Our "final exam"

Everyone knows what it is like to prepare for a final exam. The last minute cram sessions. The study lists. Classmates challenging one another with questions and answers in late night study groups. But it's a rare person who can make up in a few cram sessions for studies otherwise neglected during a semester's classes.

This week was a kind of final exam for Community General Hospital. The examiners were on-site surveyors from the Joint Commission, the body that accredits hospitals. Yes, we have been cramming for this examination for some time, but it is not a test you can study for short-term. You have to be following the polices and processes every day in order to meet accreditation standards.

We did not know the date of our examination. But we knew that Community was due for a survey in 2010.

Last Tuesday morning the surveyors arrived on campus unannounced for the four-day examination. Throughout the week they met with patients and caregivers, they reviewed our policies and processes, observed a surgical procedure, reviewed performance data, and they met with board members, physicians, nurses and support staff.

The Joint Commission has four categories of scoring:

1. There is an immediate threat to life.

2. Specific situations prompt a preliminary accreditation denial or make an accreditation conditional.

3. There is a direct impact on safety or quality

4. There is an indirect impact on safety or quality.

First, I am glad to say that Community did well. Although we won't have the final results for ten days, it appears we will receive a full three-year renewal of our accreditation.

Second, we learned a lot.

It is not strange to say that our learning continued, even during this "final exam." The surveyors score the hospital on what they find, grouping the findings into the four categories summarized above.

But the point of the survey is not only to check off "wrong answers." It is also a collaborative process, and that means surveyors suggest ways to achieve better results. They told us what other hospitals are doing, and they gave us examples.

In some cases, the surveyors asked us for copies of policies, forms, or data displays that they thought were effective and could benefit others. I was happy to hear that Community demonstrated good team work and showed evidence of good patient care. But we are far from perfect.

The surveyors cited Community for seven direct findings and for 12 indirect findings. We have six to eight weeks to address these issues, depending on whether it is a direct or indirect finding.

Here are the surveyors' findings in areas that have direct impacts on safety or quality:

▪ Managing safety: Documentation of weekly checks of emergency eye wash stations was missing in two areas. There were several instances where call-alarm pull-cords were wrapped around grab bars. And a red bag (infectious waste) was improperly left in a patient care corridor in one area.

▪ Managing hazardous materials: In two cases, employees were not able to respond immediately to questions about what to do in the event of a formaldehyde spill. (Formaldehyde is toxic chemical compound.) Also, rooftop exhaust fans were not identified with bioharzard labels.

▪ Utility risk management: Electrical junction boxes were not properly covered in several locations, and proper room ventilation was not checked in a procedure room earlier this year when such checks were done on all operating rooms.

▪ Medical equipment: The daily check of a backpack containing emergency supplies was not documented, and checking an emergency cart in another area was not documented on three different days.

▪ Construction safety: The hospital's policy did not require temporary sign placement when an emergency egress route is temporarily changed during construction.

▪ Emergency exits: The sliding doors at main entrances had manufacturer-installed locking devices that compromised the breakaway feature in an emergency. Also, surveyors noted several instances where equipment in hallways partially obstructed corridors.

▪ Informed consent: There were two instances where the informed consent process was incomplete. In one case documentation did not include a patent's likelihood of achieving his or her goals. In another, the risks, benefits, and side-effects of alternatives were not documented.

In a few cases we were able to make changes on-the spot, such as the roof vent labels, junction box covers, and breakaway door switches. Other changes will take time, and we have Joint Commission deadlines.

There is work to do as a result of these survey results, and next week we start with a meeting of the Board of Directors. The survey shows how well we are doing things, but the real goal is to get better, and our "final exam" will help us do that.

A just culture

When there was a wrong side surgery at Community in 2004, one of the many things we did was to seek help from the Joint Commission.

Our surgical mistake was the result of several factors, not an intentional act. Our follow-up naturally involved questions of system risk and individual responsibility. I asked the Joint Commission consultant where to draw the line between an individual's error and a system failure. She spoke about a blame-free work culture as one that emphasizes system solutions while a punitive culture focuses on individual responsibility. The pendulum, she said, was moving somewhere between these two points.

Two authorities, who will be in Syracuse next week for presentations at the Syracuse Healthcare Quality Forum, recently co-authored an article that addresses this issue. Drs. Peter Provonost and Robert Wachter, writing in the New England Journal of Medicine, say that in the last decade

[m]ost health care providers embraced the "no blame" model as a refreshing change from an errors landscape previously dominated by a malpractice system that was generally judged as punitive and arbitrary. . . . Many health care organizations (however). . . have (since) recognized that a unidimensional focus on creating a blame-free culture carries its own safety risks.

They authors discuss a patient safety approach that balances individual responsibility with system risk. This is the "just culture." They identify three types of risk: human error, risky behavior, and reckless behavior. Here are examples:

- When I drive through a red light because the sun is shining in my eyes, the traffic risk for which I am responsible is inadvertent -- human error.

- If I drive through the traffic signal because I am in a hurry, I am engaging in risky behavior. In this case, I am choosing to accept the additional risk of a traffic accident as preferable to the consequences of being late for work.

- If I choose to drive through red lights whenever intersections are not busy, then my behavior is not just risky, it is reckless. In other words, I am repeatedly engaging in risky behavior.

A decade ago two reports on the health care industry made it clear improvements were necessary in patient safety. These were To Err is Human: Building a Safer Health System and Crossing the Culture Chasm: a New Health System for the 21st Century. In the years since, hospitals have understood how risky healthcare environments can be and how important is systems thinking in reducing the risk.

As a result, hospitals focused more on safer processes (such as using check lists to prevent central line infections and requiring 100% compliance with the universal protocol to prevent wrong-side surgery). They have also focused on technical support for safe practices (such as making hand washing easier with more conveniently located sanitizers and computer order entry to reduce transcription and handwriting errors).

Such changes have improved patient safety, yet hospitals are still not as safe as they should be. Drs. Wachter and Provonost challenge us to create a just culture by a better balance between process and technology changes (system safety) and the importance of following safe practices consistently (accountability):

[W]e have shuffled this issue (the balance between a blame-free and an accountable culture) to the bottom of the deck, preferring to work on easier, less contentious safety activities, such as computerization and checklists. It is time to raise this topic to the top of our agenda.

These are thoughtful observations from speakers we will have the opportunity to listen to next week. The Syracuse Healthcare Quality Forum is free for healthcare professionals.

And there is still time to register here.

Click here for safety

At a recent hospital management meeting, we discussed the importance of patient safety. I promised to collect various patient safety postings from this blog. These collected messages are now at a special address, accessed by the patient safety button (above my picture) or through the Community General home page.

The messages demonstrate the importance of patient safety – and its visibility – with Community's senior management . . . and me personally. This morning I emailed all managers to suggest they use these tools to reinforce patient safety messages within their departments.

Collegiality

When David Halleran, MD, was elected president of the Community General Hospital medical staff last month, he carried a dictionary with him to the podium. He opened to the definition of “collegiality” and reminded his colleagues how important it is to maintain respect for one another and to work toward common purposes.

Dr. Halleran, who is a colon rectal surgeon, said that "collegiality" is the theme of his term of office, and he encouraged his colleagues to recall why they chose careers in medicine. He reminded them how satisfying it can be to collaborate with others on patient care. “It’s still a great profession,” he said, “when you are caring for the patient.”

The stresses and strains affecting doctors were recently the subject of a New York Times article, called “The Falling-Down Professions,” which said, among other things:

▪ About 60 percent of doctors reportedly have considered leaving the medical profession.
▪ Nearly 70 percent of doctors know a physician who has already left medicine.
▪ Applications to medical schools are down about nine percent from 1997.
▪ Physician incomes have lagged behind those of other professions.

As the Times reported, “Complaints about managed care crimping doctors’ income and authority over medical decisions are nothing new, but the problems are only getting worse…” It quoted a doctor's complaint: “What irritates me the most is the use of the term ‘provider.’ We (physicians) didn’t go to provider school.”

If physicians have become “providers,” patients have also become “consumers.” The imagery may be inexact, but the commercialization of the medical care process is clearly a factor in the changing doctor-doctor relationships, the changing doctor-patient relationships, and (as I can attest) the changing doctor-hospital relationships.

This week I again heard Dr. Halleran speak about collegiality, this time at a meeting of the Quality Committee of the Board. He said that collegiality involves more than “being cordial.” Collegiality facilitates more effective communications among physicians regarding patients and their care. It’s also facilitates physicians and nurses working effectively to improve patient safety and to assure that patients get the right care at the right time.

Professional collegiality, or the stresses and strains to which it is subject, is an issue bigger than our corner of the world. But I’m very happy to have Dr. Halleran calling us to order – and getting us to work on it.