Honoring the Best Hospitals Providing Quality Care
Each year, the American Hospital Association honors as U.S. hospital with its Quest for Quality prize, given for innovation and progress in measuring and improving the quality of care. The 2003 recipient is Abington Memorial Hospital in Pennsylvania.
Heading Off Harm Before It Happens
Abington (Pa.) Memorial Hospital
Recognizing that health care delivery will never be 100 percent error-free, Abington (Pa.) Memorial Hospital's patient safety program aims to head off errors before they cause harm. If an error does occur, redundant processes and systems are there to contain it. This philosophy is featured in the preface of Abington's Patient Safety Plan, which every employee must sign: "We, as human beings, in our roles as health professionals, will always make mistakes. We cannot change the human condition but we can change the systems within which we work."
Patient safety has long been a priority at Abington. Leaders of the 508-bed community teaching hospital in suburban Philadelphia believe safety is part of the hospital's obligation to provide quality care. But, like most health care organizations, the Institute of Medicine's reports on medical errors led the hospital to formalize its efforts. "The IOM reports galvanized us to review our approach to care," says chief patient safety officer Jack Kelly, M.D., chair of Abington's Department of Medicine. "Currently in health care, we hold people to a standard of perfection. That's not the right standard because errors will occur. We need to place enough redundancies in the system, enough barriers to prevent errors from causing harm."
One key feature: the patient safety effort has strong support from the top. The chief executive officer and other executives engage staff on safety issues. "It's got to involve more than just lip service and a mission statement," Kelly says. "The staff knows we are very serious about this." A critical step is to establish open communication and a non-punitive environment. "We have a very rigorous structure that supports our philosophy of preventing harm from reaching the patient," says Meg McGoldrick, executive vice president and chief operating officer. "We've created policies that put into writing what we need to do. Our staff feel supported on their end to improve patient safety." Abington educates employees on its safety policies and initiatives and encourages them to examine every process for potential error. "We continue to iterate this through safety education and the science of safety," Kelly says. "Communication and safety science is not something we've been trained in."
To improve communication, Abington established multiple avenues for reporting near misses and safety ideas. Twenty-six suggestion boxes throughout the hospital encourage staff, families and patients to comment. Reporting can be anonymous; if a name is provided, a thank-you note is sent as follow-up. Other means of reporting include a 24-hour hot line and direct reporting to management. "We take every opportunity to talk about patient safety," McGoldrick says. Patient safety is on the agenda at nearly all meetings, from the board to individual units. A quarterly patient safety newsletter updates staff on the hospital's efforts and bulletin boards on patient floors help spread the message. "This is not a top-down effort," Kelly says. "It's very grassroots." Continual reinforcement of the non-punitive policy and the importance of reporting hazards has paid off. "People are much more willing to come forward," says Barbara Wadsworth, administrative nurse director. "We've seen a big increase in suggestions. Before, people did not have a way to report them." Once a suggestion is made, the hospital prioritizes and tracks it.
The Integrated Patient Safety Working Document, maintained by the Patient Safety Working Group, is updated weekly to note new additions and track efforts. New items are assigned to members to evaluate for the group, which meets weekly to discuss ongoing projects and new suggestions. Projects are prioritized based on variables including likelihood of occurrence, potential severity and availability of solutions to correct it. The Patient Safety Working Group is multidisciplinary, consisting of Kelly, the vice president of professional services, staff from the department of patient safety and performance improvement and nurses. Members serve as patient safety liaisons, reporting to and from their departments. The group reports to a Patient Safety Committee, which Kelly chairs, and includes two representatives from the community. Also reporting to the Patient Safety Committee is a Patient Safety Employee Committee, comprising non-physician employees representing various hospital departments.
A separate Patient Safety Oversight Committee, which consists of board members, the chief operating officer, chief medical officer, and physician and nurse leaders, allocates money and other resources to enhance safety. Because of the large volume of patient safety improvement suggestions and the number of projects, the IPS Working Document is reviewed each year to prioritize projects. Clinical department chiefs, nursing and administration are polled to determine which projects deserve attention and resources. Kelly addresses urgent clinical matters immediately. Technology plays a central role in Abington's patient safety program. Computerized physician order entry has been available for about eight years; the hospital mandated it when it made patient safety a formal organizational priority.
CPOE is credited with reducing errors during ordering and transcription by more than 50 percent and has virtually eliminated the need for the pharmacy to ask for orders to be clarified. "We've realized a lot of improvement through technology," McGoldrick says. "CPOE provided a phenomenal running start." Abington is investing $10 million to $15 million for software upgrades for CPOE to provide physicians with speedy access to clinical information. Investment in safety technology is one way the organization demonstrates its commitment. "Whatever is in the marketplace that is tried and true, we will bring to our organization to improve patient safety," McGoldrick says. "We have a long list of patient safety goals that drives the allocation of resources. We fund good patient safety ideas. It's our No. 1 priority." A bar coding pilot is slated to begin in July 2004, she says. When good technology is not available, Abington finds its own solutions.
The hospital developed a Web-based anticoagulation clinic to monitor patients on Coumadin. The system provides physician offices a list of all their patients on it, identifies patients past due for testing and notifies the physician when the patient should stop taking the medication. The result has been a significant improvement in appropriate anticoagulation treatment. One challenge: gauging the success of the patient safety program. Measuring response and reporting is difficult because the organization has no baseline with which to compare. "We are doing things we weren't doing before," McGoldrick says.
The hospital has expanded its performance report to reflect patient safety and clinical measures. Abington leaders believe in sharing its experiences. "We are ethically obligated to share information, whether errors or system improvements, with other health care organizations," Kelly says. Much of that occurs through Abington's participation in the Delaware Valley Healthcare Council and VHA. Kelly also strongly urges hospitals to advocate for adequate resources from the government. "Mandates for safety are well intended, but need to be accompanied by appropriate resources to achieve the intended goal," he says.
