In a hospital system’s ongoing efforts to improve patient safety, a collaborative approach with other health systems sharing the same goal offers significant advantages compared to trying to go it alone. After all, sharing the experiences with other hospitals provides a benchmark that a hospital can use to measure its progress, and can lead to best practices that can be shared among other hospitals.
Case in point: Kent Hospital, a 359-bed acute care facility in Warwick, R.I., and a member of the Care New England Health System. Between 2006 and 2009, Kent, along with other hospitals in the state, experienced a number of well-publicized medical errors, says Sandra Coletta, Kent Hospital’s president and CEO. Those incidents roughly coincided with the creation of a state-wide Patient Safety Organization (PSO) that included the participation of all private acute-care hospitals in the state.
Congress established PSOs under the Patient Safety and Quality Improvement Act of 2005. The Department of Health and Human Services published the Patient Safety Rule in 2009, providing the basis for establishing PSOs under the federal Agency for Healthcare Research and Quality (AHRQ).
The Rhode Island state legislature mandated the creation of a state-wide PSO in 2008. The PSO in 2011 became an initiative led by the Hospital Association of Rhode Island (HARI). The Rhode Island PSO is managed by GE Healthcare (certified as a PSO at the federal level by AHRQ), which uses its Medical Event Reporting System (MERS) to collect and share data among the 13 hospitals in the Rhode Island PSO. MERS is Web-based software designed to enable hospitals to collect, manage, analyze and report information on adverse of near-miss events.
Creating a Patient Safety Culture
According to Coletta, who arrived at Kent in 2008, the goal of the Rhode Island PSO was to “enhance or ensure that we had a patient safety culture or environment. It was the right thing to do.” The road to better patient safety begins with the ability to identify potential safety issues: “You can’t fix anything if you don’t know there is a problem,” she says.
She notes that in order for a hospital to fix its patient safety problems, it needs a way to identify where system failures exist. Kent Hospital, as a member of the Rhode Island PSO, makes the reporting system available to all of its employees to report incidents and potential safety problems on a voluntary basis. Managers review the reports—which include both near misses and actual events resulting in harm to patients—and take action when needed. The system has provided the hospital with the means to improve its safety performance based on the available information, and organize, and identify responses through systemic improvements, she says.
It’s important to note that the reporting is done on a voluntary basis, and in a non-threatening way. Underlying the reporting system is a “human resource culture that encourages employees to come forward when things didn’t go as anticipated,” Coletta says. In October 2011, Kent adopted a “just culture” workplace model that is designed to foster an environment of open communication without fear of retribution, as well as being part of the process of improving the hospital’s safety and efficiency, she says. Since implementing the MERS system, the hospital has gotten across the message to its staff members that their reporting is needed and reviewed, Coletta says.
The system allows patterns and trends to emerge from aggregated information, opening the way for making systemic improvements in the hospital. That’s a far cry from the way incidents were formerly reported using a pen-and-paper system, which is essentially a way of reporting events after they happen, and handling them as individual events, she says.
Getting Granular About Reporting
Anna Pilkington is database coordinator, risk management, at Kent Hospital; her task is to review the reported safety information and follow up on it so that employees recognize that their feedback is being acted on. Every employee can access the MERS reporting system, which has an icon on every computer in the hospital. Users can log on using an active directory password or, if they choose, anonymously, she says.
Once the employee is in the system, he or she enters basic information about the patient and saves the information. (The patient’s demographic feed is linked to the hospital’s Cerner Millennium electronic medical record, supplied by the Kansas City-based Cerner Corporation, allowing MERS to pull patient information automatically.) A discovery page provides space for the employee to write a brief description of the incident and categorize it in one of 13 different clinical or non-clinical categories. Users are prompted with additional questions, such as whether the event was witnessed or not, what the patient was doing at the time, who was notified, and what treatment was needed.
Once the information is saved, it is sent instantaneously to the appropriate manager’s list of events, which are differentiated by whether or not harm occurred, and if it did, its severity. As CEO, Coletta also receives incident information, depending on the severity of risk and harm involved. Types of incidents include medication errors, infection control, delayed care, slip-and-fall incidents, and whether employees were put in unsafe situations.
Coletta explains that the hospital analyzes the frequency of events. She notes that patient identification issues have occurred frequently in the past, which has prompted the hospital to focus on staff education about the issue and the introduce identifier requirements. Other types of events that have occurred frequently include medication errors, both actual events and near misses, and patient behavioral issues, she says.
One example of a reported medication error that recently reached her desk was a near-miss event, in which the instructions were written incorrectly as two times a certain dose, when the two should have been part of the dosage. The nurse who reported the event recognized the error and documented it as a near miss. Even though the error was avoided, the reported event allowed the hospital to analyze and pinpoint the error and take remedial action, Coletta says.
According to Coletta, there is no right or wrong event: “We don’t discourage anything. If you feel that you need to tell somebody what happened and you think it’s a safety issue, put it in,” she says. “The minute you start to put restrictions on what you can put in, you lose the ability of knowing you are getting everything you need.”
Integrating and Sharing the Information
Information is shared on several levels, explains Cedric Priebe, M.D., CIO and senior vice president of the Care New England Health System. Data remains in MERS, but is also shared with the other hospitals in the PSO, he says. He notes that as a legal structure the PSO offers a safe harbor for sharing sensitive information with the other provider organizations about adverse events that occur in the hospital, and the information can be analyzed the information to improve the patient safety in their organizations. The information is submitted in a standard format, allowing it to be shared easily within the PSO.
Pilkington explains that as manager of the PSO, GE healthcare supplies Kent Hospital with a monthly report, analyzing the data and feeding it back to the hospital, including information such as harm ratio and near misses. The data is taken in aggregate form, without any patient identification information.
The aggregated information is discussed by the PSO’s member hospitals in meetings, she says. She also notes that the PSO members can communicate with each other via the Global Patient Safety Network (also operated by GE Healthcare), a private online community where members can get immediate feedback from other member hospitals, both inside and outside the PSO, on question about best practices, how to handle events, and other questions.
Kathy Martin, who until recently was managing director of the GE Healthcare PSO that manages the Rhode Island group (she is now patient safety principal at GE Healthcare), says GE collects the event reports from members of the Rhode Island PSO into the software and enters them into the software platform. She says it provides information such as which hospital is best in class, and where it begins to see some early breakdowns in processes.
Martin says that the information that is shared at monthly network meetings and Web meetings includes the types of events are being seen, suggestions of where hospitals should spend time and prioritize their performance improvement resources, examples of best in class, and the types of interventions that are working. In addition to sharing the data within the PSO, aggregated data is shared at a national level, with other GE PSO members in other states, Martin says. “In the monthly reports they receive, they get a national benchmark from our PSO; so they see how all of the members across the country are performing across those particular measures,” she says.
Events Recorded and Actions Taken
Kent Hospital has logged in several thousand events or near misses since it was implemented in August 2010, Pilkington says. Event types range across the board, and the hospital averages about 360 events per month. There are a lot more near misses reported than actual events, she says, adding that a near miss tells more about what’s going on regarding patient safety than actual events.
One example: early on, Kent experienced a number of near misses in radiology, prompting the radiology and ED departments to review the process of ordering X-rays, Pilkington says. This resulted in plan to streamline the process of what information the send with the patient for whom the X-ray has been ordered, she says. Priebe notes that’s an example of a low-severity issue that might occur infrequently, but the reporting system uncovered as a trend that needed to be addressed. Possible actions can be changes in physicial or procedural controls or education of the staff, he says.
Managers, who see all of the events as they log on to the system, may use patterns of events or near misses as talking points with their staffs to review a certain policies or procedures. “The managers are constantly looking at the events on the units to see if there is a trend in the unit,” she says. “They have the information right at their fingertips.”
According to Priebe, in a voluntary reporting system a high number of reported events is a good thing, because it means that more people are using the system to report actual events and near misses. “We like it when we see large numbers of events reported, but with a lower harm rate,” he says. That information is used to prevent future events that result in harm to the patient.