Patient Safety Improvement Corps:

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PSIC Texas State Team Project

• Team members
• Cindy Bednar, RN,
• Josie R Williams, MD, MMM

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Original Texas-sized Goals

•  Learn to develop and implement sustainable
  systematic patient safety processes, procedures,
  tools and techniques to improve the safety of
  medical care across our state.
• Support Texas healthcare agencies by developing
  and implementing sustainable patient safety
  programs and medical error reporting systems as
  mandated in Texas House Bill 1614.
•  Develop comprehensive and cohesive patient
  safety processes, procedures, tools, techniques
  and training curriculum.
•  Identify dissemination strategies for this
  curriculum with the potential to facilitate
  patient safety improvement throughout Texas
  healthcare organizations.
• Implement the curriculum in RCHI network
  hospitals as an alpha test of the curriculum
  ultimately improving the medical care safety for
  all Texans.
•  Develop an effective evaluation of the program
  implementation and analyze patient safety
  improvement derived from the curriculum.

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Revised Texas-sized (Ambitious) Goals

• Provide training across Texas on RCA process
  using NCPS tools, with comparative evaluation and
  explanation of Best Practice.
• Teach RCA evaluation process for rural hospital
  and provide support to rural hospital in
  implementation of action plan.
• HFMEA evaluation of High Risk Medications in
  rural hospital (Palo Pinto) and support
  implementation of action plan related to high
  risk medications.
• Implement rural hospital patient safety support
  center and website (75completion).

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Training across Texas on RCA Process

• 6 hour session-State Bill, Human Factors, RCA
  review, comparison, best practice.
• 1. Houston, Austin, Dallas, Tyler, Lubbock.
• 2. Utilized the slides from training.
• 3. Delivered tools to each participant.
• 4. Set up conference calls for support (in
  progress).
• Reviewed with approximately 365 people the RCA
  process and discussed the NCPS process as a
  current best practice with emphasis on systems
  interventions human factors.

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Teach RCA Rural Hospital and Implement Action Plan

• Small Regional Hospital taught RCA evaluation
  process.
• Average daily census 18.
• Implemented read back policy for
  medicationsstruggling with culture.
• Implemented five rights in medication
  ordering-revising order sheets and considering
  CPOE.
• Facilitating medical staff discussion around
  telephone order protocols.
• Discovered authority gradient-Not yet
  addressedculture and resources.

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Other RCA Training

• Licensed 99 bed facility with average daily
  census 30-35.
• RCA on process for implementation of performance
  measures.
• Redesign of patient care intake, follow-up, and
  tracking of performance measures in progress.

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Other RCA Training

• Licensed 20 bed facility with average daily
  census of 3-6.
• Called following RCA Training for training and
  support to do RCA on critical incident.
• Scheduled Conference Calls for support.

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HFMEA Evaluation of High Risk Medications in
Rural Hospital

• (Palo Pinto)high risk medications in emergency
  room and ICU with the transient of care.
• First training implemented May 11th, 2004.
• Anticipate utilizing resources and colleagues.

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Rural and Community Health Institute (RCHI)
Website

• Root Cause Analysis Conference Calls
• RCHI staff will be available to discuss Root
  Cause Analysis on the following dates
• April 29, 8-9 a.m.May 7, 8-9 a.m.May 21, 8-9
  a.m.June 4, 8-9 a.m.June 18, 8-9 a.m.
• To participate, call toll-free 1-866-550-1029 or
  locally 847-9189.

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Patient Safety Program Enrollment Form

• Directions To enroll in the Patient Safety
  Program, complete this form online or print and
  mail it to
• Patient Safety Program Rural and Community
  Health InstituteTexas AM University Health
  Science CenterJohn B. Connally Bldg.301 Tarrow
  Street, 7th FloorCollege Station, Texas 77840
• Organization Name Address City
  State Zip Hospital RepresentativePhon
  e
• Hospital CEO Phone
• Next

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RCHI Patient Safety Programwww.rchitexas.org

• Forms
• Enrollment (also in PDF)
• Best Practice System
• Reportable Events System
• Close Call Reporting System (_at_ UT)
•  
• Administrator Login
• Skip Navigation
• RCHI

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Rural HospitalPeer Review Inter-facility

• Blinded patient, facility, physician.
• Like specialty, like facility.
• Telephone secured committee review.
• Records posted 1 week prior to review in a
  secured password protected web-based folder.
• Appropriate guidelines posted with records
• Facility information sheet incorporates many of
  the patient safety trigger tool questions.

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Small Rural North-central Texas Hospital

• Safety Climate Survey
• March 2003
• Table 2 Psychometric Properties of the Safety
  Climate Survey

From Sexton, Helmreich, Rowan, Vella, Boyden,
Neilands, Roberts, Thomas. 2003
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Sexton Survey Overall Facility Score

• Total Employee 411
• Overall Mean 4.11 out of 5 (SD .61)
• Range 2.16 5.00
• N 247
• Largest group of respondents in Other job
  category 46
• Registered Nurse 19
• Technician 11
• LVN 7

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1 Facility Small Rural North-central Texas
Hospital Psychometrics

• Cronbach Coefficient Alpha .88
• Factor analysis revealed two factors
• 1st Trust in management (66 of variance)
• 2nd Trust in staff (13 of variance)

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Sexton Survey Highest and Lowest Areas

• Highest Scoring Question Q9 I know the proper
  channels to direct questions regarding patient
  safety.
• Lowest Scoring Question Q3 The senior leaders in
  my hospital listen to me and care about my
  concerns.

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Sexton Survey Summary

• The majority of respondents thought the climate
  was conducive to learning from mistakes
• Sixty-five percent of respondents believed
  medical errors were handled appropriately
• About half of respondents thought nurse and
  physician leaders listened
• A large majority of respondents believed leaders
  were emphasizing safety
• Seventy-percent of respondents believed
  management would act on their suggestions
• Seventy-percent of respondents believed
  productivity was not placed above safety
• Eighty-one percent of respondents believed
  colleagues encouraged safety concern reporting

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Sexton Survey Summary (cont.)

• Almost ninety-percent of respondents believed
  they knew the proper reporting channels
• About seventy-five percent of respondents thought
  appropriate feedback was offered
• Eighty-percent of respondents would feel safe
  being treated in the facility
• Sixty-four percent of respondents believed shift
  briefings contribute to safety
• About half of respondents thought briefings were
  common
• Fifty-six percent of respondents were satisfied
  with the physician leadership

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Sexton Survey Summary (cont.)

• Fifty-five percent of respondents were satisfied
  with nursing leadership
• Fifty-eight percent of respondents were satisfied
  with pharmacy leadership
• Sixty-three percent of respondents believed
  patient safety is more of a concern than a year
  ago
• About sixty-percent of respondents believed AEs
  due to multiple failures
• Over seventy-percent of respondents believed
  personnel take responsibility for patient safety
• Fifty-seven percent of respondents did not think
  personnel disregarded safety rules
• Sixty-six percent of respondents believed patient
  safety is reinforced constantly

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Rural Hospitals

• Grubb (1994) describe a successful implement
  quality improvement in a small rural hospital in
  Washington state.
• The following challenges, which are still typical
  of such hospitals, described in 1989 included
• obtaining organizational support and resources
• initiating process improvement in very small
  departments
• obtaining valid data to compare with similar
  hospitals
• improving low-volume processes.
• Five years later, the authors identified key
  factors in success as
• strong support from the board of directors
• dedication from the administrators
• a diverse Quality Council
• the hospitals warm, family culture
• working in and between departments and
• a cadre of quality champions.

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References

• Barker KN, McConnell WE. (1962). The problems of
  detecting medication errors in hospitals.
  American Journal of Hospital Pharmacology 19
  360-9.
• Brasure M, Stensland J, Wellever A. (2000).
  Quality oversight why are rural hospitals less
  likely to be JCAHO accredited? Journal of Rural
  Health, 16(4), 324-336.
• Busteed S, Barwick S, Grubb L. (1994). The
  challenges of implementing quality improvement in
  small rural hospitals. Quality Letter on
  Healthcare Leadership, 6(6), 25-29.
• Helmreich RL, Merritt AC, Sherman PJ, Gregorich
  SE, Wiener EL. (1993). The Flight Management
  Attitudes Questionaire (FMAQ). NASA/UT/FAA
  Technical Report 93-4. Austin, Tx The University
  of Texas.
• Karow HS. (2002). Creating a culture of
  medication administration safety laying the
  foundation for computerized provider order entry.
  Joint Commission Journal on Quality Improvement,
  28(7), 396-402.
• Ricketts TC. (2002). Rural Health research and
  rural health in the 21st century the future of
  rural health and the future of rural health
  services research. Journal of Rural Health, 18
  Suppl, 140-146.
• Moscovice I, Rosenblatt R. (2000).
  Quality-of-care challenges for rural health.
  Journal of Rural Health, 16(2), 168-176.
• Ricketts TC. (2000). The changing nature of
  rural health care. Annual Review of Public
  Health, 21, 639-657.
• Rogers EM. (1995). Diffusion of Innovations,
  (4th Ed.). New York, NY The Free Press.
• Rosenblatt RA, Baldwin LM, Chan L, Fordyce MA,
  Hirsch IB, Palmer JP, Wright GE, Hart LG. (2001).
  Improving the quality of outpatient care for
  older patients with diabetes lessons from a
  comparison of rural and urban communities.
  Journal of Family Practice, 50(8), 676-80.

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Texas Team Observations

• Training alone is probably insufficient.
• Ongoing support maybe essential.
• Trust and partnerships are crucial.
• Marked variation in current knowledge
  sophistication of current hospital staffs.
• Resources-(personnel,knowledge finances) in our
  rural population will make implementation
  painfully slow but doable.
• Significant gaps in understanding, knowledge,
  implementation and utilization across state.

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Texas Team Observations

• Quantification of results across a state
  especially early in this process is very
  difficult, we felt it superficial.
• Ratings of training are still being evaluated but
  anecdotally have received high marks.
• We believe the RCAs the state receives from the
  facilities attending the training will probably
  be of a higher quality.
• RCHI anticipates utilizing the rural network
  support center and will do a semi-annual
  evaluation of the types of challenges and issues
  rural facilities experience including resource
  demands in reporting and doing root cause
  analysis.

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Texas Team Observations

• NCPS best practice RCAs is significantly more
  rewarding and useful for change than other
  processes.
• Significant education/change for sustainable
  implementation will be required.
• Implementation is just beginning and will likely
  be slow.
• Resources are scarce, and
• The collective will in our State to implement
  maybe lacking without significant incentive
  and/or resource supplementation.
• Smallness/rural is both advantage and barrier to
  implementation.

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Wish Lists

• Include in the application the expectation of
  project completion and the level of completion
  you anticipate.
• Establish an ongoing connectivity between teams
  at least annually.
• Consider the inclusion of methods and or tools
  for qualitative and quantitative evaluative
  results in the training sessions early in the
  process.
• Consider including some funding or sponsors to
  help in the implementation of the projects.

• Consider state team building each year.

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Steady as She Goes Conclusions (or Rome wasnt
built in a day)

• Training alone is probably insufficient.
• Trust and partnerships are crucial.
• Marked variation in current knowledge
  sophistication of current hospital staffs.
• Resources/training in our rural population will
  make implementation painfully slow but doable
  with support.
• Significant gaps in knowledge, implementation and
  utilization across state hospital facilities.
• Smallness is both advantage and barrier to
  implementation.
• Consider training of significant professional
  societies.

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Our Websites

• http//www.rchitexas.org/
• http//www.rchitexas.org/patientsafety/enroll.php