Mistakes happen — or, to quote the title of the well-known Institute of Medicine report from 1990, To Err is Human. That report found up to 98,000 Americans died annually due to medical errors. Unfortunately, things haven't improved with time: A 2013 study showed medical errors may cause as many as 400,000 deaths a year.
Those statistics, and the increased tie between patient safety and reimbursement, have patient safety at top of mind for many healthcare leaders.
According to Jeffrey Shapiro, MD, director of Patient Safety at American Anesthesiology, these facts drove the creation of American Anesthesiology's HRO Patient Safety Initiative, a push to help the company's practices develop and sustain a strong culture of safety and become HROs, or high reliability organizations.
Dr. Shapiro and American Anesthesiology first rolled out the program about two years ago at Piedmont Atlanta Hospital. Acknowledging that pilot's success, the organization plans to roll the initiative out to approximately one-third of its practices through the end of this year. American Anesthesiology has 29 practices, providing anesthetic care in 13 states, and is a division of MEDNAX, a national medical group that also provides neonatal, maternal-fetal, pediatric physician subspecialty services throughout 34 states and Puerto Rico. It's MEDNAX that invests in the clinical, information and management systems needed to improve patient outcomes through research, education, continuous quality improvement and patient safety initiatives.
American Anesthesiology's HRO Patient Safety Initiative focuses on the following:
Culture surveys. Before launching the initiative at a practice, American Anesthesiology measures the practice's existing culture of safety by conducting surveys, using elements of the Agency for Healthcare Research and Quality survey. The American Anesthesiology survey evaluates various practice functions such as error reporting, communication openness and teamwork.
Leaders from American Anesthesiology also conduct on site evaluations incorporating discussions with perioperative staff and colleagues working with the anesthesiology care team every day in hospitals and other settings; this includes members of the perioperative team, nurse managers and OR leaders. These individuals are queried about how they feel American Anesthesiology clinicians are performing and what areas can be improved upon in terms of patient transfers and other critical patient safety areas.
Leadership development. After evaluating the OR's current state of safety and perceived safety, the next step is to find the program's champions and help them become empowered patient safety advocates.
"When we first come in and start the program, we ask for natural leaders within a practice who are passionate about patient safety and are in a position to influence others," explains Katherine Grichnik, MD, director of the Center for Research, Education and Quality for American Anesthesiology.
Anesthesiologists and their teams may be the perfect proponents to drive a safety initiative for surgical patients, says Dr. Grichnik. "We believe anesthesiologists…are ideal for championing [a safety improvement program]. If you think about the OR environment, ensuring overall safe patient care is a key component of the anesthesiology team's responsibility. Anesthesiologists are often the glue that bonds the patient care experience between what happens in the pre-op area, in the operating room and in the post-operative care area."
Once identified, leaders go through an education process, which includes change implementation and leadership development, before helping roll out the program to the entire practice. During the development sessions, leaders go through a series of workshops and conduct hands-on practice. "We practice one-on-one so we have people who are inspired as leaders to implement the program and influence everyone in the perioperative setting," says Dr. Grichnik.
Dr. Shapiro adds, "It's our mission to train leaders to create the change necessary to establish a high reliability organization."
Team training. Once the leaders are trained, those leaders must in turn train the entire perioperative team on safety culture and how to support a high reliability organization. What's the most critical part of this training? It's communication, individual empowerment and establishing "just culture."
"We specifically teach the concept of just culture," says Dr. Grichnik, meaning that healthcare workers have a duty to speak up if they spot a problem. When they do speak up, they will not be penalized or otherwise retaliated against. "That's one of the single most impactful aspects of this initiative, that there will be no retaliation, if [they] speak up in the interest of patient safety," she says.
Team members also go through teamwork exercises and train to reduce variability in practice.
Safety tools. Developing leaders and teaching high reliability protocols won't lead to change unless the perioperative team has to the right tools to make the OR a safer place. American Anesthesiology developed a toolkit to empower the team. Two of the tools stand out.
Safety app: The organization created an application for smartphones that allows team members to report a concern or observation electronically. "The safety app has been a uniquely successful part of the program," says Dr. Grichnik.
For example, the safety app — in combination with a surgical team member's mindfulness — prevented a surgical fire. "Someone had inadvertently turned on a hot light source that was up against a paper surgical drape," Dr. Shapiro explains. A team member who "was mindful and engaged in the safety process" alerted the entire OR team through the safety app and the burnt drape was extinguished before causing a fire.
The app is effective because it makes it easy and simple for anesthesia providers to "speak up" digitally and message the entire team quickly to communicate alerts and concerns in real time.
Handoff checklist. This is another tool provided to employees through the program, for when the perioperative team "hands off" a patient to the PACU, the ICU or to each other during transitions of care. "We're all human," says Dr. Shapiro. "But the handoff checklist helps prevent mistakes and reduce variability in practice."
Although the checklists are important, both physicians are quick to say that they are not a "silver bullet solution" to safety issues in the OR. "They don't work unless we instill a culture of safety though a leadership and advocacy program," says Dr. Grichnik. "It's critically important to have all of these layers."
While both the app and the handoff checklist are standard for American Anesthesiology's program, the organization also tailors tools to specific practices based on information gleaned from the initial site assessment interviews and culture of safety surveys.
All of these components have contributed to the program's success, which American Anesthesiology measures through its post-program site assessment. "We know we're seeing more effective communication among providers," says Dr. Grichnik.
And the post-program safety culture surveys show the same, with one practice's results for the question "How often is a potentially harmful mistake reported?" jumping from 30 percent positive responses in the pre-program survey to 66 percent post-program.
"It is gratifying and impactful to empower team members to speak up, act fast and prevent errors in a team-oriented care environment," Dr. Shapiro states.