Wide-ranging collaborative drives improvement in patient safety
PDAs provided to staff for safer medication administration
A broad collaborative covering numerous hospitals in Tennessee has implemented an impressive patient safety initiative for which results were just reported in the Journal of Rural Health.1 The collaborative involved three main initiatives:
- providing clinical staff with PDAs to aid in safer medication administration;
- use of a tool provided by the Agency for Healthcare Research and Quality (AHRQ) to assess an institution's safety culture;
- standardization of protocols in the emergency departments of participating facilities.
The PDAs were pre-loaded with a drug database software program with drug information, such as dosing, drug-drug interactions and adverse reactions, as well as formulary and pricing information. The software provided clinical tools, including diagnostics such as lab reference values, clinical tables and guidelines, symptom assessment, disease and condition compendium, and medical calculators.
A provider survey on the impact of the PDAs revealed that:
- 83.2% of respondents reported increased self-reported drug knowledge;
- 88.6% reported improved drug-related decisions;
- 93.3% said they were better able to inform patients;
- 77.7% said the use of the PDAs reduced the potential for adverse drug-related events;
- 66% said patients were more satisfied with their care.
A follow-up AHRQ patient culture survey one year after the initiation of the collaborative showed:
- improvement in overall perceptions of safety from 56% to 69%;
- increase in frequency of events reported from 51% to 69%;
- supervisor expectations of promoting patient safety increased from 72% to 80%;
- communication openness increased 50% to 67%;
- nonpunitive response to errors increased from 35% to 50%;
- hospital management support increased from 72% to 78%.
The collaborative involved the Tennessee Hospital Association (THA), BlueCross BlueShield of Tennessee, the Upper Midwest Rural Health Research Center, the University of Southern Maine, and Q-Source (the quality improvement organization for Tennessee)
"I think we had the right people at the table; having the rural research centers involved gave the project a lot of credibility, and it was extremely important to have the necessary funding from BlueCross BlueShield because we had to make pretty significant investments in technology," says Bill Jolley, MPA, vice president of THA. "We had a good cross-section of hospitals involved, and their engagement was extremely beneficial; they really bought into it from the top down."
Getting things going
Jolley says the initiative came about because "there was some initial interest by BlueCross BlueShield in supporting our small and rural hospitals in some capacity as related to quality and patient safety. We had several discussions with them and had also been made aware of the research and work being done out of the rural research centers." THA was the "convener" of the hospitals, generating initial interest, he adds.
"Bill Jolley had experience with my center and contacted us because we do critical access hospital monitoring work, and they wanted us to evaluate the project," says Jill M. Klingner, RN, PhD, assistant professor of health care and operations management at the Labovitz School of Business and Economics, the University of Duluth, MN, as well as investigator at the University of Minnesota Rural Health Research Center and lead author of the article. "Judy had done a good deal of patient safety work, so she was a natural."
"Judy" is Judy Tupper, MS, CHES, research associate and managing director, population health and health policy, the Cutler Institute for Health and Social Policy at the University of South Maine Muskie School of Public Service. She "guided the hospital staff through much of the project," Klingner notes.
"We brought to the table relevant safety interventions and asked hospitals to do the self-assessment," says Tupper. "From that, we were able to come up with three interventions over two years." Actually, she adds, there originally were going to be two interventions — the PDAs and the protocols. "We thought the AHRQ tool was going to be part of the assessment, but it turned into an intervention. It offered a great opportunity to try to improve parts of the patient safety culture and allowed us to look at national benchmarks for the first time," Tupper says.
Her center, she continues, provided staff resources. "We were expected to take a leadership role in facilitating different interventions," she explains. After BlueCross BlueShield funded the purchase of the PDAs, for example, "we used East Tennessee University Medical librarians to do the training."
Tupper and her team held quarterly face-to-face meetings in Tennessee, and also had monthly conference calls. "We were able to build up very strong relationships; everyone shared how things were going," she recalls. "We also brought in best practices we could identify nationally."
The Tennessee QIO, she continues, took the lead with ED protocols. "They asked any of the hospitals if they wanted to contribute their protocols, and then put a collection together and turned around and gave it to the hospitals so they could bring them to individual meetings," says Tupper.
Sharon Doran, RN, director of the "Quality Plus" program and safety and risk management at Gibson General Hospital in Trenton, TN, says her facility was asked to participate in the collaboration in early 2007. "We were given an outline of things they wanted to accomplish and a list of projects; we decided which would be the most beneficial," she shares. The options were reviewed at each hospital by the quality staff, the medical staff, and the governing bodies, she adds.
The PDA initiative made great sense for the rural hospitals, she notes. "The availability of information on an instantaneous basis was just not there," she says. "We did not have access to large libraries without going off campus, but we needed that information to be on campus on the front end for doctors, so when they were prescribing medication they could have the information right at their fingertips, talk to patients about the meds, check for adverse interactions, and reduce medication errors." The PDAs, she explains, were linked up to a site at East Tennessee.
The ED protocol initiative, she continues, involved networking with other hospitals to develop a set of evidence-based protocols. "We shared them through meetings, and Judy and Jill made sure we were sharing them," she says. "We then took them back to our medical staff so they could be tweaked to fit our facility."
In terms of the PDAs, she says, some of the older staff members were "a little more resistant," but that was just a matter of overcoming the learning curve. "The people from East Tennessee and Bill Jolly had a special education session for the doctors," she adds. "I and one other staff member were very computer savvy and went initially to the doctors as needed, reinforcing the key messages and making sure they were using the PDAs." Most of the doctors, she says, "were really excited to have them." Toward the end of the study, she adds, nurse managers were also given PDAs.
Doran says that medication errors have dropped "at least 15%," which she calls "a dramatic drop," especially since according to the study the reporting of adverse events actually increased. "We continue to slowly see more decreases," she says.
In addition, Doran continues, staff felt the time they were spending on the job was better utilized. "Staff satisfaction also improved," she says. The subsequent patient safety culture surveys, she shares, showed a much higher awareness of safety.
There also was some resistance to the protocols, says Doran, since some doctors object to standardization. "But I had been working with them for over 12 years," she notes. "And once you've proved yourself to them and explain how you can make their life easier in the long run, they accept it. We were also careful to choose the ER, because they have a very proactive physician director who is very open to doing this kind of thing — he's a quality manager's dream."
Keys to success
The key to success for such a wide-ranging collaborative, says Klingner, is "having engaged staff at each individual hospital — and we really had that. A lot of the quality managers or directors of nursing had strong physician or CEO champions — and you really need that dedication of leaders. You also have to identify which projects you need; in order for the project to work, it has to be something everybody cares about. In these hospitals, they had similar needs so it was easy to target these three initiatives."
"I give the credit to preparation of the staff preceding the actual project, picking champions who were proactive and had good staff relations," adds Doran. "You have to be careful about picking the right people on the front end. We also had excellent buy-in from administration, which is critical, and the support of THA and the research staff — they were really good facilitators for us in everything we did."
"It was a great experience to work with the small hospitals," says Tupper. "The combination of the hospital association, the research team, the funder, and the QIO — everyone came to the table. The great thing was that everybody agreed there would be no competition around patient safety; it freed them to work together as a collaborative."
Tupper adds: "We've developed a model here that has worked with critical access hospitals in Maine; you can take a small initiative, do it quickly, and spread it out to the whole institution."
Klingner agrees. "I think this is a unique collaborative that really can be a model for other kinds of projects," she asserts. "You had the hospital association and the QIO involved in some ED guideline sharing — a real cross-section of stakeholders that helped to neutralize some of the ulterior motives that might have been there if you just had the insurance company or the hospital association involved. This made it not 'just' an improvement project — not something designed to meet any of our individual priorities. These kinds of collaboratives really have lot of potential to make a big difference."
Reference
- Klingner J, Moscovice I, Tupper J, Coburn A, Wakefield M. Implementing patient safety initiatives in rural hospitals. J Rural Health. 2009; 25:352-357.
[For more information, contact:
Sharon Doran, RN, Director, Quality Plus and Safety and Risk Management, Gibson General Hospital, 200 Hospital Drive, Trenton, TN 38382-3324. Phone: (731) 855-7903.
Bill Jolley, MPA, Vice President, Tennessee Hospital Association, 500 Interstate Boulevard South, Nashville, TN 37210. Phone: (615) 401-7410. E-mail: [email protected].
Jill M. Klingner, RN, PhD, Assistant Professor of Healthcare and Operations Management, Labovitz School of Business and Economics, 1318 Kirby Drive, 335 K LSBE, University of Minnesota Duluth, Duluth MN 55812. Phone: (218) 726-8626. Fax: (218) 726-7516. Investigator, University of Minnesota Rural Health Research Center, 2520 University Avenue SE, Suite 201, Minneapolis, MN 55414. Phone: (612) 623-8317. Fax: (612) 623-8324.
Judy Tupper, MS, CHES, Research Associate, Managing Director, Population Health and Health Policy, Cutler Institute for Health and Social Policy, USM Muskie School of Public Service, P.O. Box 9300, Portland, ME 04104. Phone: (207) 228-8407. Fax: (207) 228-8138.]
A broad collaborative covering numerous hospitals in Tennessee has implemented an impressive patient safety initiative for which results were just reported in the Journal of Rural Health.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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