This contribution from Allied Services Rehabilitation Hospital continues the PA-PSRS Patient Safety Advisory series on leadership perspectives of patient safety. Allied Services was instrumental in a task force initiative to reduce the risks associated with use of color-coded patient wristbands, as reported previously in the December 14, 2005, supplementary Advisory. In the wake of this initiative, at least 10 other states have followed suit to some degree, and Joint Commission has linked to the task force’s toolkit at http://www.jcipatientsafety.org.
While there is no single formula to achieve a culture of safety in an organization, one key ingredient that drives and sustains the process is leadership. As we look back on how we arrived at an open culture of safety and reporting in our organization, we consider the synergistic dynamic between the leadership at our facility and the Patient Safety Authority. Our foundation for change was built on teamwork and the commitment from hospital leadership that focused on patient-centered care and improvement. Our efforts began a little more than a year before mandatory reporting was enacted within the commonwealth when we initiated a project to revamp our incident reporting processes. Over the ensuing year, we saw a convergence of change locally and nationally with the passing of Act 13 and the initial set of National Patient Safety Goals. As all of these dynamics came together, it reinforced the vision of change underway in our organization. As we retrospectively looked at the impact of the Authority during this period, we found our program benefited in two ways. First, PA-PSRS led us to analyze our data from a different perspective, which allowed us to identify new opportunities for improvement. Second, the Authority offered the ability to learn from the experiences of other facilities by publishing the PA-PSRS Patient Safety Advisory.
Responding to Data
Theadvent of PA-PSRS led to an expansion of the categories of reportable events at our facility. For example, prior to the implementation of PA-PSRS, our facility did not analyze pressure ulcers with respect to whether they developed pre- or posthospitalization. Through the use of our own data available in PA-PSRS, we began to intensely analyze pressure areas that were pre-existing as compared to those that developed after admission. The necessity for reporting this information combined with the ability to extract and analyze the data allowed our Patient Safety Committee to assess the root causes of skin breakdown that occurred after admission to our facility. This led us to develop new skin protocols that promote a more proactive approach in targeting at-risk patients. Although our initially observed post-admission incidence of skin breakdown was low, we have further lowered that rate by 47% since introducing the revised processes.
Responding to Advisories
Our patient safety program has also benefited from the Authority sharing “lessons learned” in other facilities in Advisory issues. In December 2005, the Authority alerted hospitals to the risks associated with use of color-coded patient wristbands. A statewide survey by the Authority revealed that a significant number of hospitals used color bands to communicate risk, and that there was no standardization in color, even within divisions of the same healthcare systems. As a rehabilitation hospital, with two units in local acute care facilities, this potential for error struck a chord. The review of the December 14, 2005, supplementary Advisory issue at our patient safety meeting in January 2006 launched a community initiative. Within five months, the Color of Safety Task Force, comprised of 11 hospitals from the northeast and central regions of Pennsylvania, was well on its way to developing the first standardized approach to use of color-coded wristbands. Ultimately, the task force developed a toolkit that could be adopted at any facility, and the Authority published a follow-up supplementary Advisory outlining the task force’s information and risk reduction strategies. Since that date, the information has been used state- and nationwide as a basis for other facilities and agencies. This is now available as a reference document on the Joint Commission International Center for Patient Safety Web site and is listed as a best practice (see http://www.jcipatientsafety.org).
PA-PSRS Data and the Patient Safety Authority: Hype or Help?
Without the Patient Safety Authority and PA-PSRS, would we have reached this point? As leaders, we recognize that each resource that plays a role in our patient safety program contributes to improving quality. How we respond is up to us. While the scope and size of organizations and technology vary greatly in Pennsylvania healthcare facilities, we have found the utility of the data from PA-PSRS and the lessons shared in issues of the Advisory provide added benefit to our patient safety program, and directly benefit the people we care for. With more than a half million reports entered thus far, the Authority has the capability to expand their efforts into producing a more detailed database for hospitals to tailor to their facilities’ scope of practice.
Going forward, it has been suggested that the Authority develop a standardized “how and when” reporting methodology for hospitals to follow. This would foster a more meaningful benchmark capability for providers interested in comparing their facility’s performance to similar institutions. Additionally, the development of a formalized way for hospitals to access standards of care or processes successfully developed in response to “lessons learned” would be an invaluable educational resource.
Even without these enhancements, no available resource to improve patient safety should be discounted. Although we are already subscribing to alerts published by ECRI Institute, the Institute for Safe Medication Practices, and the Joint Commission, the PA-PSRS Patient Safety Advisory is yet an additional tool for us to use in evaluating whether we had the same risks present within our organization that other Pennsylvania facilities were experiencing. There was a time when hospitals were reluctant to openly discuss adverse events. Details of these occurrences were “whispered” in fear of punishment and legal retribution. The efforts of the Authority have led to honest sharing of information within and between facilities. Finally, they have us talking out loud.