Development and testing of Baylor Scott & White Health's "Attitudes and Practices of Patient Safety Survey".

Improving the quality of patient care requires a culture attuned to safety. We describe the development, implementation, and psychometric evaluation of the Attitudes and Practices of Patient Safety Survey (APPSS) within the Baylor Scott & White Health system. The APPSS was designed to enable safety culture data to be collected and aggregated at the unit level to identify high-priority needs. The survey, with 27 Likert-scale core questions divided into 4 concept domains and 2 open-ended questions, was administered electronically to employees with direct patient care responsibilities (n = 16,950). The 2015 response rate was 50.4%. The Cronbach's α values for the four domains ranged from 0.78 to 0.90, indicating strong internal consistency. Confirmatory factor analysis results were mixed but were comparable to those of established safety culture surveys. Over the years, the adaptability of the APPSS has proven helpful to administrative and clinical leaders alike, and the survey responses have led to the creation of programs to improve the organization's patient safety culture. In conclusion, the APPSS provides a reliable measure of patient safety culture and may be useful to other health care organizations seeking to improve the quality and safety of the care they provide.

Team consistency and occurrences of prolonged operative time, prolonged hospital stay, and hospital readmission: a retrospective analysis.

BACKGROUND: Human factors research has suggested benefits of consistent teams yet no surgical team consistency measures have been established for teamwork improvement initiatives. METHODS: Retrospective analysis was conducted of teams performing consecutive elective procedures of unilateral primary total knee and hip replacement between June 2008 and May 2010 at a large tertiary medical center. Surgeons who performed fewer than 50 cases of the procedures during the study period were excluded. A team was defined as consistent when its nurse and surgical technologist members were both among the three most frequent working with the surgeon during the study period. Odds ratios for prolonged operative time (in the longest quartile), prolonged hospital stay (longer than median), and 30-day all-cause readmissions were adjusted for patient characteristics (sex, age, comorbidity, American Society of Anesthesiology status), surgery characteristics (procedures, time of day), and surgeons. RESULTS: Inconsistent teams performed 61% of the 1,923 cases with eight surgeons, each of which worked with a median of 43.5 (range, 28-58) nurses and 29 (range, 13-47) technologists. Inconsistent teams were associated with higher likelihood of prolonged operative time [odds ratio 1.52, 95% confidence interval (CI) 1.20-1.91], higher likelihood of prolonged hospital stay (odds ratio 1.51, 95% CI 1.23-1.86), and more readmissions (adjusted odds ratio 1.42, 95% CI 1.07-1.89). CONCLUSIONS: Team consistency was an independent predictor of prolonged operative time, prolonged hospital stay, and 30-day hospital readmission in elective, primary, unilateral total knee, and hip replacement procedures, after adjusting for patient and surgery characteristics and surgeons.

Development of a tool to measure user experience following electronic health record implementation.

OBJECTIVE: The aim of this study was to develop a survey tool to assess electronic health record (EHR) implementation to guide improvement initiatives. BACKGROUND: Survey tools are needed for ongoing improvement and have not been developed for aspects of EHR implementation. METHODS: The Baylor EHR User Experience (UX) survey was developed to capture 5 concept domains: training and competency, usability, infrastructure, usefulness, and end-user support. Validation efforts included content validity assessment, a pilot study, and analysis of 606 nurse respondents. The revised tool was sent to randomly sampled EHR nurse-users in 11 acute care facilities. RESULTS: A total of 1,301 nurses responded (37%). Internal consistency of the survey tool was excellent (Cronbach's α = .892). Survey responses including 1,819 open comments were used to identify and prioritize improvement efforts in areas such as education, support, optimization of EHR functions, and vendor change requests. CONCLUSION: The Baylor EHR UX survey was a valid tool that can be useful for prioritizing improvement efforts in relation to EHR implementation.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed. STUDY DESIGN: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. DATA COLLECTION: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Description and evaluation of adaptations to the global trigger tool to enhance value to adverse event reduction efforts.

OBJECTIVE: To adapt the Global Trigger Tool (GTT) as a sustainable monitoring tool able to characterize adverse events (AEs) for organizational learning, within the context of limited resources. METHODS: Baylor Health Care System (BHCS) expanded the AE data collected to include judgments of preventability, presence on admission, relation to care provided or not provided, and narrative descriptions. To reduce costs, we focused on patients with length of stay (LOS) of 3 days or more, suspecting greater likelihood they had experienced an AE; adapted the sample size and frequency of review; and used a single nurse reviewer followed by quality assurance review within the Office of Patient Safety. We compared AE rates in patients with LOS of less than 3 days versus 3 days or greater, assessed trigger yields and interrater reliability, and submitted identified AEs to each hospital for validation as event types targeted for reduction. RESULTS: In 2008, 91% of identified AEs were in patients with LOS of 3 days or greater; there were 6.4 AEs per 100 discharges with LOS of less than 3 days versus 27.1 AEs per 100 discharges with LOS of 3 days or greater. Over 4 years, we reviewed 16,172 medical records; 14,184 had positive triggers, 17.1% of which were associated with an AE. Most AEs were identified via the "surgical" (36.3%) and "patient care" (36.0%) trigger modules. Reviewers showed fair to good agreement (κ = 0.62), and hospital clinical leaders strongly agreed that the identified events were AEs. CONCLUSIONS: The GTT can be adapted to health-care organizations' goals and resource limitations. This flexibility was essential in crossing our organization's "value threshold."

Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000-2009.

Healthcare is a complex industry burdened by numerous and complicated clinical and administrative transactions that require many behavioral changes by patients, clinicians, and provider organizations. While healthcare information technology (HIT) is intended to relieve some of the burden by reducing errors, several aspects of systems such as the electronic medical record (EMR) may actually increase the incidence of certain types of errors or produce new safety risks that result in harm. Healthcare leaders must appreciate the complexity surrounding EMRs and understand the safety issues in order to mandate sound EMR design, development, implementation, and use. This article seeks to inform executives, clinicians, and technology professionals what has been learned through published research on the safety of HIT systems during the last decade, focusing on computerized physician order entry (CPOE), clinical decision support systems (CDSS), and bar-coded medication administration (BCMA).

Journey to no preventable risk: the Baylor Health Care System patient safety experience.

The patient safety vision at Baylor Health Care System (BHCS) has 3 components: (1) achieving no preventable deaths, (2) ensuring no preventable injuries, and (3) seeking no preventable risk. These goals require strategic efforts in the categories of culture, processes, and technology. Culture focuses on tactics such as teamwork training and quality improvement education. Processes are measured using the percentage adoption of a variety of target clinical processes such as order set use and adherence to National Patient Safety Goals. Technology includes focus areas such as clinical decision support and reliability of the electronic health record. BHCS has also achieved significant systemwide standardization of safety processes and development of the systemwide Office of Patient Safety to facilitate the implementation of evidence-based patient safety practices. Associated with these improvements, BHCS has made significant progress toward reducing hospital-standardized mortality rates and rates of hospital-acquired adverse events.

A randomized controlled trial using the school for anti-inflammatory therapy in asthma.

This study investigated the impact of providing low-dose inhaled corticosteroids (ICS) at school or at home to asthmatic inner city children over a 14-week period, compared with the existing community standard. Eight elementary schools in the Dallas Independent School District with a high incidence of asthma located in predominantly urban African-American communities were randomly assigned to one of four groups. The treatment arms were school-based delivery of inhaled steroids, home-based delivery of inhaled steroids, and home-based delivery of inhaled steroids with school-based asthma education, and the control group was no change in current therapy. Fifty students were objectively diagnosed with mild, persistent asthma and participated in the study. Students in the treatment arms received beclomethasone (42 mcg/puff) 4 puffs, twice a day, either at school or at home. Students in the control, "community standard of care" group received no additional medical intervention. Higher peak flows for the treatment groups were seen in the first week and maintained throughout the study (P = .047). By week 5 significant differences were found in frequency of bronchodilator use (P = .025), episodes of nocturnal awakening with asthma symptoms (P = .022), and visits to the primary health care provider (P = .022). Treatment groups rated their asthma as "better than the week before" more frequently than the control group (P = .001). Delivering ICS in school is associated with improved asthma control than when anti-inflammatory medication was delivered to children with asthma in a home-based setting, and both are superior when compared with a control, "community standard of care" group in which no additional medical intervention occurred.