Aiming for zero preventable deaths: using death review to improve care and reduce harm.

In 2005, our organization set a goal of zero preventable deaths by 2010--notionally a sound goal but extremely challenging to measure, monitor and evaluate. The development of an interdisciplinary Death and Adverse Event Review process has provided a measure and framework for action to decrease adverse events (AEs) that cause harm. Death and Adverse Event Review is a formal process in which trained reviewers consider patient deaths using a modified Global Trigger Tool to establish the presence of AEs or quality of care issues that may have potentially led to death or harm. When identified, these charts go to second-level review by a physician/interdisciplinary team to determine recommendations for actions to prevent future reoccurrences. Data have provided trending of system influences to patient safety. In 2008-2009, 1,817 deaths were reviewed and AE rates of 12.1% and 16.3% were identified. There were 422 AEs and 114 quality of care issues identified for follow-up. Of the 4.7% and 6.3% referred to the physician/interdisciplinary team for secondary review, 2.3% and 2.6% resulted in recommendations for improvement. In addition to local improvements, many system improvements have occurred as a result of the review, such as proposed minimum standards for physician documentation; a formal review of post-operative guidelines for patients with sleep apnea; and a working group to review nursing documentation, communication/follow-up of vital signs, fluid balance and pain management. The Death and Adverse Event Review process provides a new critical level of detail that supports continuous improvements to our care processes and ongoing progress toward our goal of zero preventable deaths.

Assessment of safety culture maturity in a hospital setting.

The Manchester Patient Safety Culture Assessment Tool (MaPSCAT) was used to examine the levels of safety culture maturity in four programs across one large healthcare organization. The MaPSCAT is based on a theoretical framework that was developed in the United Kingdom through extensive literature reviews and expert input. It provides a view of safety culture on 10 dimensions (continuous improvement, priority given to safety, system errors and individual responsibility, recording incidents, evaluating incidents, learning and effecting change, communication, personnel management, staff education and teamwork) at five progressive levels of safety maturity. These levels are pathological ("Why waste our time on safety?"), reactive ("We do something when we have an incident"), bureaucratic ("We have systems in place to manage safety"), proactive ("We are always on alert for risks") and generative ("Risk management is an integral part of everything we do"). This article highlights the use of a new tool, the results of a study completed with this tool and how the results can be used to advance safety culture.

An evaluation of patient safety leadership walkarounds.

Patient safety leadership walkarounds (PSLWA) have been identified as an effective tool to improve patient safety culture. At Hamilton Health Sciences, after one year of monthly PSLWA in all clinical and service programs, 1,351 patient safety issues were identified, of which 64-80% have been resolved or have active improvement work in progress. Five hundred staff were invited to complete a process evaluation regarding the effectiveness of the current process of PSLWA. A total of 341 surveys were returned (68%). The overall evaluation demonstrated satisfaction with the process of PSLWA; 93% of those surveyed reported that they felt comfortable openly and honestly discussing patient safety issues and had an enhanced awareness of patient safety. Five areas of opportunity for process improvement were identified: scheduling, scripts, feedback, reporting and resolving issues deferred for an organization approach. PSLWA have offered an effective way to engage leadership and staff in open discussions about patient safety and collaborative approaches for solutions suggesting an enhanced patient safety culture.

Developing a patient safety plan.

Many healthcare organizations are focused on the development of a strategic plan to enhance patient safety. The challenge is creating a plan that focuses on patient safety outcomes, integrating the multitude of internal and external drivers of patient safety, aligning improvement initiatives to create synergy and providing a framework for meaningful measurement of intermediate and long-term results while remaining consistent with an organizational mission, vision and strategic goals. This strategy-focused approach recognizes that patient safety initiatives completed in isolation will not provide consistent progress toward a goal, and that a balanced approach is required that includes the development and systematic execution of bundles of related initiatives. This article outlines the process used by Hamilton Health Sciences in adopting Kaplan and Norton's strategy map methodology underpinned by their balanced scorecard framework to create a comprehensive multi-year plan for patient safety that integrates best practice literature from patient safety, quality and organizational development.

Communication and relationship skills for rapid response teams at hamilton health sciences.

Rapid response teams (RRT) are an important safety strategy in the prevention of deaths in patients who are progressively failing outside of the intensive care unit. The goal is to intervene before a critical event occurs. Effective teamwork and communication skills are frequently cited as critical success factors in the implementation of these teams. However, there is very little literature that clearly provides an education strategy for the development of these skills. Training in simulation labs offers an opportunity to assess and build on current team skills; however, this approach does not address how to meet the gaps in team communication and relationship skill management. At Hamilton Health Sciences (HHS) a two-day program was developed in collaboration with the RRT Team Leads, Organizational Effectiveness and Patient Safety Leaders. Participants reflected on their conflict management styles and considered how their personality traits may contribute to team function. Communication and relationship theories were reviewed and applied in simulated sessions in the relative safety of off-site team sessions. The overwhelming positive response to this training has been demonstrated in the incredible success of these teams from the perspective of the satisfaction surveys of the care units that call the team, and in the multi-phased team evaluation of their application to practice. These sessions offer a useful approach to the development of the soft skills required for successful RRT implementation.

A framework for local accountability for patient safety.

Despite numerous publications outlining the magnitude of patient safety issues, the literature provides limited strategies for organizations to develop comprehensive, effective patient safety programs. Hamilton Health Sciences (HHS) has created a framework to foster local accountability called Patient Safety Triads and Networks. The Networks operationalize patient safety initiatives, develop knowledge and improve patient safety culture in a collaborative interdisciplinary team model. They have proven to be an effective way to support patient safety at the local level and to integrate organizational and local work on patient safety.

How does fast track affect quality of care in the emergency department?

STUDY OBJECTIVES: Use of fast track has been shown to improve the emergency department flow of less urgent patients. It has been speculated, however, that this could negatively affect the care of urgent patients. The objective of this study was to determine whether a dedicated fast track for less urgent patients [Canadian Triage and Acuity scale category 4/5 (CTAS 4/5)] affected (1) the time to assessment for urgent patients (CTAS 3), (2) the length of stay for less urgent patients (CTAS 4 and 5), and (3) the left-without-being-seen rate. METHODS: In June 2003, fast track was opened in our emergency department from 13:00 to 19:00 h. A before-after intervention comparison analysis was completed for 1 week in Aug 2002 and the same week in Aug 2003. Data collected included (1) time to assessment of CTAS 3 patients, (2) the length of stay for CTAS 4/5 patients, and (3) percentage of patients who left without being seen. RESULTS: A total of 368 patients were reviewed for 2002 and 380 patients were reviewed for 2003. Median time to assessment of CTAS 3 patients presenting from 13:00 to 19:00 h was reduced from 66 min (Interquartile range: 40, 94 min) in 2002 to 60 min (IQR: 38, 108 min) after fast track was open in 2003 (P = 0.95). Median length of stay of CTAS 4 and 5 patients was reduced from 170 min (IQR: 111, 256 min) to 110 min (IQR: 69, 185 min) (P < 0.001). The overall left-without-being-seen rate decreased from 5% (20/368) to 2% (9/380). CONCLUSION: A dedicated fast track for CTAS 4/5 patients can reduce the length of stay and the left-without-being-seen rate with no impact on CTAS 3 patients seen in the main emergency department.