Why It Matters
Three projects presented at the IHI/NPSF Patient Safety Congress remind us how real change is possible when teams come together with a shared purpose.
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Projects in Safety: How Teamwork and Research Push Patient Safety Forward

By Joanna Carmona | Wednesday, August 23, 2017
ASPPS appreciation

Dariele Cooper, RN, CGRN, Health Center Administrator at Private Diagnostic Clinic, the physician practice of Duke Health, presented patient safety work at the IHI/NPSF Patient Safety Congress.

Teamwork and communication, improvement and measurement, and learning systems are key components for the delivery of safe health care. It’s easy to read about these concepts, but on the ground doing quality improvement and patient safety work, it’s sometimes difficult to remember how essential these elements can be to even the most focused projects.

Recent work presented at the IHI/NPSF Patient Safety Congress demonstrates how each of these components helps in the success of any safety initiative. Here are just three projects that remind us how real change is possible when teams come together with a shared purpose.

Encouraging Close Call Reporting

Kaiser Permanente Colorado Medication Safety Team started a journey in 2012 to increase close call reporting in ambulatory pharmacy settings. The objective was to collect as many reports as possible in order use them to identify medication-safety related patterns and trends — and learn from them.

To make reporting easier, the team developed and tested paper and voicemail reporting systems, then learned that both systems were cumbersome. Instead, they were able to develop an online close call reporting system based on staff preferences. This project aimed to make reporting easier and to improve departmental support, which resulted in a 3,800% increase in close call reporting (see figure below). 

 close call reporting graph ASPPS

“Many factors came into play to increase close call reporting. Our experience suggests that decreasing the time needed to report events and improving the user experience with an online reporting system, having leadership support, creating observable department-wide goals, providing robust training, and sharing with staff the changes that were made as a result of event reporting positively affected close call reporting rates,” said Sheryl J. Herner, PharmD, MHSA, BCPS, CPPS, FCCP, Clinical Pharmacy Supervisor and Specialist in Medication Safety.

Improving Time Outs

The Patient Safety Department of Sinai Health System in Chicago completed an audit of caregiver engagement in, and the performance quality of, intraoperative time outs at Mount Sinai Hospital. The baseline audit data collected over a two-month period suggested that time out performances were not standardized or team-based. 

To improve the quality of the time out performances, the Patient Safety Department formed a Time Out Committee of Operating Room nurses and scrub technicians to assist in the revision of the content and signage, held a Time Out Celebration to review performance expectations, and provided real-time coaching during a post-implementation audit to ensure compliance. This approach to improving teamwork and communication during the intraoperative time out was so successful that executive leadership support has been given to expand the project across the health system.

“Patient safety initiatives cannot be effectively implemented or sustained without frontline staff engagement. This project would not have been successful without the unwavering commitment of the Time Out Committee and our project champions,” said Alison E. Miller, MHA, CPPS, Patient Safety Manager.

Sustaining Performance Improvement in Ambulatory Care

An initiative by the Private Diagnostic Clinic, the physician practice of Duke Health, was born out of a need to create a standard performance improvement program that would be sustainable across multiple primary and specialty ambulatory clinics. A team of Six Sigma-trained professionals provided oversight and mentoring to help the team come up with tools and education in the areas of medication safety, patient education, and patient identification. Throughout the process, the team began identifying organizational priorities that were consistent with national standards, started implementing a train-the-trainer program, and worked on a standardized curriculum and auditing tool to monitor and sustain improvements.

"By implementing these impactful and sustainable changes, we'll be working towards a consistent, team-wide process to build a culture of safety and quality across our ambulatory care specialties," said Dariele Cooper, RN, CGRN, Health Center Administrator, pictured above.

These projects show how important it is to include the essential elements of teamwork, communication, improvement and measurement, and learning in safety initiatives. And they have something else in common: Each was led by a member of the American Society of Professionals in Patient Safety (ASPPS), an IHI/NPSF membership program. They show the diversity of the membership and enforce the belief that safety in health care is everyone’s job.

Throughout August, we are recognizing ASPPS Member Appreciation Month. Renew or join this month for special benefits. Learn more.

Joanna Carmona is a Communications Coordinator at IHI.

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