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PSIC Texas State Team Project : 

PSIC Texas State Team Project Team members: Cindy Bednar, RN, Josie R Williams, MD, MMM

Original Texas-sized Goals: 

Original Texas-sized Goals · Learn to develop and implement sustainable systematic patient safety processes, procedures, tools and techniques to improve the safety of medical care across our state. · Support Texas healthcare agencies by developing and implementing sustainable patient safety programs and medical error reporting systems as mandated in Texas House Bill 1614. · Develop comprehensive and cohesive patient safety processes, procedures, tools, techniques and training curriculum. · Identify dissemination strategies for this curriculum with the potential to facilitate patient safety improvement throughout Texas healthcare organizations. · Implement the curriculum in RCHI network hospitals as an alpha test of the curriculum ultimately improving the medical care safety for all Texans. · Develop an effective evaluation of the program implementation and analyze patient safety improvement derived from the curriculum.

Revised Texas-sized (Ambitious) Goals: 

Revised Texas-sized (Ambitious) Goals Provide training across Texas on RCA process using NCPS tools, with comparative evaluation and explanation of Best Practice. Teach RCA evaluation process for rural hospital and provide support to rural hospital in implementation of action plan. HFMEA evaluation of High Risk Medications in rural hospital (Palo Pinto) and support implementation of action plan related to high risk medications. Implement rural hospital patient safety support center and website (75%completion).

Training across Texas on RCA Process: 

Training across Texas on RCA Process 6 hour session-State Bill, Human Factors, RCA review, comparison, best practice. 1. Houston, Austin, Dallas, Tyler, Lubbock. 2. Utilized the slides from training. 3. Delivered tools to each participant. 4. Set up conference calls for support (in progress). Reviewed with approximately 365 people the RCA process and discussed the NCPS process as a current best practice with emphasis on systems interventions & human factors.

Teach RCA Rural Hospital and Implement Action Plan: 

Teach RCA Rural Hospital and Implement Action Plan Small Regional Hospital taught RCA evaluation process. Average daily census 18. Implemented read back policy for medications—struggling with culture. Implemented five rights in medication ordering-revising order sheets and considering CPOE. Facilitating medical staff discussion around telephone order protocols. Discovered authority gradient-Not yet addressed—culture and resources.

Other RCA Training: 

Other RCA Training Licensed 99 bed facility with average daily census 30-35. RCA on process for implementation of performance measures. Redesign of patient care intake, follow-up, and tracking of performance measures in progress.

Other RCA Training: 

Other RCA Training Licensed 20 bed facility with average daily census of 3-6. Called following RCA Training for training and support to do RCA on critical incident. Scheduled Conference Calls for support.

HFMEA Evaluation of High Risk Medications in Rural Hospital: 

HFMEA Evaluation of High Risk Medications in Rural Hospital (Palo Pinto)high risk medications in emergency room and ICU with the transient of care. First training implemented May 11th, 2004. Anticipate utilizing resources and colleagues.

Rural and Community Health Institute (RCHI) Website: 

Rural and Community Health Institute (RCHI) Website Root Cause Analysis Conference Calls RCHI staff will be available to discuss Root Cause Analysis on the following dates: April 29, 8-9 a.m. May 7, 8-9 a.m. May 21, 8-9 a.m. June 4, 8-9 a.m. June 18, 8-9 a.m. To participate, call toll-free 1-866-550-1029 or locally 847-9189.

Patient Safety Program Enrollment Form : 

Patient Safety Program Enrollment Form Directions: To enroll in the Patient Safety Program, complete this form online or print and mail it to: Patient Safety Program Rural and Community Health Institute Texas A&M University Health Science Center John B. Connally Bldg. 301 Tarrow Street, 7th Floor College Station, Texas 77840 Organization Name: Address: City: State: Zip: Hospital Representative: Phone: Hospital CEO: Phone: Next »

RCHI Patient Safety Program www.rchitexas.org : 

RCHI Patient Safety Program www.rchitexas.org Forms Enrollment (also in PDF) Best Practice System Reportable Events System Close Call Reporting System (@ UT)   Administrator Login » Skip Navigation RCHI

Rural Hospital Peer Review Inter-facility: 

Rural Hospital Peer Review Inter-facility Blinded patient, facility, physician. Like specialty, like facility. Telephone secured committee review. Records posted 1 week prior to review in a secured password protected web-based folder. Appropriate guidelines posted with records Facility information sheet incorporates many of the patient safety trigger tool questions.

Small Rural North-central Texas Hospital: 

Small Rural North-central Texas Hospital Safety Climate Survey March 2003 Table 2: Psychometric Properties of the Safety Climate Survey* From: Sexton, Helmreich, Rowan, Vella, Boyden, Neilands, Roberts, Thomas. 2003

Sexton Survey Overall Facility Score: 

Sexton Survey Overall Facility Score Total Employee ~ 411 Overall Mean = 4.11 out of 5 (SD = .61) Range 2.16 – 5.00 N = 247 Largest group of respondents in “Other” job category 46% Registered Nurse 19% Technician 11% LVN 7%

1 Facility Small Rural North-central Texas Hospital Psychometrics: 

1 Facility Small Rural North-central Texas Hospital Psychometrics Cronbach Coefficient Alpha = .88 Factor analysis revealed two factors 1st – Trust in management (66% of variance) 2nd – Trust in staff (13% of variance)

Sexton Survey Highest and Lowest Areas: 

Sexton Survey Highest and Lowest Areas Highest Scoring Question: Q9 I know the proper channels to direct questions regarding patient safety. Lowest Scoring Question: Q3 The senior leaders in my hospital listen to me and care about my concerns.

Sexton Survey Summary: 

Sexton Survey Summary The majority of respondents thought the climate was conducive to learning from mistakes Sixty-five percent of respondents believed medical errors were handled appropriately About half of respondents thought nurse and physician leaders listened A large majority of respondents believed leaders were emphasizing safety Seventy-percent of respondents believed management would act on their suggestions Seventy-percent of respondents believed productivity was not placed above safety Eighty-one percent of respondents believed colleagues encouraged safety concern reporting

Sexton Survey Summary (cont.): 

Sexton Survey Summary (cont.) Almost ninety-percent of respondents believed they knew the proper reporting channels About seventy-five percent of respondents thought appropriate feedback was offered Eighty-percent of respondents would feel safe being treated in the facility Sixty-four percent of respondents believed shift briefings contribute to safety About half of respondents thought briefings were common Fifty-six percent of respondents were satisfied with the physician leadership

Sexton Survey Summary (cont.): 

Sexton Survey Summary (cont.) Fifty-five percent of respondents were satisfied with nursing leadership Fifty-eight percent of respondents were satisfied with pharmacy leadership Sixty-three percent of respondents believed patient safety is more of a concern than a year ago About sixty-percent of respondents believed AEs due to multiple failures Over seventy-percent of respondents believed personnel take responsibility for patient safety Fifty-seven percent of respondents did not think personnel disregarded safety rules Sixty-six percent of respondents believed patient safety is reinforced constantly

Rural Hospitals: 

Rural Hospitals Grubb (1994) describe a successful implement quality improvement in a small rural hospital in Washington state. The following challenges, which are still typical of such hospitals, described in 1989 included: obtaining organizational support and resources; initiating process improvement in very small departments; obtaining valid data to compare with similar hospitals; improving low-volume processes. Five years later, the authors identified key factors in success as: strong support from the board of directors; dedication from the administrators; a diverse Quality Council; the hospital’s warm, family culture; working in and between departments; and a cadre of quality champions.

References: 

References Barker KN, McConnell WE. (1962). The problems of detecting medication errors in hospitals. American Journal of Hospital Pharmacology 19: 360-9. Brasure M, Stensland J, Wellever A. (2000). Quality oversight: why are rural hospitals less likely to be JCAHO accredited? Journal of Rural Health, 16(4), 324-336. Busteed S, Barwick S, Grubb L. (1994). The challenges of implementing quality improvement in small rural hospitals. Quality Letter on Healthcare Leadership, 6(6), 25-29. Helmreich RL, Merritt AC, Sherman PJ, Gregorich SE, Wiener EL. (1993). The Flight Management Attitudes Questionaire (FMAQ). NASA/UT/FAA Technical Report 93-4. Austin, Tx The University of Texas. Karow HS. (2002). Creating a culture of medication administration safety: laying the foundation for computerized provider order entry. Joint Commission Journal on Quality Improvement, 28(7), 396-402. Ricketts TC. (2002). Rural Health research and rural health in the 21st century: the future of rural health and the future of rural health services research. Journal of Rural Health, 18 Suppl, 140-146. Moscovice I, Rosenblatt R. (2000). Quality-of-care challenges for rural health. Journal of Rural Health, 16(2), 168-176. Ricketts TC. (2000). The changing nature of rural health care. Annual Review of Public Health, 21, 639-657. Rogers EM. (1995). Diffusion of Innovations, (4th Ed.). New York, NY: The Free Press. Rosenblatt RA, Baldwin LM, Chan L, Fordyce MA, Hirsch IB, Palmer JP, Wright GE, Hart LG. (2001). Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities. Journal of Family Practice, 50(8), 676-80.

Texas Team Observations: 

Texas Team Observations Training alone is probably insufficient. Ongoing support maybe essential. Trust and partnerships are crucial. Marked variation in current knowledge & sophistication of current hospital staffs. Resources-(personnel,knowledge & finances) in our rural population will make implementation painfully slow but doable. Significant gaps in understanding, knowledge, implementation and utilization across state.

Texas Team Observations: 

Texas Team Observations Quantification of results across a state especially early in this process is very difficult, we felt it superficial. Ratings of training are still being evaluated but anecdotally have received high marks. We believe the RCA’s the state receives from the facilities attending the training will probably be of a higher quality. RCHI anticipates utilizing the rural network support center and will do a semi-annual evaluation of the types of challenges and issues rural facilities experience including resource demands in reporting and doing root cause analysis.

Texas Team Observations: 

Texas Team Observations NCPS best practice RCA’s is significantly more rewarding and useful for change than other processes. Significant education/change for sustainable implementation will be required. Implementation is just beginning and will likely be slow. Resources are scarce, and The collective will in our State to implement maybe lacking without significant incentive and/or resource supplementation. Smallness/rural is both advantage and barrier to implementation.

Wish Lists: 

Wish Lists Include in the application the expectation of project completion and the level of completion you anticipate. Establish an ongoing connectivity between teams at least annually. Consider the inclusion of methods and or tools for qualitative and quantitative evaluative results in the training sessions early in the process. Consider including some funding or sponsors to help in the implementation of the projects. Consider state team building each year.

Steady as She Goes Conclusions (or Rome wasn’t built in a day): 

Steady as She Goes Conclusions (or Rome wasn’t built in a day) Training alone is probably insufficient. Trust and partnerships are crucial. Marked variation in current knowledge & sophistication of current hospital staffs. Resources/training in our rural population will make implementation painfully slow but doable with support. Significant gaps in knowledge, implementation and utilization across state hospital facilities. Smallness is both advantage and barrier to implementation. Consider training of significant professional societies.

Our Websites: 

Our Websites http://www.rchitexas.org/ http://www.rchitexas.org/patientsafety/enroll.php

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