, even insurance premiums have been reduced. Under discussion is though physicians rotate through the entire delivery system. further development of in-hospital simulators for use in During CVC insertions, having in attendance an un- teamwork and skill-based training. scrubbed assistant and an experienced attendant or fellow In addition to CPOE, information technologies such as has been historically difWcult to institute. Epidemiologists electronic medical records, automated medication administra- and intensivists have instituted and spread best practices tion records and bar coding are all currently in use in some using education, protocols, and audits. The focusing of Partners settings and are becoming more widespread attention combined with the pilot study facilitated spread of throughout Partners Healthcare System. However, having a the best practices with excellent results. One organization logical strategy for implementation is the key to acceptance of with incomplete penetration of the suggested practices, after these new technologies, and Partners Information Systems is fully adopting these practices, decreased the central line putting signiWcant effort into creating a common information blood stream infection (BSI) rate over a 12-month period technology structure for the entire network. from 162 to 120, yielding a calculated saving of $2.5 million. Patient Xow is another possible area of intervention. Given The rates placed the institution in the top quartile of organi- our current nursing and pharmacist shortage, empowering zations compared with the Centers for Disease Control and nurse managers and frontline nurses to control patient Xow Prevention benchmark rates. based on safety is imperative. This may be accomplished using innovative strategies such as the unit assessment tool used by Luther Middlefort Hospital in Eau Claire Wisconsin, in which Computerized physician order entry frontline nurses use a trafWc light concept to delineate the state Computerized physician order entry (CPOE) has been found of safety on their unit. Hospital workers use red, green, and to substantially decrease the rate of serious medication errors yellow colors to identify the level of risk they perceive in their [14,15], and appears to be one of the most potent technolog- area based on parameters such as nurse:patient ratios and ical changes for improving patient safety [28]. While CPOE patient acuity. The colors are broadcast through the institution is in place in the two large teaching hospitals in the Partners as the screen-saver on the hospital computers and determine network, it has not yet been implemented in the smaller hos- where patients are admitted and transferred. Resources are pitals. Because of the recommendations of the Partners diverted to aid those areas in the ‘red’ zones [29]. Patient Safety Advisory Group regarding the substantial Finally, standards are necessary that direct hardware pur- safety beneWts of CPOE, the Partners leadership has made a chases based on safety. Medication infusion pumps are a sen- commitment to the implementation of CPOE in all in- tinel example in this category. Testing for human factor patient institutions over the next few years. The Patient problems should determine the choice of pumps, favoring i36
  • 7. Improving patient safety those that have ‘intelligent’ but simple redundancies to alert Process measurement: adverse drug event the care provider. There are currently numerous pilot tests monitor underway in the Partners Healthcare System to evaluate and Patient safety will be improved further by the implementa- standardize these technologies. tion of routine measurement across a variety of domains. The common reporting system will be a vital tool in this Outcome measurement: a common reporting regard. However, spontaneous reporting detects only a small system minority of events [32,33], and we believe that automated detection methods will be useful in improving routine detec- Another key to a culture of safety is having an easily availa- tion of safety issues [34–36]. A computerized Adverse Drug ble and simple way for health care workers and patients to Event Monitor that searches for signs of an adverse event report adverse events. Critical components of a safety and sends this information to a pharmacist for follow-up is improvement program in a large delivery system are the now in routine use at one hospital [37]. The monitor is a pro- adoption of a common language for reporting errors and gram (consisting of > 30 triggers) that searches the patient’s near misses, and an ability among hospital staff members to computerized medication and laboratory test proWles for evi- learn from each other. The goal of Partners is to create a dence of adverse drug events and generates alerts. An exam- common reporting system for all member institutions, so ple of an alert would be a patient whose creatinine is rising that information can be rendered anonymous and shared taking an aminoglycoside. The monitor generates a daily list conWdentially to promote measurement, learning, and Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 of these alerts and the hospital pharmacists review the alerts benchmarking. To accomplish this, Partners has opted to for their patients and make interventions. Most interventions promote the use of a Web-based reporting system, and has involve calling the physician to discontinue or change the been evaluating those commercially available [30]. The use- dosage of a medication; the goal is to intervene before the fulness of these kinds of systems relies on the simplicity of adverse drug event becomes serious or prolonged. This also the data entry method, the system’s ability to receive and promotes a culture of safety within pharmacy by actively store a large volume of data in a secure environment, and involving the pharmacists in event prevention. The Adverse the breadth of analysis and ad hoc reporting available to the Drug Event Monitor won the Institute for Safe Medication site manager [31]. Practices Cheers Award in 2002 for its excellence in proac- Our main criteria for application selection are security, tively identifying potential adverse drug events. These kinds ease of use, and speed, since these are major barriers to of proactive monitoring will eventually be used at other insti- staff reporting. We are evaluating the breadth of scope of tutions within the network to supplement spontaneous the product (Does it include near misses? Does it include reporting. ambulatory care? Does it have detailed modules for more than just medications and slips/falls?). In addition, we are evaluating the coding taxonomy to make sure it would col- Process measurement: future initiatives lect enough systems-related information. We require a fol- low-up module where the appropriate leaders could edit/ Vital components of safety measurement include ascertain- modify the report once follow-up was complete. We ing provider willingness to report problems and conducting require an ability to integrate into our network e-mail sys- audits looking for adverse events and near misses. Surveying tem so that appropriate leadership would get e-mail notiWca- provider attitude and tracking the use of spontaneous tion of the Wling of the report. We are looking at the reporting systems will elucidate whether willingness to system’s capacity to generate reports or export data into report events improves. Web-based reporting systems will databases for our own report generation. Finally, adequate improve our ability to evaluate both of these. Adverse customer support is essential. A system is currently in a events and near misses can be monitored in many ways. For pilot phase and nursing staff have been very pleased with example, in one of our hospitals, pharmacy interventions are the speed and ease of use. We have seen increases in report- used to identify areas of knowledge deWciency on the part of ing in the pilot areas, particularly in areas that had house staff, and a medication competency exam has been extremely low reporting rates previously. In addition, we developed based on these interventions. The exam is given have seen increases in reports from physicians, which we to incoming interns and then again as their internship ends. attribute to the speed of the system. The exam results are monitored to evaluate how effective The Patient Safety Leaders Group is given regular pharmacy education has been during the year. The compe- updates on experience with the pilot and the impact of this tency exam is modiWed each year based on the previous on a plan for larger rollout. The ultimate goal is for all the year’s pharmacy interventions. Partners institutions to use this common reporting system As noted earlier, another hospital has implemented a com- so that hospitals can then share information about certain puterized monitoring program in which an event monitor common event types and learn from each other about screens the computerized database and sends alerts daily to systems improvements. Issues such as medication errors and pharmacists who can then review them and make interven- adverse drug events can be discussed using common termi- tions. This generic approach will likely eventually be suitable nology, and rare but serious events can be measured jointly so for screening other sources (such as discharge summaries) for that hospitals can learn from the experiences of others. adverse events [38]. i37
  • 8. A. Frankel et al. Conclusions and the Institute for Safe Medication Practices for executive level and middle management patient-safety positions. These As the concepts underlying patient safety mature, it is becom- positions must be empowered to integrate safety, quality, and ing possible to develop a cohesive and broad patient-safety risk management departments, and to base actions on promot- strategy. We have described the path we have taken, although ing transparency and open communication [39,40]. other alternatives might have been chosen, and in addition to In conclusion, developing and implementing a strategy for the efforts described, each hospital has numerous individual improving patient safety within this large, loosely integrated projects underway. A broad patient-safety strategy may be delivery system has been challenging but exciting. Initial divided into three categories: cultural change, core process efforts have focused on cultural change, process change, and change, and process measurement. Our initial efforts across process measurement, and many other projects in these areas the Partners integrated health care system include initiatives are being evaluated and considered for pilot testing. Clearly, in each of these areas. We have many additional projects that there is no right answer as to which projects an integrated we are considering in each category, including both technology- delivery system or hospital should undertake, and there are related and non-technology-related interventions. numerous possibilities from which to choose. Some of the strategies involve technology but many do not. Decisions need to be based on measured need, leadership support, inter- Conceptual models for the future est, and resources. However, we feel that an emphasis on culture, process, and measurement makes the most sense Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 Theoretical concepts determined the initial framework for for both short-term and long-term safety improvements. our patient safety strategy. Further construction was based on hospital interests and the efforts of those invested in each project. Two years later, collaborative efforts by all have Acknowledgements helped reWne patient safety theory. Hospitals and integrated delivery systems just beginning to formulate a patient safety We acknowledge support from Partners HealthCare (see plan can build on work done and may develop a more solid page i40). framework for themselves. While still mostly theoretical and unproven, safety in overview is becoming clearer and should include the following: (i) leadership promotes patient safety as References a core value by participation in safety-based activities; (ii) open communication and effective reporting, leading to a 1. Institute of Medicine. To Err is Human. Building a Safer Health sense of psychological safety [4]; (iii) allocation of resources System. Washington, DC: National Academy Press, 1999. to support patient safety efforts is required in every budget; 2. Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, (iv) training and education in patient safety concepts and Sheridan T. Reducing the frequency of errors in medicine using practice is part of orientation, credentialing, and competency information technology. J Am Med Informatics Assoc 2001; 8: evaluations; (v) the search for new knowledge in patient safety 299–308. is a component of any research program; (vi) active projects 3. Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation are developed to enhance disclosure and improve public per- on physician rounds and adverse drug events in the intensive ception about safety and honesty, including increasing patient care unit. J Am Med Assoc 1999; 282: 267–270. participation and input in hospital management; (vii) sharing best practices and collaboration is expected of all physician 4. Carroll JS, Edmondson AC. Leading organisational learning in specialties and hospital locations; and (viii) new measures to health care. Qual Health Care 2002; 11: 51–56. assess patient safety are constantly sought and tested. These 5. Leape LL, Kabcenell AI, Gandhi TK, Carver P, Nolan TW, eight ideas should determine the array of projects undertaken Berwick DM. Reducing adverse drug events: lessons from a by an institution, the goal being to ensure that work is being breakthrough series collaborative. Jt Comm J Qual Improv 2000; performed to address all of them. In a truly robust institution, 26: 321–331. every hospital location and each physician group or specialty 6. Pizzi LT, Goldfarb NI, Nash DB. Promoting a culture of safety. should be able to identify its own group of safety and quality In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, projects, also aimed at improving their environment in all eds. Evidence Report/Technology Assessment No. 43, Making Health eight areas. Care Safer: A Critical Analysis of Patient Safety Practices, AHRQ Pub- Measurement of effectiveness will exist in two categories: lication No. 01-E058. Agency for Healthcare Research and culture and patient outcome. Measurement of speciWc Quality, 2001. Available at http://www.ahrq.gov/clinic/ projects should include effectiveness and likelihood of patient ptsafety/chap40.htm (last accessed on July 12, 2002). harm. Institutional improvement in promoting a safety cul- 7. Rozich JD, Resar RK. Medication safety: one organization’s ture will be apparent through workforce attitudinal surveys, approach to the challenge. J Outcomes Manag 2001; 8: 27–34. the willingness to report adverse events, and the speed of test- 8. Brennan TA, Leape LL, Laird N et al. Incidence of adverse ing and implementation of worthwhile projects. events and negligence in hospitalized patients: results from the Patient safety personnel job descriptions have changed as the Harvard Medical Practice Study I. New Engl J Med 1991; 324: science has matured. Templates are available through Premier 370–376. i38
  • 9. Improving patient safety 9. Leape LL, Brennan TA, Laird NM et al. The nature of adverse 27. Gandhi TK, Shojania KG, Bates DW. Protocols for high-risk events in hospitalized patients: results from the Harvard Medical drugs: reducing adverse events related to anticoagulants. In: Practice Study II. New Engl J Med 1991; 324: 377–384. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Evidence Report/Technology Assessment No. 43, Making Health Care 10. Bates DW, Cullen D, Laird N et al. Incidence of adverse drug Safer: A Critical Analysis of Patient Safety Practices, AHRQ Publica- events and potential adverse drug events: implications for pre- tion No. 01-E058. Agency for Healthcare Research and Quality, vention. J Am Med Assoc 1995; 274: 29–34. 2001. Available at: http://www.ahrq.gov/clinic/ptsafety/chap9.htm 11. Leape LL, Bates DW, Cullen DJ et al. Systems analysis of (last accessed July 12, 2002). adverse drug events. J Am Med Assoc 1995; 274: 35–43. 28. The Leapfrog Group. Fact Sheet: Computerized physician order entry 12. Kuperman GJ, Teich JM, Tanasijevic MJ et al. Improving (CPOE). November 2000. Available at: http://www.leapfrog- response to critical laboratory results with automation: results of group.org/FactSheets/CPOE_FactSheet.pdf (last accessed on a randomized controlled trial. J Am Med Inform Assoc 1999; 6: July 12, 2002). 512–522. 29. Rozich JD, Resar RK. Using a unit assessment tool to optimize 13. Gandhi TK, Burstin HR, Cook EF et al. Drug complications in patient Xow and stafWng in a community hospital. Jt Comm J outpatients. J Gen Intern Med 2000; 15: 149–154. Qual Improv 2002; 28: 31–41. 14. Bates DW, Leape LL, Cullen DJ et al. Effect of computerized 30. DoctorQuality, Inc. Risk Prevention and Management System physician order entry and a team intervention on prevention media center. Available at: http://www.doctorquality.com/ of serious medication errors. J Am Med Assoc 1998; 280: www/RPM_Media/default.htm (last accessed July 12, 2002). Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 1311–1316. 31. Joshi, MS, Anderson JF, Marwaha S. A systems approach 15. Bates DW, Teich J, Lee J et al. The impact of computerized phy- to improving error reporting. J Healthcare Inf Manage 2002; 16: sician order entry on medication error prevention. J Am Med 40–45. Informatics Assoc 1999; 6: 313–321. 32. Tubert P, Begaud B, Pere JC, Haramburu F, Lellouch J. Power 16. Frankel, A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, and weakness of spontaneous reporting: a probabilistic Gandhi TK. Patient Safety Leadership WalkRounds™. Jt Comm J approach. J Clin Epidemiol 1992; 45: 283–286. Qual saf 2003; 29: 16–26. 33. Dormann H, Muth-Selbach U, Krebs S et al. Incidence and costs 17. Institute for Healthcare Improvement [Internet homepage]. of adverse drug reactions during hospitalisation: computerised Available at: http://www.ihi.org/ (last accessed on July 12, 2002). monitoring versus stimulated spontaneous reporting. Drug Saf 2000; 22: 161–168. 18. NASA. Aviation Safety Reporting System [Internet homepage]. Available at: http://www.asrs.arc.nasa.gov/ (last accessed on 34. Jha AK, Kuperman GJ, Teich JM et al. Identifying adverse drug July 12, 2002). events: development of a computer-based monitor and compar- ison with chart review and stimulated voluntary report. J Am 19. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Med Inform Assoc 1998; 5: 305–314. Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. 35. Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized Jt Comm J Qual Improv 1995; 21: 541–548. surveillance of adverse drug events in hospital patients. J Am Med Assoc 1991; 266: 2847–2851. 20. Reason J. Human Error. Cambridge, UK: Cambridge University Press, 1990. 36. Honigman B, Lee J, Rothschild J et al. Using computerized data to identify adverse drug events in outpatients. J Am Med Informat- 21. Rasmussen J. Human error and the problem of causality in ics Assoc 2001; 8: 254–266. analysis of accidents. Philos Trans R Soc Lond B Biol Sci 1990; 327: 449–462. 37. Silverman JB, Stapinski CD, Churchill WW, Neppl C, Bates DW, Gandhi TK. The adverse event prevention program 22. Ryan B, Gross N. The diffusion of hybrid seed corn in two Iowa (ADEPP): Putting the literature into action. Am J Health Syst communities. Rural Sociol 1943; 8: 15–24. Pharm 2003, in press. 23. Waldrop MM. Complexity: the emerging science at the edge of 38. Murff HJ, Forster AJ, Peterson JF, Fiskio JM, Heiman HL, order and chaos. London: Viking, 1992. Bates DW. Electronically screening discharge summaries for 24. Helmreich RL, Merritt AC. Culture at work in aviation and adverse medical events. J Gen Intern Med 2001; 17(suppl. 1): medicine: national, organizational and professional inXuences. A205. BrookWeld, VT: Ashgate, 1998. 39. http://www.my.premierinc.com/all/safety/resources/patient_ 25. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and team- safety/downloads/18_Safety_Job_Description_07-09-02.DOC work in medicine and aviation: cross sectional surveys. Br Med 40. http://www.ismp.org/Tools/CovenantJobDesc.html J 2000; 320: 745–749. 26. Shortell SM, Zimmerman JE, Rouseau DM et al. The perform- ance of intensive care units: does good management make a dif- ference? Med Care 1994; 32: 508–525. Accepted for publication 21 July 2003 i39
  • 10. Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010 A. Frankel et al. i40