Driving the culture of safety


Driving the culture of safety

Linking with a Patient Safety Organization is a way to drive up safety not only in your own organization but in other organizations too, by reporting errors without fear of legal repercussions. HRMR investigates.

One sure sign of a healthcare organization’s commitment to quality, safety and driving down risk is Patient Safety Organization (PSO) participation. Although some of these organizations have been around for decades, PSOs as we now know them were created as a result of the Patient Safety and Quality Improvement Act of 2005, and exist to improve the quality and safety of US healthcare delivery. The act encourages clinicians and healthcare organizations to voluntarily report and share quality and patient safety information without fear of legal discovery. This can be done by reporting errors confidentially to the PSO, which will then disseminate the lessons learned without any danger of legal repercussions for the reporting entity.

The benefits of sharing information in this way are self-evident, yet the majority of US healthcare providers are still not affiliated with a PSO, possibly because many are still anxious about disclosing errors and near-misses, despite the promise of confidentiality and legal immunity. At present, reporting to a PSO is not mandatory, but the Affordable Care Act stipulates that by 2015 hospitals with 50 or more beds can participate in a Health Insurance Marketplace (ie, a health insurance exchange) only if the hospital has established a patient safety evaluation system (PSES) and participates in a PSO.

“As healthcare providers, we have an ethical as well as a contractual obligation to provide care that is safe, effective, high quality, and efficient,” says Gail Horvath, patient safety analyst at ECRI Institute PSO. ECRI Institute PSO is one of the most well-established and largest PSOs in existence. Officially listed as a PSO in 2008, it was one of the first 10 PSOs to be so designated by the US Department of Health and Human Services under the Patient Safety and Quality Improvement Act of 2005.

“By actively participating in a PSO, healthcare providers have the benefit of learning not only from their own experiences but from the experiences of hundreds of other providers in a collaboration that transcends business competition to provide optimal care to the populations they serve and improve healthcare on a global level,” Horvath says.

PSOs offer valuable support in a variety of ways, from one-to-one advice to a detailed, analytical review of reported events. Kamarra Fauese, associate decision support analyst from Alaska Native Medical Center, a member of ECRI Institute PSO, says PSO participation “decreases the time our staff spends researching process improvements and allows them to get back to taking care of patients”.

“A PSO should provide help or tools that can be spread throughout the organization,” says ECRI Institute’s Kathy Connolly. For example, ECRI Institute PSO offers not only secure reporting and analysis, but also members-only publications, webinars, toolkits, assessments, individual support, and more. “Members willingly share in a secure forum where information is protected and others can learn from near-misses and events,” explains Connolly.

While many PSOs, like ECRI Institute PSO, have a broad reach, others have narrower remits. Some serve specific healthcare organizations; others, such as the Institute for Safe Medication Practices (ISMP), which was also one of the first 10 PSOs to be so designated, have a focus on one specific area. In ISMP’s case this is medication errors. Susan Paparella, vice president of ISMP, says this focus makes ISMP unique.

“We have an in-depth understanding of medication use,” she says. “Since the 1970s people have been reporting errors to ISMP and we have developed a comprehensive understanding of the causes of errors from these reports. That’s what drives our work and it is the basis for the newsletter articles we write every two weeks, which are distributed to hospitals, health systems, and practitioners, not only across the country, but also internationally.”

ISMP’s primary role is to obtain clear, detailed information about errors, investigate the information, and to share the lessons learned.

“It’s not as much about a quantitative, large aggregate data base; it’s about the stories and details that lead us to a deeper understanding of the issues that have repeatedly contributed to medication errors,” says Paparella. “If we have a concern about a particular practice, a particular device or a particular drug, then we are able to investigate these reported errors, and provide a comprehensive perspective based on our experience and understanding, ultimately helping organizations resolve their safety issues.

“We look at our newsletters as a way to share the lessons learned, hopefully leading others to a proactive approach to medication safety.” In addition to the five newsletters that ISMP publishes, they offer a variety of tools and services to support organizations looking to improve medication safety.

One such service is ISMP’s Proactive Risk Assessment, one of many consulting services, in which ISMP makes onsite visits to hospitals and health systems to help address specific issues. Most commonly the director of quality and risk, director of pharmacy or director of nursing makes the call to ISMP, often because they have had an event or a near-miss event and they want an outside expert perspective.

“A lot of times they may not tell us initially when they contact ISMP that they’ve had an issue but we often learn when we are on site that they’ve had a couple of close calls. Other times it’s clear from the beginning that they’ve had a serious event and they appreciate having an organization with specialised expertise to give them an objective opinion about their activities,” says Paparella. In such circumstances, ISMP’s representatives spend time in the organization, examining the medication use systems, looking for problems, investigating variations, and offering sound advice.

“Often they’re thinking, ‘What are we missing? We thought we’d dealt with this issue but we’re still having problems; is there something else we can do?’” says Paparella. “We’ll review what they’re seeing in their information and what kind of data they’re collecting. We’ll talk about the key indicators in an organization that will help them know if they’ve got problems with medication use. We also typically discuss any recent medication-related RCAs (root cause analyses), and provide them with some specific feedback about their analysis or action plan.”

Crucial to ISMP’s work, as with ECRI Institute PSO and other PSOs, is the fact that errors can be reported without fear of retribution. Only by making it legally safe to report errors can lessons be learned and passed on.

“Our practice has always been to maintain strict confidentiality around the information that comes to ISMP. We treat the reports as protected information that we are privileged to hear, understanding that the ultimate purpose is to help organizations resolve these safety issues and protect their patients,” says Paparella.

It’s a view shared by Rory Jaffe, executive director of a major regional PSO, California Hospital Patient Safety Organization (CHPSO). Formed in 2008, CHPSO has 280 members, and is emphasizing its ‘safe tables’, where particular areas of concern are discussed in a confidential environment.

“A regional PSO can get people together,” says Jaffe. “Sharing with each other helps people understand that they’re not in it alone; everybody has the exact same issues. Healthcare delivery systems have been predicated on the misconception that if you train somebody enough and make sure they’re vigilant enough they won’t make mistakes. Now we recognise mistakes are an inherent part of human nature: it’s how we’re wired.

“For example, we make assumptions, jump to conclusions and selectively pay attention. Everybody has the same issues and once you peel down to the layer or two below the particulars of the specific event you often see things that are shared with other people and other organizations.”

Jaffe’s hope is that as healthcare providers become more comfortable with the concept of sharing information about errors, it will start to happen spontaneously, without the need for safe tables.

“We need to get people really used to the structure and comfortable with the legal protections because that’s what’s allowing this—that’s why those legal protections are in place, to improve information transfer.”

CHPSO is about more than safe tables, however. It also helps organizations work through causal analyses after an event or near-miss, identifying areas for improvement, and reviews incident reports to spot issues that need attention.

“We’re concentrating on areas where we’ve had reports that show emerging issues or issues people haven’t known about or addressed,” says Jaffe. In the case of one recent report of a death, CHPSO has opened discussions with the manufacturer of the equipment involved in order to pursue a redesign of the equipment that will improve its safety. It also relayed news of the safety issue to other hospitals in the hope that no further deaths would occur—a move that was enthusiastically backed by the hospital where the incident occurred.

“They were ecstatic that we spread the information about what went wrong at their place,” he says. “That’s contrary to what the general public would think about hospitals; I suppose the traditional public thinking is that if there’s an error there is some malpractice, some bad person that has to be singled out.

“The malpractice system is partly to blame for that because it’s the only way for the victim to get compensated in most countries. The dialogue about aviation is much more sophisticated these days—people now know that when there’s an accident it may or may not have been the pilot’s fault; it may have been a system issue.”

Similar problems have been observed with IT in healthcare, and CHPSO recently helped identify a potentially very dangerous problem with the way that information is displayed on screens. The issue was first flagged up by two members who experienced “very serious and frightening” near-misses. CHPSO was able not only to survey its members to establish that these were not one-off occurrences; it was also able to survey other PSOs, because it leads a voluntary organization called the Nationwide Alliance of Patient Safety Organizations (NAPSO), which enables PSOs to communicate safety issues to each other. CHPSO found that members of other PSOs were reporting the same IT problem.

“We’re not going to solve every problem this way because our resources are relatively small, but what we can do is bring this issue up, make it abundantly clear to manufacturers that in this case it really is a design issue and make it clear to them that this is not just one hospital grousing about an issue,” he says.

Being a regional PSO has its advantages, notably the relative ease with which members can be brought together for face-to-face meetings. But this is just one factor that is worth considering when choosing what PSO to join. Jaffe recommends finding out how many members a PSO has; if you are trying to choose between several, opt for the biggest. Another point in a PSO’s favour is its collaboration with other PSOs.

“In short, you want to ask, ‘How big is this knowledge base I’m entering into?’” he says. Joining a PSO can mean a paradigm shift, and it can take time to get used to being open about errors, but the key point is that a PSO provides a legally secure environment in which to be open—and a golden opportunity to allow other hospitals to learn from the safety issues faced by your own organization, and vice versa. 

Beyond PSOs
Looking to boost patient safety and raise standards? Then don’t stop at joining a PSO. Another organization that can help you make great steps forward is the Institute for Healthcare Improvement, IHI.

IHI is a not-for-profit organization dedicated to improving health and healthcare around the world. One way it does that is to focus on improving the delivery of healthcare by making it safer. It focuses on building the skills of individuals, from leaders to those who deliver care, so that they can identify defects in their processes and make improvements.

IHI uses a variety of methods to achieve these goals, including its annual national forum; national campaigns; collaborative groups of up to 50 hospitals working on a topic such as ventilator-associated pneumonia; working with large hospital groups and organizations; and offering in-person and virtual programs to assist in making improvements at a system or hospital level. Taking out one membership covers the cost of training, tools, and expert resources for your entire staff for the year.

“Improvement requires change and not all change is improvement,” says IHI’s executive director Frank Federico. “We also remind people that it takes more than writing a policy and training and education. Each of those is necessary but not sufficient. We coach teams by helping them understand how to test new processes, determine if they are effective, and then implement those processes as the new way of working.”

The advantage of forging links with IHI is that it has a global perspective on safety in healthcare, bringing together insights from all over the globe.

“We have been working on safety for quite some time and no matter where we go round the world I think that the challenges are similar,” says Federico. “All are facing issues with hospital-acquired infections, pressure ulcers and medication-related issues. Some areas may be ahead of others. There are great examples of successful hand hygiene programs in the UK and Denmark. The Danish Society for Patient Safety and IHI are leading an effort in which some hospitals have reported more than 300 days without a pressure ulcer. Scotland has reported a mortality reduction of more than 14 percent.

“We are constantly learning how people work and what contributes to defects in our system, and we are learning from high reliability organizations how to reduce defects that may cause harm to patients and providers.”

Patient Safety Organization, PSO, ECRI Institute, IHI, ISMP