A decade of improvements in patient care quality and safety
Fall 2009 marked the 10th anniversary of To Err is Human, the Institute of Medicine’s
groundbreaking report on medical errors. Its publication brought the issue of patient safety into sharp focus and spawned a decade-long endeavor across the United States to develop approaches to prevent medical errors and to improve delivery of care and the patient experience in all settings. That endeavor continues. The questions and answers below were prepared to describe to patient families, future patient families and the public Children’s Hospital Boston’s efforts in patient care quality and safety
across all fronts.
Is your hospital safer today than it was 10 years ago?
Yes. Safety has been a focus at Children’s Hospital Boston for many years, and we can
unequivocally say our care is safer today. In the last decade, we have focused major efforts on improving both safety and quality. We have:
; Built a Program for Patient Safety and Quality headed by a senior vice
president/practicing physician and composed of over 30 clinicians, biostatisticians,
risk managers, survey developer expertise, health science researchers, data
collectors and other professionals who examine our practices, identify and/or
establish quality benchmarks and metrics, study best practices in pediatric care
across the country and develop processes for designing and implementing safety
and quality initiatives.
; Implemented a full electronic clinical system, one of the first in a pediatric hospital,
that includes computerized physician order entry (CPOE), charting, notes and
medication administration records. Implementing point-of-care bar coding
technology across the inpatient units for medication administration and other
processes of care..
; Examined and addressed through education and training those behaviors that inhibit
open communication between senior physicians and trainees and between
physicians and nurses that put care at risk.
; In 2007, developed a Strategic Plan for Clinical Safety and Quality with the goal of
providing “safe, high-quality, high-value, coordinated care from the perspective of
the child with particular need(s), condition(s) or disease(s) and their family.” The
plan was developed with input from stakeholders across the organization, including
the Board of Trustees. A hospital-wide computer-based learning module to educate
the Children’s staff about the goals of the plan was deployed in fall 2008.
; Embraced CMS requirements, The Joint Commission’s National Patient Safety Goals
(NPSGs), Leapfrog recommendations, Institute for Healthcare Improvement
initiatives and other safety recommendations to ensure we are continually
improving the safety and quality of the care we provide.
What are you doing as a hospital to improve safety?
Our safety improvements fall into four main areas: Children’s-designed initiatives,
regulatory or accreditation requirements such as the NPSGs, flagship clinical projects and engagement with parents and the public.
Associate Attending policy: To the best of our knowledge, this is the first such practice change of its kind in the US. The policy’s goal is to improve the care of children with
complex conditions by improving communication among that child’s many specialists.
Every child is assigned a primary attending physician in CHAMPS, our clinical system. If a child is seen in the ED or admitted, his/her Associate Attending—the physician who
knows that child the best—is notified. The communication to the Associate Attending
and a response that he/she is aware the child is receiving care is documented in the chart. This helps prevent errors, complications, duplications of testing and services and improves the experience for the family.
Change of Service Policy: When patients are transferred from one service to another,
the transfer requires an attending-to-attending communication and it must be documented in the chart. This ensures that both services are aware who is responsible for the patient and that the transfer of knowledge about the patient has occurred.
Physician Consult Policy: This policy sets specific time expectations for consultations called from the ED. ED physicians are responsible for notifying the consulting service of the urgency of the consult, and consulting physicians are expected to meet the time expectations for both initiating and completing the consult. Consulting services are expected to have plans in place to activate additional back-up coverage, if necessary, to meet the time expectations. Data on response times is collected and reported to the chief of the consulting services. The goal of this policy is to make care safer through timeliness of physician consults, improve the ED experience for patients and families and to prevent back-ups in the ED.
ICU Infection Control: This program was launched in 2004 in the Cardiac Intensive Care Unit and has since been rolled out to all Children’s ICUs (NICU, MSICU, MICU) by an
interdisciplinary team of nurses and physicians, along with staff from Infection Control and Respiratory Therapy. The project involved establishing baseline infection rates for each unit; developing training programs to implement and formalize best practices across the units; and establishing databases and links between the ICUs to ensure reliable data collection and analysis.
Structured Communication (SBAR, appropriate assertion, closed loop) training: Communications issues are at the heart of nearly 40 percent of medical errors,
according to studies by the Risk Management Foundation, the hospital’s medical insurer.
Structured communication techniques enable and empower members of clinical teams to convey important information concisely yet thoroughly in situations where immediate attention and response are needed. To date, 5700 clinicians and patient care staff have gone through Structured Communication training. This training is given in new hire orientation for physicians, nurses and interdisciplinary staff. Monthly training sessions have been established for all physicians rotating from other hospitals.
CHEWS (Children’s Hospital Early Warning Score): Pediatric cardiopulmonary arrest
outside of the intensive care unit has a high mortality rate. In collaboration with a nationwide effort under Children's Health Corporation of America (CHCA), Children’s
implemented CHEWS as an objective tool to identify patients whose condition places them at risk for an arrest. The system establishes specific steps for a nurse’s
management of these patients and when to call in senior nurses and physicians. Children’s successfully piloted CHEWS in 2008 on surgical units, which went 202 days without an arrest, and then rolled it out to our medical units.
National Patient Safety Goals: Over the last decade, education, publicity campaigns,
measurement and auditing has taken place for all of these initiatives:
Labeling medications and solutions on the sterile field
Read back/feed back on panic lab values
Informed Consent policy: This is a major initiative for 2009. Signed and documented Informed Consent is now a Centers for Medicare and Medicaid Services (CMS) regulation for all surgical or invasive procedures involving a skin incision or puncture. Children’s is implementing an additional step—a Leapfrog standard—that requires that
clinicians verify that each patient or patient representative can "teach back" the procedure he/she just explained, in their own words. PPSQ Education and Implementation committees are developing training and a publicity campaign for physicians, nurses and others who ask for informed consent.
CHB Surgical checklist: This is another major initiative currently underway. The checklist, developed by the World Health Organization and adopted by CMS in 2009, has been modified to apply specifically to pediatric practice. The CHB Surgical Checklist identifies three phases of an operation: Before the induction of anesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgical team has
completed the tasks on the checklist before it moves on to the next phase. children’s is
in the process of implementing the checklist is the ORs and all other procedural areas, such as the cardiac cath lab, interventional radiology, etc.
Flagship clinical projects
Perioperative peripheral nerve injuries elimination: In 2008, SERS picked up a higher
than expected number of PPNI at Children’s. The Senior Clinical Leadership Committee (SCLC) assigned the issue to PPSQ, where a team was assembled to analyze the cases where injuries occurred, identify risk factors in patients and in practices, and develop protocols to prevent injuries where possible.
Engaging with parents and the public in a transparent way
Tips brochure: A booklet inpatients and families, describing the role of
parents/guardians as active participants in their child’s care, and the need for the patient identification and medication reconciliation NPSGs. It is also available in Spanish. Disclosure policy: A policy that requires patients/parents/guardians receive timely, understandable and accurate information about an error or adverse event, delivered by the patient’s attending physician.
Patient Experience Committee: A committee charged assessing our current capabilities to assure patient and family satisfaction with their care at Children’s; improving
approaches and tools to assess patient and family satisfaction with the care delivery experience; and implementing optimized models of care delivery based on feedback from patients and families.
Family Advisory Committee: A committee composed of parents of children who are
treated frequently at Children’s, staff members and current and former patients that
provides consultation on how to improve collaboration between families and health care providers.
External Quality and Safety website: An external web site on the Children’s Hospital
Boston site that describes the mission, vision and values PPSQ and reports on clinical outcomes, SREs and other safety-related measures.
Risky Business-Safe Solutions conferences: The second of these conferences was held
in spring 2009, where quality experts and business leaders offer the benefit of their expertise and experience through lectures and workshops on areas related to leadership, teamwork and human factors that contribute to adverse events. Day one of the two-day conference was open to the public.
Are you in support of mandatory reporting of hospital errors?
Yes. In August 2008, Massachusetts Governor Deval Patrick signed “An Act to Promote
Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care,”
which requires hospitals to report health-care associated infections, “never events” and
serious reportable events (SREs) to the Massachusetts Department of Public Health. Since April 2009, “never event” and SRE information has been publicly reported on the
web site of the Massachusetts Health Care Quality and Cost Council. This information is posted here on our the Patient Safety and Quality site.
Are hospitals underreporting errors to the public?
That is impossible to truly know. However, because there is a lack of specificity in the reporting requirements, it is possible. Until the exact requirements are mandated, there will be inequities in the types of errors and unexpected outcomes each hospital reports. Hospitals that “over report” may be perceived as less safe than those who “under report,” while this may just be a reflection of how the rules are interpreted. Children's Hospital Boston errs on the side of over-reporting as we feel an open and transparent relationship with the public serves their “right to know” and will engender greater trust in the long term.
How do I know if your hospital is safe?
All clinicians are encouraged—and required—to report errors through our electronic
Serious Event Reporting System (SERS) program. Every suspected error or incident
submitted is followed up on by staff from PPSQ. There is ongoing, regular training for staff on reporting requirements and all safety initiatives and goals. Administrators are responsible for reviewing SERS that pertain to their areas of responsibility, ensuring that proper follow-up to the event is attained, and ultimately signing off on the event. Over 40 administrators attended the meeting held in January 2009.
PPSQ continually monitors and measures compliance with CMS, TJC and other regulations, requirements and initiatives. Children’s was recognized by the Leapfrog
Group as a “Top Hospitals for 2008,” one of only seven children’s hospitals.
In addition, we have in place:
Peer review processes
PPSQ, Patient Care Services and the Office of General Counsel established the Medical and Nurse Peer Review Committees in August 2006. The committees are a component of the hospital’s Patient Care Assessment Program, charged with providing an
interdisciplinary review of all significant adverse clinical events with the goal of improving patient care and systems of care when the need is identified.
Patient Safety Data Dissemination
A data dissemination plan for patient safety goals, publicly reported quality measures and other important safety and quality indicators of unit- and service-based performance was created this year. This system will enable individual areas to assess their current level of compliance with safety and quality indicators at any time. Data is collected by PPSQ data coordinators and submitted by unit observers. The data is entered into a database, from which reports are generated and posted for all unit staff to see every month.
Harvard Business School Quality and Safety Leadership Development Symposium
In January and April 2008, Children’s sponsored 75 senior leaders, including physicians,
nurses, and administrators to attend a two-part session at Harvard Business School. The purpose of the series was to provide context and managerial tools from both the
healthcare and non-healthcare industry to help implement our Strategic Plan for Clinical Safety and Quality. Members of the Board of Trustees also participated in part of the session.
Physician Quality and Safety Metrics
Children’s is establishing a system to track and analyze performance measures for all staff physicians. At this time, 98 percent of all procedural staff are covered by at least one measure and 94 percent of all full-time staff have measures established. This information is provided to physicians’ chiefs and is also provided to the Board of
Registration in Medicine when required in response to an adverse event.
The departmental review process was established so that each chief would work in collaboration with PPSQ to develop a comprehensive report for Senior Clinical Leadership Quality Committee (SCLQC). Each report includes department/division level data for each applicable measure contained within the overall CHB Comprehensive Quality Report.