Get at root causes to reduce risk
Patient surveys can be invaluable source
How can an ED manager reduce the risk of lawsuits once problem areas have been identified? Experts agree you've got to get to the root cause of those problems. Sometimes, they say, it might take the use of formal quality improvement tools such as root-cause analysis. Other times, it can be a simple as listening to patient complaints.
"If a theme is identified, you must find the root cause and try to eliminate that theme or attitude," says Corey M. Slovis, MD, FACEP, FACP, FAAEM, chair of emergency medicine at Vanderbilt University Medical Center in Nashville, TN. The Vanderbilt ED began a concerted risk reduction program about 30 months ago. "I believe some of our earliest themes were things like patients not knowing who their doctor was," Slovis says.
As the department interviewed patients to identify the root cause of this problem, they learned that even though the provider might say who they were, the name tags and picture IDs would flip around. "I was able to convince the hospital this was an important theme, so now we have two name tags, one on the front and one on the back, so no matter which way it spins, the person's name, title, and picture stand out," says Slovis.
The ED team places a strong emphasis on follow-up calls to ascertain whether a follow-up visit might be required and to enhance patient satisfaction ED nurses try to make follow-up calls to 100% of all "treat-and-release" patients, says Slovis. "We reach more than half," he reports. The purpose of the call is to provide excellent customer service and to ensure appropriate follow-up for the patients. The nurses have a short script that starts with "I'm a nurse from Vanderbilt; I'm just calling to check on you." They also ask if the patient got a prescription and if they filled their prescription. Finally, they ask if they think they had a good visit to the ED.
Like many ED managers, Slovis recognizes that unhappy patients are more likely to sue. He uses the Omaha, NE-based patient satisfaction firm Professional Research Consultants to conduct random surveys on such issues as quality of care, cleanliness, and professionalism. The surveys are telephone-based and are implemented on a weekly basis via a random sample of ED patients, according to Denise G. Rabalais, director of survey research strategic development at Vanderbilt. The results are accumulated online on a daily basis, but most managers review the results monthly. "The cost varies based on volume, and it is a corporate-level expense overseen by the department," she notes.
The quality and satisfaction ratings are distributed to each doctor and nurse. "When a theme is developed, you get the appropriate group together and ask how we can fix it," Slovis says. "If the staff create the policies and protocols, they are much more likely to support them; and the more you empower them to make changes, the more likely they are to adhere to those changes." So, for example, when the patients said that they did not like the discharge instructions because they were illegible and the instructions were too generic, "that drove us to invest in discharge instruction software, to retrain physicians on the importance of discharge instructions to patients, and for nurses to ask the patient about understanding of discharge instructions prior to signing the patient out of the ED," says Brent Lemonds, MS, RN, EMT-P, FACHE, administrative director of emergency services.
Areas of risk can widely vary from ED to ED, notes Martin E. Ogle, MD, regional director for the southern division of CEP/MedAmerica, an Emeryville, CA-based provider of ED management and staffing solutions. "At one hospital, the primary problem was on the front end," Ogle says. "They couldn't get patients into the treatment area, and the 'left-before-treatment' [LBT] number was very high."
Patients leaving before being treated can be very dangerous, Ogle points out. "You do not know what they have, but you have probably established some degree of responsibility even if [they get sicker] when you're not there," he explains.
To address this problem, says Ogle, his organization identified a solution that enabled the ED to drop the LBT number from 11% to less than 1% in 30 days. "The biggest change was cultural, to get buy-in from all the players including the CEO, nursing leadership, and physicians, to follow what we thought was the right solution," he says.
The solution began with a clear articulation of the revised processes Ogle's firm proposed to not only nursing leadership, but also to the highest levels of hospital leadership to gain their support. "In addition, having access to other sites in our network that have been successful in rolling out this process, we organized a site visit with selected clinical ED nursing leaders, the ED nurse manager, the CNO, the director of registration — a crucial stakeholder — and the ED medical director," he says. "In one day, we were able to visit two sites, both with [LBT] below 1% and average time-to-provider below 20 minutes, were toured by the medical directors and the ED nurse manager, and most importantly, we observed the process live with real patients being cared for in an incredibly efficient manner." Ogle says that with this approach he could "see the light bulbs going off above the groups' heads."
Because of the wide range of challenges faced in risk management, Ogle says his firm has hired experienced and trained internal consultants with a wide variety of backgrounds. "Several are experienced ED management nurses, some are industrial engineers, one is a risk manager, and we call each of those 'malpractice management consultants,'" he explains. "If, for example, we see a PA issue or credentialing is not as tight as it should be — which could certainly create an issue downstream vis-à-vis scope of practice — we can bring in the appropriate expert to explain state requirements or hospital bylaws and give us a best practice to make that piece a little safer."
A realistic attitude on the part of your staff is also critical in successfully reducing risk, adds Gerald B. Hickson, MD, professor of pediatrics, associate dean of clinical affairs, and director of risk prevention at Vanderbilt University School of Medicine in Nashville. "If you ask me, one of the most important things to do if you want to address unnecessary risk in the ED is to dispel and explode the old myths, like, 'We're in the ED, and we're just gonna get sued,' or 'We're at risk because of our discipline,'" he says. "Until you explode those myths, you're not going to effectively address this." To do that, says Hickson, emergency department leaders need to encourage their colleagues to simply review the evidence-based literature about malpractice and to decrease reliance on antidotes and war stories.
Resource
For more information on patient satisfaction surveys, contact:
- Professional Research Consultants, 11326 P St., Omaha, NE 68137-2316. Phone: (800) 428-7455. Fax: (800) 553-4500. Web: www.prconline.com.
Education may not be enough Educating your staff about risk management might be important, but education itself will not reduce risk, says Daniel Sullivan, MD, JD, FACEP, president and CEO of The Sullivan Group, an Oakbrook Terrace, IL-based provider of patient safety, risk management, and performance improvement solutions for health care professionals. "The information transmitted in a lecture or via audiotape will not change the error or litigations landscape," says Sullivan, who lectures to about 100 ED medical directors twice a year at events sponsored by the American College of Emergency Physicians. "A dog-and-pony show will not work." The only thing that will work, he maintains, is a systems approach similar to that used by airlines. "It's a system built into the 'moment to moment' of taking care of people in the ED," Sullivan says. "It addresses how doctors think, the biases in their subconscious, and so on." For example, practitioners cannot remember lists of risk factors and forget to inquire whether a febrile neonate has been exposed to strep or herpes in the maternal birth canal. "When you walk into a room and you do not have a tool [to remind you], there is a missed opportunity to make a diagnosis," Sullivan says. "This is a critical clinical practice issue." Build a tool kit A key part of the solution is to build a medical record tool to be used at the point of care as a reminder for the staff, he says. So, for example, electronic health records can make key information immediately available, can remind practitioners about key risk situations that might easily be forgotten, and can alert practitioners to an abnormal vital sign prior to patient discharge. For EDs that do not have electronic medical records, Sullivan has built visual tools, such as a paper template or freestanding software program that provides immediate access for a complete evaluation of the hand. "Most practitioners cannot remember the names of the extensor tendons of the hand or how to examine each one," he explains. "You need something immediately available in case you have a laceration that requires tendon evaluation." Once you have these tools, Sullivan says, you measure performance. "Until you show people how they are doing, they are never going to consistently change their behavior," he says. So, for example, in 2003, Sullivan's firm began working with one of the largest health care organizations in the United States, providing care for several million emergency patients per year. Initially the data showed that 19% patients with very abnormal vital signs were discharged home without a single repeat of the abnormal vital signs. The practitioners were educated about the vital sign issue through web-based CME and CNE and then viewed their personal clinical performance through an audit provided by Sullivan's firm. Over time, the physicians and nurses altered their clinical practice and dramatically improved the vital sign issue and overall patient care. "All it takes is letting doctors and nurses know a critical issue exists, and giving them something to help them at the point of care," Sullivan says. "We want to do a great job, but we need help at the point of care because we can't remember everything we need to." |
Culture change can reduce risk The ED at Vanderbilt University Medical Center in Nashville, TN, has achieved "a significant reduction in the number of lawsuits," according to Corey M. Slovis, MD, FACEP, FACP, FAAEM, chair of emergency medicine, who says it wouldn't have been possible without significant culture change. According to Gerald B. Hickson, MD, professor of pediatrics, associate dean of clinical affairs, and director of risk prevention at Vanderbilt University School of Medicine, overall Vanderbilt University Medical Center has reduced malpractice suits by 50% "during a time when we have more than doubled in size." Slovis says in terms of the ED, changing culture and attitude "has got to be both bottom up and top down. You have to involve all members of the team: residents, attending faculty, nurses, and all your support staff." To involve them, you need to target each group in multiple ways, he suggests. The groups are targeted through meetings, special presentations, and e-mail, and by having senior faculty and nurses model the behavior. Clovis confesses that early on in the process, he was teased for adopting specific phrases to say to the patient, such as "I'm closing the door for your privacy." He also says hello to everyone in the room and introduces himself to the patient. The primary item he emphasized was for the staff to think about how they would want a family member to be treated in an emergency. "We made it very clear that we behave in a certain way, and if you don't, you are an outlier, and outliers need to have their actions and words corrected," says Slovis. Also, residents are evaluated on customer service, he says. "Part of the faculty bonus is based on customer satisfaction, and part of the nurses' evaluation is based on how patients perceive bedside care," he says. "We talk about it, teach it, measure it, and reward it." Finally, Slovis says, whenever he receives patient comments that are positive, he removes all specific patient identifiers, and then an edited version is sent to the doctors or nurses involved. He compliments them and shares the information with the staff. "People look for compliments; they try and earn complements, and so more and more patients get better care," Slovis explains. "The more you say early on, the more this becomes ingrained and natural." |
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