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Implementation of a safety structure in a rural region
ORIGINAL ARTICLE
Implementation of a safety structure in a rural region by Lise Roy
Lise Roy, CHE, BN, MPA is currently the Vice-President of Planning and Evaluation for Regional Health Authority 4 in New Brunswick. She has over 20 years of experience in management roles and is a Fellow of the EXTRA program.
P
atient safety is a fast-growing field of interest in numerous countries including Canada. Studies previously undertaken in Canada1 and in the United States2 have shown that many patient deaths result from adverse events and that about half of them could have been avoided. In light of these facts, our organization has decided to implement an organizational structure focused on safety and quality.
Problem Even with all of our efforts focused on emphasizing the importance of improvement, staff and medical practitioners in general still do not perceive complaints or reports of adverse events as a means of identifying improvement opportunities. Stakeholders feel blamed and often link event follow-ups to malpractice. Adverse events are not always reported because they are too often seen as complications, and reporting near-misses is not common practice. Being in a rural setting where everybody knows everybody, news of events rapidly spread throughout the community, dampening open discussions among professionals. Consequently, this leaves us with a limited understanding of the importance of problems as they relate to safety. Environment Our project is set in Regional Health Authority 4 (RHA4) in northeast New Brunswick. The Authority serves a predominantly French-speaking rural population of 50,000 residents. It is responsible for the delivery of primary and secondary care with services covering the full continuum of care, including community care, pre-hospitalization care, hospital care, public and mental health, long-term and palliative care, with the exception of home care centres and nursing homes. The Authority manages a budget of nearly $100 million, with approximately 1,500 employees and about 100 medical practitioners spread over three sub-regions. Geographically and professionally, the Authority is somewhat isolated and operates within a traditional hierarchical system. We have manual clinical systems that are fragmented and the organization has just started using evidence-based information in the organizational decision-making process. Finally, a culture of blame and the fear of reprisal run rampant. To better understand… We have done a literature review and realize that a wealth of information has been published on the subject. Recent publications3-7 have identified specific strategic actions that are considered essential to any safety program. Vision, leadership and mentorship, training and development of coaching skills, event reporting, open communications, the establishment of partnerships with patients, root cause analysis, process re-engineering and results follow-up are among the many strategies used to create a safety culture. However, marginal progress is still recorded despite the sustained efforts of some organizations.8 This confirms the importance of dealing with the systemic barriers discussed by Amalberti et al.9 The standardization of practices and the application of operating rules that support safe practices and interdisciplinarity are examples of procedures that must be adopted in order to deal with the barriers described by the authors.
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007
47
Richardson, Watson, and Wrong
Figure 1. Results by aspect in obstetrics.
Barach and Small10 recommend the reporting of events, especially near-misses, as it allows proactive follow-ups and promotes training without blame in an environment of accountability and trust. Regular meetings called “Safety Forums,” recommended by the Institute for Healthcare Improvement,11 take stock of the events and other strategies that should be promoted. Kotter12 and Champagne13 discuss the criteria necessary for a successful long-lasting change. Our action plan and its objectives Inspired by the experience of our leaders, and taking into account our specific context, we have retained four main quadrants in our action plan: administrative and clinical leadership; training and safety culture; structures, processes and environment; and finally, communications with clients and among stakeholders. All include specific and complementary strategies. The main objective is to develop a safety culture based on various consistent and integrated strategies, supported by clinical and administrative commitment and leadership, valuing the use of evidenced-based knowledge in the decision-making process and ensuring compliance with the rules and policies regarding changes to practices deemed risky. Results to date In order to ensure that we had the leaders’ commitment, we formed a working structure with committees. A steering committee comprising members of the Board of Directors, leading medical practitioners and senior management was used as a forum to validate the intervention model, target primary strategies and adopt key policies. The implementation committee, comprising many managers and clinical workers, relied on the expertise of a change management resource and ensured the timely deployment of key strategies. We have also been able to rely on the involvement of a leading medical practitioner interested in patient safety. We have trained approximately 400 people, including members of the steering and implementation committees, medical staff, managers, staff in the pilot unit and others, on the results of the survey and various concepts and tools related to safety. 48
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007
TABLE 1 ________________________________________________ Assessment criteria ________________________________________________ 1. Frequency of event reports 2. Perception on safety 3. Actions taken by manager 4. Learning of best practices 5. Teamwork within departments/units 6. Openness and fluidity of communications 7. Communication of errors 8. Constructive (not punitive) learning methods 9. Staff workload 10. Senior management support 11. Teamwork between departments/units 12. Communication at shift changes ________________________________________________
A reporting process of near-misses was set up for the pilot unit. Since then, we have received nearly 150 reports of nearmiss events, and follow-ups have allowed us to bring many organizational improvements to work distribution, to the medicine cart and the emergency cart, among others. We have organized “safety forums” to deal with the reported problems and maintain staff mobilization through followups. Root cause analyses have been made regarding coordination problems, practice methods and administration of medication. The workload of the pilot unit has been revised and sub-groups are working on improvements to an epidural protocol and means of communication between professionals. Complementary to the strategies listed, four teams have participated in the Canada-wide initiative “Safer Healthcare Now!” We have completed the implementation of a new process for the preparation, distribution and administration of medication and analyzed failure modes in order to ensure that we have a safe process. We have revised our follow-up and adverse and sentinel event analysis processes. To determine the status of our project, we implemented a survey on safety culture by using the questionnaire developed by the Agency for Healthcare Research and Quality. The same survey was repeated 15 months later in order to confirm the impacts of the deployed strategies. A return rate of 54.7% in 2005 (70.97% in 2006) allowed us to select the obstetrics as
IMPLEMENTATION OF A SAFETY STRUCTURE IN A RURAL REGION
our pilot unit because of its results regarding patient safety. For this unit, we obtained a return rate of 58.33% in 2005 compared to 81.5% in 2006. Of the 12 criterion that were assessed (Table 1), many areas showed significant improvements (Figure 1). Survey results show that the culture of blame is fading with the increase in the open discussion of errors, and the methods used to foster a constructive learning process. Impact Although our preliminary findings already show some of the expected results described in the literature, the pilot unit staff confirmed that they are more cognizant of patient safety and they feel closer to senior management and are blamed less when events occur. These findings motivate decisionmakers to revise the way priorities, leadership, management models, means of accountability and follow-ups are linked to the desired culture change. Rules and drivers must be coherent to give credibility to words and actions.
The sustained and dynamic commitment of the staff in the quality and risk department allowed us to go through the change management process in the spirit of mutual support and collegiality. The support of our “champion” medical practitioner has helped in the contacts and strategies involving the medical staff. Last but not least, thanks go to the EXTRA program, our mentors and the teachers who have paved the way to acquire the best practices based on research data. Without the contribution of one and all, the project would not have taken off. References 1.
2.
3.
Next steps To help guarantee long-lasting changes, our organization will have to consolidate the commitment and the leadership of senior management and medical practitioners to maintain the vision and the goals that have been set, and work with organizational barriers in full confidence. The senior management team will have to revise its management philosophy and the human resources management processes so that performance incentives are attuned to the desired safety culture. Consistency within management should be encouraged by instituting “management walkarounds,”14 and through regular discussions of the issues and impacts of the changes in progress. The organization will have to increase its investment in training and resources and establish systematic follow-up mechanisms in order to maintain the momentum of desired changes. It is essential to maintain a network of committed individuals, having access to a sustained and renewed expertise, to correct any inconsistency. Communication with patients and the implication of families in patient care are other strategies that need to be explored. Finally, the organization intends to rely more on the use of evidence-based information in the decision-making process for the deployment of the action plan. The change in organizational culture is a long-range project and because of the instability in the health environment as well as multiple external influences, it will require a rigorous follow-up. Constant adjustments on the basis of objectives, challenges and performance will be required.
4.
5.
6.
7.
8.
9.
10.
11.
12. 13.
Acknowledgments The author wishes to thank the many collaborators who helped give birth to this project and make it grow within the organization. The CEO, members of the steering and implementation committees along with the staff in the pilot unit have allowed us to experiment, learn and adjust our course.
14.
Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 2004;170(11):1678-86. Kohn LT, Corrigan JM, Donaldson MS. To err is human – Building a safer health system (p. 287). Washington, DC:National Academy Press;2001. McFadden KL, Stock GN, Gowen CR, Cook P. Exploring strategies for reducing hospital errors. Journal of Healthcare Management 2006;51(2):123-35. Ovretveit J. The leader’s role in quality and safety improvement. Journal of Health Organization and Management 2005;19(6):413-30. Odwazny R, Hasler S, Abrams R, McNutt R. Organizational and cultural changes for providing safe patient care. Quality Management in Health Care 2005;14(3):132-43. Wong J, Beglaryan H. Strategies for hospitals to improve patient safety: A review of the research. The Change Foundation 2004;1-50. Claseen DC, Kilbridge PM. The roles and responsibility of physicians to improve patient safety within health care delivery systems. Academic Medicine 2002;77(10):963-72. Longo DR, Hewett JE, Hewett GE, Hewett B, Schubert S. The long road to patient safety. American Medical Association 2005;294(22):2858-65. Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine 2005;142(9):756-64. Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from non-medical near-miss reporting systems. British Medical Journal 2002;320:759-63. Institute of Healthcare Improvement [home page on the Internet]. Leadership guide to patient safety: Resources and tools for establishing and maintaining patient safety;2005. Available from: http://www.ihi.org/IHI/Results/Whitepapers/ LeadershipGuidetoPatientSafetyWhitePaper.htm Kotter JP. Leading change (pp. 17-31). Boston, MA: Harvard Business School Press;1996. Champagne F. La capacité de gérer le changement dans les organisations de santé (p. 37). Université de Montréal (Étude, no 39). Budrevics G, O’Neill C. Changing a culture with patient safety walkarounds. Healthcare Quarterly 2005;8(Special Issue): 20-25.
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007
49
Implementation of a safety structure in a rural region by Lise Roy
Lise Roy, CHE, BN, MPA is currently the Vice-President of Planning and Evaluation for Regional Health Authority 4 in New Brunswick. She has over 20 years of experience in management roles and is a Fellow of the EXTRA program.
P
atient safety is a fast-growing field of interest in numerous countries including Canada. Studies previously undertaken in Canada1 and in the United States2 have shown that many patient deaths result from adverse events and that about half of them could have been avoided. In light of these facts, our organization has decided to implement an organizational structure focused on safety and quality.
Problem Even with all of our efforts focused on emphasizing the importance of improvement, staff and medical practitioners in general still do not perceive complaints or reports of adverse events as a means of identifying improvement opportunities. Stakeholders feel blamed and often link event follow-ups to malpractice. Adverse events are not always reported because they are too often seen as complications, and reporting near-misses is not common practice. Being in a rural setting where everybody knows everybody, news of events rapidly spread throughout the community, dampening open discussions among professionals. Consequently, this leaves us with a limited understanding of the importance of problems as they relate to safety. Environment Our project is set in Regional Health Authority 4 (RHA4) in northeast New Brunswick. The Authority serves a predominantly French-speaking rural population of 50,000 residents. It is responsible for the delivery of primary and secondary care with services covering the full continuum of care, including community care, pre-hospitalization care, hospital care, public and mental health, long-term and palliative care, with the exception of home care centres and nursing homes. The Authority manages a budget of nearly $100 million, with approximately 1,500 employees and about 100 medical practitioners spread over three sub-regions. Geographically and professionally, the Authority is somewhat isolated and operates within a traditional hierarchical system. We have manual clinical systems that are fragmented and the organization has just started using evidence-based information in the organizational decision-making process. Finally, a culture of blame and the fear of reprisal run rampant. To better understand… We have done a literature review and realize that a wealth of information has been published on the subject. Recent publications3-7 have identified specific strategic actions that are considered essential to any safety program. Vision, leadership and mentorship, training and development of coaching skills, event reporting, open communications, the establishment of partnerships with patients, root cause analysis, process re-engineering and results follow-up are among the many strategies used to create a safety culture. However, marginal progress is still recorded despite the sustained efforts of some organizations.8 This confirms the importance of dealing with the systemic barriers discussed by Amalberti et al.9 The standardization of practices and the application of operating rules that support safe practices and interdisciplinarity are examples of procedures that must be adopted in order to deal with the barriers described by the authors.
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007
47
Richardson, Watson, and Wrong
Figure 1. Results by aspect in obstetrics.
Barach and Small10 recommend the reporting of events, especially near-misses, as it allows proactive follow-ups and promotes training without blame in an environment of accountability and trust. Regular meetings called “Safety Forums,” recommended by the Institute for Healthcare Improvement,11 take stock of the events and other strategies that should be promoted. Kotter12 and Champagne13 discuss the criteria necessary for a successful long-lasting change. Our action plan and its objectives Inspired by the experience of our leaders, and taking into account our specific context, we have retained four main quadrants in our action plan: administrative and clinical leadership; training and safety culture; structures, processes and environment; and finally, communications with clients and among stakeholders. All include specific and complementary strategies. The main objective is to develop a safety culture based on various consistent and integrated strategies, supported by clinical and administrative commitment and leadership, valuing the use of evidenced-based knowledge in the decision-making process and ensuring compliance with the rules and policies regarding changes to practices deemed risky. Results to date In order to ensure that we had the leaders’ commitment, we formed a working structure with committees. A steering committee comprising members of the Board of Directors, leading medical practitioners and senior management was used as a forum to validate the intervention model, target primary strategies and adopt key policies. The implementation committee, comprising many managers and clinical workers, relied on the expertise of a change management resource and ensured the timely deployment of key strategies. We have also been able to rely on the involvement of a leading medical practitioner interested in patient safety. We have trained approximately 400 people, including members of the steering and implementation committees, medical staff, managers, staff in the pilot unit and others, on the results of the survey and various concepts and tools related to safety. 48
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007
TABLE 1 ________________________________________________ Assessment criteria ________________________________________________ 1. Frequency of event reports 2. Perception on safety 3. Actions taken by manager 4. Learning of best practices 5. Teamwork within departments/units 6. Openness and fluidity of communications 7. Communication of errors 8. Constructive (not punitive) learning methods 9. Staff workload 10. Senior management support 11. Teamwork between departments/units 12. Communication at shift changes ________________________________________________
A reporting process of near-misses was set up for the pilot unit. Since then, we have received nearly 150 reports of nearmiss events, and follow-ups have allowed us to bring many organizational improvements to work distribution, to the medicine cart and the emergency cart, among others. We have organized “safety forums” to deal with the reported problems and maintain staff mobilization through followups. Root cause analyses have been made regarding coordination problems, practice methods and administration of medication. The workload of the pilot unit has been revised and sub-groups are working on improvements to an epidural protocol and means of communication between professionals. Complementary to the strategies listed, four teams have participated in the Canada-wide initiative “Safer Healthcare Now!” We have completed the implementation of a new process for the preparation, distribution and administration of medication and analyzed failure modes in order to ensure that we have a safe process. We have revised our follow-up and adverse and sentinel event analysis processes. To determine the status of our project, we implemented a survey on safety culture by using the questionnaire developed by the Agency for Healthcare Research and Quality. The same survey was repeated 15 months later in order to confirm the impacts of the deployed strategies. A return rate of 54.7% in 2005 (70.97% in 2006) allowed us to select the obstetrics as
IMPLEMENTATION OF A SAFETY STRUCTURE IN A RURAL REGION
our pilot unit because of its results regarding patient safety. For this unit, we obtained a return rate of 58.33% in 2005 compared to 81.5% in 2006. Of the 12 criterion that were assessed (Table 1), many areas showed significant improvements (Figure 1). Survey results show that the culture of blame is fading with the increase in the open discussion of errors, and the methods used to foster a constructive learning process. Impact Although our preliminary findings already show some of the expected results described in the literature, the pilot unit staff confirmed that they are more cognizant of patient safety and they feel closer to senior management and are blamed less when events occur. These findings motivate decisionmakers to revise the way priorities, leadership, management models, means of accountability and follow-ups are linked to the desired culture change. Rules and drivers must be coherent to give credibility to words and actions.
The sustained and dynamic commitment of the staff in the quality and risk department allowed us to go through the change management process in the spirit of mutual support and collegiality. The support of our “champion” medical practitioner has helped in the contacts and strategies involving the medical staff. Last but not least, thanks go to the EXTRA program, our mentors and the teachers who have paved the way to acquire the best practices based on research data. Without the contribution of one and all, the project would not have taken off. References 1.
2.
3.
Next steps To help guarantee long-lasting changes, our organization will have to consolidate the commitment and the leadership of senior management and medical practitioners to maintain the vision and the goals that have been set, and work with organizational barriers in full confidence. The senior management team will have to revise its management philosophy and the human resources management processes so that performance incentives are attuned to the desired safety culture. Consistency within management should be encouraged by instituting “management walkarounds,”14 and through regular discussions of the issues and impacts of the changes in progress. The organization will have to increase its investment in training and resources and establish systematic follow-up mechanisms in order to maintain the momentum of desired changes. It is essential to maintain a network of committed individuals, having access to a sustained and renewed expertise, to correct any inconsistency. Communication with patients and the implication of families in patient care are other strategies that need to be explored. Finally, the organization intends to rely more on the use of evidence-based information in the decision-making process for the deployment of the action plan. The change in organizational culture is a long-range project and because of the instability in the health environment as well as multiple external influences, it will require a rigorous follow-up. Constant adjustments on the basis of objectives, challenges and performance will be required.
4.
5.
6.
7.
8.
9.
10.
11.
12. 13.
Acknowledgments The author wishes to thank the many collaborators who helped give birth to this project and make it grow within the organization. The CEO, members of the steering and implementation committees along with the staff in the pilot unit have allowed us to experiment, learn and adjust our course.
14.
Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 2004;170(11):1678-86. Kohn LT, Corrigan JM, Donaldson MS. To err is human – Building a safer health system (p. 287). Washington, DC:National Academy Press;2001. McFadden KL, Stock GN, Gowen CR, Cook P. Exploring strategies for reducing hospital errors. Journal of Healthcare Management 2006;51(2):123-35. Ovretveit J. The leader’s role in quality and safety improvement. Journal of Health Organization and Management 2005;19(6):413-30. Odwazny R, Hasler S, Abrams R, McNutt R. Organizational and cultural changes for providing safe patient care. Quality Management in Health Care 2005;14(3):132-43. Wong J, Beglaryan H. Strategies for hospitals to improve patient safety: A review of the research. The Change Foundation 2004;1-50. Claseen DC, Kilbridge PM. The roles and responsibility of physicians to improve patient safety within health care delivery systems. Academic Medicine 2002;77(10):963-72. Longo DR, Hewett JE, Hewett GE, Hewett B, Schubert S. The long road to patient safety. American Medical Association 2005;294(22):2858-65. Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine 2005;142(9):756-64. Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from non-medical near-miss reporting systems. British Medical Journal 2002;320:759-63. Institute of Healthcare Improvement [home page on the Internet]. Leadership guide to patient safety: Resources and tools for establishing and maintaining patient safety;2005. Available from: http://www.ihi.org/IHI/Results/Whitepapers/ LeadershipGuidetoPatientSafetyWhitePaper.htm Kotter JP. Leading change (pp. 17-31). Boston, MA: Harvard Business School Press;1996. Champagne F. La capacité de gérer le changement dans les organisations de santé (p. 37). Université de Montréal (Étude, no 39). Budrevics G, O’Neill C. Changing a culture with patient safety walkarounds. Healthcare Quarterly 2005;8(Special Issue): 20-25.
Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007
49