FIGURE 3: In healthcare, to err can be lethal
How can we readress the scale?
To err is... human
FIGURE 4: Redressing the balance
No matter what job we do, we all make mistakes
To err can be... lethal
To err is... human
We need to catch errors before they become fatal
To learn from our mistakes is... imperative
Emotional support, relieving fear and anxiety Involvement of family and friends.
WALK THE VOC (VOICE OF CUSTOMER) In Lean methodology the aim is to eliminate non-value added steps within any process. To achieve that, the ‘customer’s’ (or patient’s) perspective must shape all activities and define the approach taken to achieve better quality and safer care. Once we adapt the patient’s view of the healthcare system, some activities incorporated within healthcare delivery start to take on a different look: they become easily recognized as ‘waste’, that type of work that stands in the way of healthcare givers; that hinders the clinical team from performing at higher levels and degrades quality; that saps morale, and is ultimately detrimental to a patient’s health. We need to introduce culture change to front-line staff to empower them with self-leadership and take the initiative to report unsafe conditions, near misses and minor injuries as well as major ones. However, the question remains: can the industry introduce culture change on a scale bigger than individual hospital or directorates; can the industry implement a countrywide culture change programme?
STATE-WIDE LEADERSHIP CREATES A CULTURE OF PATIENT SAFETY IN RHODE ISLAND, US GE Healthcare Performance Solutions, through its Patient Safety Organization (PSO), co-authored a series of articles published in the Patient Safety and Quality Healthcare journal focusing on how state- wide leadership can create a culture of patient safety as is currently the case in Rhode Island (RI) state, US. PSO’s, authorized by the US Congress, and created through the Patient
Safety and Quality Improvement Act, help hospitals reduce or eliminate adverse events by capturing and pooling data and analyzing and sharing de- identified information and insights. GE’s PSO received its official designation from the US Agency for Healthcare Research & Quality (AHRQ) in February 2011. Members of GE PSO have a single common medical-event reporting platform (Medical Event Reporting System or MERS), and comprehensive data analytics (SAS Analytics) and advisory support (Performance Solutions – Patient Safety practice), to assist hospitals in the identification of root causes or risks and help hospitals make lasting safety improvements. In the state of Rhode Island, US, 13 hospitals participated in GE PSO to implement MERS to gain insights that allow for improvement in the patient care processes. At the heart of the issue of reporting and managing medical errors
is that risk and quality managers typically do not have the operational responsibilities and mandated authority to make such changes. GE PSO RI program has set out to address this ‘ownership’ issue by putting in place state-wide Steering Committees made up of chief nursing officers. Besides this, program leadership in each hospital is represented by multi- disciplinary teams (MDT) including nursing, pharmacy, IT, medical staff, and administration, as well as quality and risk management.
038 HOSPITAL BUILD & INFRASTRUCTURE MAGAZINE ISSUE 1 2012
CHANGING MINDSETS – ‘JUST CULTURE’ PROGRAMME
All 13 hospitals in the RI programme have MERS installed (incorporated within GE PSO) to standardize event capture. The introduction of MERS was accompanied by comprehensive manager trainings and at some of the hospitals, a written policy was also developed that clearly laid out expectations for the management in patient safety events. Several of the RI hospitals combined the MERS roll out with development of a non-punitive, but accountable culture for reporting, modelled after the Just Culture (JC) programme. The JC programme is about creating a work environment in which healthcare professionals are motivated to recognize, report, and reform unsafe care practices. This requires developing organizational consensus about what constitutes a medical error and replacing an overly punitive approach to error management with a system of positive reinforcement for safe behaviours. The core of Just Culture is the belief that the system can learn from the error and make improvements that enable safer delivery of care across the institution. Throughout the JC programme meetings, educational staff conducted role-playing exercises based on true event management scenarios while attendees participated in question-and-answer sessions. To ensure senior leadership sponsorship, and as part of the MERS
roll out, a training video was created in which hospital CEOs were featured, introducing the programme and explaining its importance. The Rhode Island state wide approach is already demonstrating large-scale change and this is due in large part to the commitment demonstrated by senior leadership across all RI hospitals. To err is human; but in healthcare to err can be lethal. It is
imperative to learn from our mistakes if we want to redress the balance. To have an open culture we will be able to catch small errors before they become too big to manage. By reporting unsafe conditions, non-harm and near miss events, which herald harm-events, we will be able to learn a great deal by gaining insights through the use of technologies like MERS (see figures 3 and 4).
AUTHOR INFO Dr Al-Ani is a Senior Consultant based in Dubai working within the GE Healthcare Performance Solutions team, which builds solutions to address some of the most pressing needs of hospitals and health systems: Patient Flow, Patient Safety and Service Line Innovation. Each Performance Solutions engagement is customized to match GE’s proprietary solution with the unique needs of healthcare organizations. The solutions are built upon Lean technology, the Change Acceleration Process, deep clinical expertise, and sophisticated simulation technology developed at GE’s Global Research Center. Contact:
azhar.alani@
ge.com
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56