A positive sentinel event? AI says it’s possible
Use root-cause analysis in excellent outcomes, too
(Editor’s note: In last month’s cover story, we took an in-depth look at appreciative inquiry, or AI, an approach to quality improvement that seeks to model and duplicate instances of outstanding performance. In the following story, we look at the AI concept where the rubber meets the road — how it unfolds in real-world situations. What we discover in the process is a fascinating concept: the "Positive Sentinel Event.")
One of the more interesting concepts derived from AI is the "Positive Sentinel Event," says James Espinosa, MD, FACEP, FAAFP, chairman of the emergency department (ED) at Overlook Hospital in Summit, NJ.
"What the Joint Commission [on Accreditation of Healthcare Organizations] calls a sentinel event would be an outcome that was at the far left of a bell-shaped curve: the extreme of negative," he notes. "It is an unlikely event that has significant enough consequences worthy of study that we can come to understand the root causes — things such as policies and procedures, inputs, people issues, equipment, environment — all of which go into good, standard state-of-the-art root-cause analysis. What we are saying is that there are actually cases at the other extreme of the probability curve as well."
For example, Espinosa says, his facility had a series of cases in which the arrival-to-diagnosis times for thoracic aortic aneurysm had been seven minutes or less. "The reason we got the last two or three was that we studied the first. What people would generally say about unexpected positive outcomes would be ascribed to luck, but in reality, we did a root-cause analysis on this process and took it apart."
The Overlook staff actually did a sit-down session that the performance improvement person attended, just as they would for a sentinel event. "We created a mini-root-cause analysis tool, and in fact, it turns out that if you want to produce the same positive result, it’s a process," he adds.
What staff discovered was that producing the positive result requires the right equipment, i.e., having a 12-lead electrocardiogram (ECG), and an ECG reading that is negative for myocardial infarction despite the fact that the patient has sharp chest pain dissecting to the back. "What you have is an equipment-related issue, a people-related issue [such as medics with training enough to note crushing chest pain], and a doc who recognizes that this might be a dissecting thoracic aneurysm," Espinosa says. "It takes having an echo machine available and a tech available to do a four-chamber view after they arrive."
Would all medics be alert as that medic? Would other emergency physicians? Probably not, "but if you ascribe it to luck and give an attaboy’ to one individual, you ignore all the steps it took to create that process. We try to make that process more likely to happen again," he says.
"We need to identify those reasons so we can replicate the same things, not only for that particular case but because, since we are teaching people a process, they learn to transport that learning to another event," says Pat Gabriel, RN, BSN, CEN, manager of the ED.
Staff also are reminded they sometimes can do things really well, Gabriel adds. "They might start thinking, We did really well with this aneurysm thing; what can we do for emergency angioplasty?’ That’s what’s important about looking at process — looking at good things. We need to think of the enhancements: What made that nurse, that physician know what to do? Who was their champion? What sort of relationship did the staff have with the surgeon? All those things become building blocks for the next event."
This type of approach also enables staff to see positives where once they might have seen only negatives.
"There was the case of a child who died of SIDS [sudden infant death syndrome]," Espinosa relates. "It was a tragedy. But as part of the experience, we created a memory box. Pat [Gabriel] took pictures of the child, and there were footprints, handprints, and items with the scent of the baby on them."
All of those things were meant to be healing mechanisms for the staff and family, he explains. The family did not go home empty-handed, and staff felt that at least they had done something for the family. Staff also put the family in contact with support groups.
In this particular case, Espinosa notes, a tragic event ultimately led to something positive: The mother felt a tremendous sense of gratitude to the hospital for its caring treatment and now serves as a volunteer. In addition, she spearheaded an effort to present the staff with an award and made a donation to the hospital.
What happened, in essence, was the family found out the experience had been different from that of others who had lost children to SIDS. "Our chaplain was not afraid to stay with them for two hours and was not afraid to cry with them," Espinosa adds. "We created a positive experience out of a negative event."
By examining this experience closely, staff were able to apply AI to it. "Why were we able do such a positive thing for this mother? How can we do it for others? Why not get the ED involved in orientation for new chaplains? Can we work on creating a separate place for families to be when they are grieving? From each of these experiences, we learn how to transport what we have gone through, turn it into a positive, and spread it in our own group."
In addition, he notes, the two cases actually have something in common: They didn’t prevent illness from happening. "We were in the secondary and tertiary areas," Espinosa explains. "We kept disease from taking a life in the aneurysm case. In the SIDS case, yes, the child died, but the tertiary prevention was trying to prevent the propagation of psychological trauma, which would have made a bad thing even worse."
Eliminate the negative?
In a negative sentinel event, Espinosa posits, "The fate of the universe relies on reducing the likelihood it will happen again. We talk of barriers." As it turns out, on the positive side, it requires several layers of the process placed in proper alignment "to increase the bandwidth of opportunity," he observes.
In addition to teaching your staff to create barriers to the negative, Espinosa continues, you also want people to learn how to take a case apart. "If you do it in the negative, it’s much harder to put people together and widely disseminate bad things. Success has 1,000 fathers: A lot more people feel good, and the positive event is likely to become a myth and translate into behaviors and increase the likelihood this will happen in the future."
Gabriel agrees. "It works to everyone’s advantage; people are quite willing to give you information on the causes of a good event."
"No one here is saying not to look at problems," Espinosa emphasizes. "What we are saying is that there is this whole other world of information to sort out, such as how an unexpectedly fast door-to-balloon process, in the 40-minute range, occurred."
There’s some psychology at work, here, he adds. "Everyone will tell you that for criticism to work effectively you need praise at a rate of two to three times as much," Espinosa says. "That’s where a self-aware microsystem in the ED is able to imbed as part of an agenda what went well and how you can make sure that it happens again and that other events like it will also happen."
This also becomes a wonderful recruitment and retention tool, he says. "Experienced nurses and physicians need things that challenge them to remember why they came into the field and what has kept them interested," Espinosa observes. "With AI, we get an inner sense of them, and it allows them to still feel important and useful. It challenges everyone to do better. New people will be grateful that these veterans made it easier for them, and the veterans will be proud to have helped."
The approach increases the chance of duplication in a microsystem. "Because we are microsystem-based, it’s easy for one ED in our system to appreciate the work of another ED and to transport that quickly and easily," he says. "With a more negative approach, you tell the ED [staff] they’ve screwed up and they need to go and learn from someone who hasn’t. It’s much easier to adapt when you’re in an atmosphere of appreciation."
Need More Information?
For more information, contact:
- James Espinosa, MD, FACEP, FAAFP, Chair-man, Emergency Department (ED), Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.
- Pat Gabriel, ED Manager, Overlook Hospital. Telephone: (908) 522-5310.
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