Hospitals can be very hierarchical places, but patient safety and quality improvement is a top down, bottom up, everybody in this together task. The Agency for Healthcare Research and Quality (AHRQ)’s latest Innovations Exchange report spotlights how Chicago’s Northwestern Memorial Hospital. notably improved its patient safety culture. One key step was monthly meetings, including moderated panel discussions, where employees from all levels could hear or talk about adverse events that occurred, learn from them, and think through how to prevent mistakes from happening again.
With the consequences of mistakes so serious and the threat of punishment so constant, many health workers are afraid to come forward and talk about problems -- even if the goal is coming up with solutions. (Anyone who watches Scrubs may remember JD’s epic flop sweat at the prospect of going to a morbidity and mortality conference.) Northwestern leaves out identifying details when discussing cases to raise staff comfort level (and the report says Illinois law exempts health workers from subpoena and discovery when discussion of adverse events is part of a quality improvement process.)
Ultimately, the goal of the meetings is to change the patient safety culture of the hospital. Staff at all levels need to be empowered to review events and problem solve. At the start of every meeting, one or two people get a “Good Catch” award -- meaning they were able to catch an error or error-to-be before a patient was harmed. Each meeting also includes a review of the prior month's case to ensure follow-up.
Here’s an example of a problem and solution employees came up with:
The wrong patient was taken to a treatment room in radiology for diagnostic testing because the patient responded to another person's name when staff called the name in the waiting room. No diagnostic intervention was performed but the event highlighted a vulnerability in the system. After discussing this case at a monthly meeting, the improvement team implemented a verification process whereby a member of the radiology staff calls the patient's name in the waiting room and then asks the individual to confirm and initial his/her name and date of birth on the patient requisition form before any imaging.
Between 2004 and 2008, the AHRQ patient safety survey found positive improvement in scores at Northwestern Memorial in “hospital management support for patient safety,” “feedback and communication about error” and “nonpunitive response to error” among staff. An increasing number of nurses agreed “we are actively doing things to improve patient safety” (74 to 90 percent) and “we discuss ways to prevent errors from happening” (from 60 to 89 percent). Between 2003 and 2009, voluntary reporting of adverse events on the hospital’s electronic system increased by 66 percent.
Instituting these monthly meetings wasn’t costly, but they do require time commitment for preparation, analysis and follow up. One reward -- a free lunch as meetings were usually held during staff breaks. Other rewards? A more collaborative, better-communicating hospital committed to safer care.