Model of the Future: Neighborhood Watch

Patient safety is best done as a grass roots initiative.

People talk about establishing a culture of safety in the hospital. But the fact is, hospitals comprise many, many cultures. Each department, each floor, each unit, even each shift is its own culture. And if administrators fail to recognize that, their messages about the importance of patient safety will probably go unheeded. At least, that’s what Cynthia Blair believes.

Blair is VP of organizational development and planning for Tallahassee Memorial Healthcare in Tallahassee, Fla. It’s a big job, comprising a myriad of responsibilities, including case management, peer review, executive decision support, regulatory compliance, performance improvement and medical staff services. A large part, though, has to do with patient safety.

Indeed, Tallahassee Memorial takes the issue seriously. A service-line administrator serves as patient safety officer, aided by the executive director of quality management, from Blair’s office. Both have received training through the Institute for Healthcare Improvement, Cambridge, Mass., at a cost to the hospital of $40,000.

Blair spent 14 years at South Miami Hospital in South Miami, Fla., as administrator of performance improvement before joining Evanston, Ill.-based Solucient, a healthcare business intelligence firm. During her five years with Solucient, she had the opportunity to work with many hospitals and study how they were dealing with issues such as outcomes measurement and operational benchmarking. She joined Tallahassee Memorial a year ago.

In the neighborhood
“The thing we have really come to realize, and that others will come to realize too, is that a patient safety officer cannot do it alone,” says Blair. “He or she can help tailor the message or start the initiative. But patient safety has to be a grass-roots effort.”

By grass roots, she means down to the unit level. Blair calls it “neighborhood improvement.” “We’re looking at the culture of the unit and trying to make it the safest environment for each patient,” she says.

Improvement advisors are assigned to each unit. But the cornerstones of the patient safety program are the twice-weekly interdisciplinary rounds, in which a pharmacist, case manager, nurse, improvement advisor and physician meet to talk about each patient on each unit. Patient safety is part of their discussion.

“[The process] allows us to translate that culture of safety to the particular nurse and the particular patient,” says Blair. “Sometimes we have lofty programs in hospitals, but the staff doesn’t know how to apply them or what they should or shouldn’t be doing. We’re trying to make that leap between having a program and getting information to the people who need it on a daily basis.”

The rounds process has helped raise the staff’s awareness of the many patient safety issues that they face all the time, says Blair. For example, rounds have helped the staff identify and address the potential dangers of discontinuing a patient’s anti-depressant medication. “We were able to raise awareness that this is a medication that, if at all possible, has to be continued,” she says.

Rounds have proven again and again that patient safety is an ongoing process, as exemplified in Tallahassee’s fall prevention program. Nurses attach distinguishable icons to the doors of patients whom they believe are at risk of falling. While a good idea in theory, the system developed some flaws in practice. Specifically, Blair noticed that many of these doors were often closed, making it impossible for passersby to observe whether, in fact, the patient had fallen in his or her room. Consequently, the staff was educated to keep these doors open as much as possible, and were trained on how to communicate the reason why. “We tell the patients and families that as much as we want to respect their privacy, we want to observe them as much as possible because of the risk of falling,” says Blair.

“The real lessons learned come out not in committee meetings, but in discussions and rounds. That’s why it’s so important to bring your philosophy to the bedside.”

Avoiding a trap
A discussion about patient safety wouldn’t be complete without mention of electronic medical records, automated physician order entry and e-prescribing. Blair is talking about them too. “They can be a great adjunct” to a safety program, she says. In fact, Tallahassee Memorial is gearing up for computerized order entry.

But at the same time, the hospital is taking steps to avoid falling into a trap that has affected other facilities while implementing electronic record-keeping. (See “Rocky Road,” the Observation Deck entry in January/February 2006 Journal of Healthcare Contracting.)

“Hospitals don’t take seriously the fact that the transition period can be a time of danger,” says Blair. For example, nurses may convert to the electronic system before doctors. Consequently, nurses might focus on documents in the computer but fail to read hand-written progress notes. Conversely, physicians can become frustrated with having to search for information in multiple locations.

“We want to build a safeguard program that will protect us while we are living in these two different environments,” says Blair. For a period of time, initial assessments will be printed out and placed in each patient’s hard-copy chart. “Hospitals forget that we need a system that follows the way people work, even in a transition period.”

Group effort
Blair and others at Tallahassee Memorial understand that building a safe environment for patients doesn’t happen in a vacuum. Individuals learn from each other (hence, the significance of the interdisciplinary rounds). On a larger scale, hospitals and IDNs can learn from each other too. That’s why Tallahassee Memorial participates in Florida Medical Quality Assurance Inc. (www.fmqai.com), which is the state’s Medicare Quality Improvement Organization and the Florida node for the Institute for Healthcare Improvement’s 100K Lives Campaign, a national campaign whose goal is to prevent 100,000 patient deaths between December 2004 and June 2006.

“We’re a good VHA member,” Blair adds. “We use our colleagues in VHA – through listservs and other means – to learn lessons that we don’t have to discover ourselves.”

There’s no doubt that Blair’s experience with Solucient plays a role in this regard. “I came back to the hospital environment knowing that no hospital can become so locked into what it’s doing that it stops looking for better models. There’s always something to learn by stealing ideas from others.”

Payoff?
Blair is a big believer that a business case can be made for quality, and she’s determined to make it at Tallahassee. She is working to quantify the cost of such things as a patient fall, a nosocomial infection, and more common complications that, if not recognized early, can lead to adverse events.

“We’re beginning to see some fairly tremendous results and improvements in areas that are [aligned] with national patient safety goals,” she says. “There’s a whole lot of excitement for what we call reliability units and practices.” Units are volunteering to be part of the effort, as they see what a difference it can make for their patients, she says.

“Most people want to do what’s best for the patient, but they don’t always know how,” says Blair. “It’s not something administration does, but something that nurses and others do with their patients each day.”

And that brings her full circle. “Safety has to exist at the very grass roots of the organization. A lot of coaching and resources go into it. But there must be a strong translation: What does it mean for this patient on this day?”

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