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July 2017 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Recognizing Those Who Contribute to Safety Culture: The Trust-Report-and-Improve Dynamic

Jul 31, 2017 | Comments (0) | 3128 Views

Smith_C_09-13By Coleen Smith
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the fifth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic: This post examines the fifth tenet: Recognize and praise care team members who report adverse events and close calls, identify unsafe conditions, or present good suggestions for safety improvement.

The “trust-report-and-improve” dynamic is a crucial aspect of establishing high reliability in health care. When team members report adverse events or share concerns or ideas about safety, it’s important for team leaders to recognize their contributions, use their information to make improvements, and communicate back to team members how safety was enhanced as a result.

Establishing a process for consistently recognizing individuals who identify safety improvement opportunities reinforces the importance of both identifying and responding to unsafe conditions. This recognition also creates a bond of trust with leadership and contributes to building a safety culture. 

Personal Recognition Works Best
Expressing personal thanks for safety-related contributions within the unit or organization is so appreciated by team members.  Many organizations offer small incentives for reporting safety issues such as: 

  • providing “good catch” awards in the shape of a baseball mitt for reporting close calls
  • large trophies for the most improved adverse event reporting
  • raffles for a close-by parking space among contributors of safety ideas
  • recognizing individuals in newsletters and on bulletin boards
  • paying for a unit pizza parties 
  • providing gift cards 

Pre-Emptive Mentality

In developing both recognition and a safety culture initiative, it is important to progress from simply reporting adverse events, to reporting close calls, and then to thinking more broadly about unsafe conditions or situations that could lead to adverse events or suboptimal outcomes. It’s a challenge to expand safety mindfulness from identifying mistakes that have or nearly happened to include what may happen.

What may happen because two patients on the floor have the same or similar names? What may happen because a particular piece of equipment is difficult to find or obtain? Situations that team members may currently view as daily annoyances may actually be unsafe conditions. After a potentially unsafe situation is found, it’s even better to devise a solution. For example, to prevent venous thromboembolism after surgery, a nursing unit decided to stock sequential compression devices on the unit, rather than in central storage, to reduce the time post-surgical patients waited for this intervention.

Hallmark of High Reliability
Getting team members to identify these kinds of situations is a definite evolution toward a safer culture. High-reliability health care is more than not harming patients; it’s making sure patients receive recommended care as soon as possible and without overuse. This highly reliable performance is particularly important for the diagnosis and treatment of sepsis, heart attack, stroke, and many other conditions. Proactive thinking leads to the best treatment and reduces the chances of errors.

As safety cultures within organizations become more adapt at anticipating and responding to potentially unsafe conditions, they move further away from the “sharp end of the stick” where adverse events occur. Reporting adverse events and close calls, and then further evolving toward identifying unsafe conditions and making safety suggestions is crucial work within a safety culture. Leaders must recognize and praise those contributing to this work; this creates the trust, report and improve dynamic that makes high-reliability health care possible.

Beyond the Study: A Q&A with Eisenberg Patient Safety and Quality Award Recipients: Part 3

Jul 06, 2017 | Comments (0) | 1622 Views

By David W. Baker, MD, MPH, FACP
Executive Vice President, Division of Health Care Quality Evaluation
Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety
The Joint Commission



Tabassum Salam, MD, FACP, CHCQM
Medical Director of Carelink CareNow
Christiana Care Health System



This is the final post in a three-part series highlighting the quality improvement and patient safety achievements of this year’s John M. Eisenberg Patient Safety and Quality Award recipients, showcased in the July 2017 issue of The Joint Commission Journal on Quality and Patient Safety. This post examines the quality and patient safety efforts of Christiana Care Health System’s Christiana Care Care Link, recently renamed Carelink CareNow, recognized in the award’s local achievement category. Carelink CareNow is a technology-driven, care coordination program based in Wilmington, Delaware. 

Here are the highlights of a conversation between the Journal’s Editor-in-Chief Dr. David Baker and Carelink CareNow’s Dr. Tabassum Salam. 

Dr. Baker: Can you speak to how Carelink CareNow addresses the needs of patients whose co-morbid conditions would place them into a number of population health groups?

Dr. Salam: We fully recognize that it is not realistic to compartmentalize patients under the assumption that each patient only has a single co-morbidity or need. For patients with multiple, interwoven medical and socioeconomic risk factors, we take a multi-professional complex case management approach. There is a lead case manager for each patient, and he or she reaches out to a multi-disciplinary team member who can best address the patient’s needs at any moment. Even though a patient may have diabetes, heart disease and chronic obstructive pulmonary disease (COPD), at any time, the lead case manager must assess which of these co-morbidities is currently significantly affecting the patient’s health. 

For example, immediately after a hospital admission for COPD exacerbation, the case manager determines whether the pulmonary disease is on the forefront, and he or she will subsequently reach out to the Carelink CareNow respiratory therapist for detailed support of the patient. Once the pulmonary issues are stabilized, the case manager will reassess the issue and ascertain, again, which co-morbidity is most active and significantly affecting the patient’s health. From there, the case manager will pivot to a different Carelink CareNow colleague(s) for in-depth support. 

Dr. Baker: Patients’ behavioral health needs have generally been conceptualized as separate from their physical health needs. What is Carelink CareNow’s role in addressing behavioral health needs?

Dr. Salam: We have realized that behavioral health and physical health needs cannot be separated, so we take a holistic approach to each patient. Here too, we use the multi-disciplinary Carelink CareNow team model in the case management of these patients. We have team members, such as registered nurses and social workers, with experience in working with patients who have behavioral health disorders to:

  • Meet with patients in their home or community. Seeing patients outside of the clinical environment significantly augments our ability to engage patients with behavioral health disorders. 
  • Hold case conferences with patients’ medical and behavioral health providers in order to create a multi-faceted care plan.
  • Conduct bi-weekly group conferences with a psychiatrist in order to brainstorm about new intervention options for challenging cases.

Dr. Baker: You mention the “next step” of developing new data sources, such as biometric monitoring, may expand your predictive analytics capabilities, even to the point of redefining the state of rapid response systems for clinical deterioration. How would that fit into your other goals

Dr. Salam: We partner with patients to ensure they receive the best health care and support in a timely manner. We also plan to use new data signals, such as real-time results from ambulatory biometric devices (e.g. blood pressure cuffs or glucometers) in order to identify patients whose medical conditions might worsen. We strive to proactively reach out to our patients in order to guide them off what otherwise could be the inevitable trajectory toward exacerbations of medical conditions that lead to unnecessary emergency department or hospital utilization.

The Joint Commission Journal on Quality and Patient Safety provides open access to articles about the Eisenberg Award recipients in its July 2017 issue.