Top 5 Learnings for Patient Safety Week

By Katie Hilbert, Manager, Quality Initiatives

For the past 13 years, The Health Collaborative has awarded The Patient Safety Award to a team or individual that exemplifies dedication and commitment to patient safety. Since patient safety is not an issue confined to hospital walls, in 2015 we had 12 outstanding nominations (listed below) that included hospitals, skilled nursing facilities, health clinics, and physician offices.

Read on for the top 5 themes we’ve learned from our nominees and awardees over the years that have helped them improve patient safety in our community.

“To the community, patient safety means ‘Please keep my loved one safe while you’re doing the great things that I know you can do.’ ” – Steve Muething, MD, CCHMC (2009 Awardee)

Rena M. Sorensen (center),
2015 Richard M. Smith, MD
Patient Safety Award Winner

1. Communication is key

Actively listen to your coworkers and patients and communicate with them in a way that they will understand. There are many techniques that are helpful with communication and patient safety. SBAR (Situation, Background, Assessment, and Recommendation) is a best practice communication standard that helps doctors and nurses communicate with each other in a clear, concise, and structured format that helps improve accuracy of information.

3-way communication, or repeat back, is a useful technique to ensure understanding of communication. A sender gives a communication, the receiver acknowledges and repeats back that communication, and sender confirms that acknowledgement. 3-way communication is very important in all aspects of patient safety, but specifically for medication orders.

2015 nominee Nicole Barnett, Infection Prevention Specialist at The Jewish Hospital – Mercy Health, has mastered the art of communication with physicians, nurses, case managers, staff members, and patients & their families. Her nominators say she connects instantly with them and understands that people absorb information in different ways. She “speaks their language” to help them understand what’s going on in terms of infection prevention. Thanks to her efforts, the C-diff rate at her facility saw an 87% reduction in the first half of 2015!

“We need to all work together to share best practices, to standardize and simplify care processes, and to support each other in quality and patient safety collaboratives.” – Lisa Banks, RN, CPHQ, Margaret Mary Health (2005 Awardee)

2. We can’t do it without a culture of trust

We are all responsible for patient safety, but if the culture of your organization doesn’t allow you to feel comfortable identifying quality and safety problems then we’ll never improve. Organizations need to embrace a questioning culture in which a nurse feels comfortable questioning a doctor without being reprimanded, or a patient/family can speak up without being ignored, if they don’t think something is right.

This culture can be established through anonymous reporting programs where workers can report “near misses” or “good catches,” mistakes that are caught before they hit the patient. Leadership acknowledges these reports as learning opportunities for the entire organization to improve their processes.

The Quality Assessment and Performance Improvement (QAPI) team at The Beechwood Home were nominated for the Patient Safety Award in 2015, for developing a culture that involves seeking input from the nursing home’s faculty, staff, residents, and their families/representatives. Team members include: Mike Branam, Megan Randolph, Tom West, Patricia Clark, Belinda Rose, Janet Murphy, Mayer Rosen. Great work, QAPI team!

“Patient safety is really the starting point to patient care and quality improvement – it has to be the foundation of what we do, and not just an individual’s specific job title or role, but baked into the culture.” – Barbara Tobias MD, Medical Director, The Health Collaborative

3. Patients and families must be partners in care

Patient and family engagement is an important part of patient safety. Patients are the experts of their bodies, and families know the patient’s personality better than the care provider. Therefore, we need to listen to patients’ and families’ concerns. Many organizations have started family advisory councils and include them on quality improvement teams. Patients and families can provide a non-medical perspective which will help with preparing patient education. Involvement also makes the patient and family feel empowered to be in control of their health.

Gary Blank, SVP Patient Services and Chief Nursing Officer of St. Elizabeth Healthcare, is a 2015 nominee who has structured his organization around patient-centered care. He has worked to develop goals that align the organization around a formalized system of patient and family centered care (Partners in Care) across all patient care areas.

“We, as physicians and hospitals and nurses, need to see the patients and families as our true partners.” – Steve Muething, MD, CCHMC (2009 Awardee)

4. It’s about employee safety too

As patient safety has evolved, the conversation of employee safety has also become an important topic. Employee injuries are a concern for many organizations, and may result from needle sticks, hazardous work environments, exposure to germs, and aggressive patients. If employees are not safe then they will not be able to keep the patients safe. Reporting employee injuries is as important as reporting patient errors, as it will allow you to develop processes to prevent these injuries.

Employee safety is at the top of the list for Rachel White, Infection Prevention Coordinator at Margaret Mary Health and 2015 Patient Safety award nominee. Rachel is respected by senior management and front-line staff alike for her extensive knowledge of infectious disease and prevention, and her passion for making the environment and workplace safer for all.

“If we can’t keep our staff safe, the patients don’t get the care they need.” – Rena Sorensen, CCHMC (2015 Awardee)

5. It takes a lot of work

Patient safety is not something that happens overnight – it takes persistence and patience. Changing the culture of your organization is a huge undertaking, and role modeling is key. Developing policies and procedures for patient safety takes coordination from people in all areas of the hospital to identify the areas of opportunity. Include patient safety as an agenda item at every meeting. Educate employees on patient safety and culture change, and encourage them to always identify patient safety issues.

Nobody understands the process of culture change better than Denise Page, Quality and Compliance Coordinator at St. Elizabeth Physicians and 2015 award nominee. Denise is persistent in developing and instituting workflows,  she is patient when working with offices and staff while they develop policies and procedures, and she confidently and effectively interfaces with all team members – from front office associates and clinical staff to providers and administrative or clinical leadership – to create effective solutions.  Keep up the great work, Denise.

“This is not a race, it’s not a competition. It’s about collaboration and everybody learning from each other.” – Rena Sorensen, CCHMC (2015 Awardee)

About the Patient Safety Award

Instituted in 2003 in memory of Richard M. Smith, MD, a tireless proponent of patient safety, this award is given each year to a person who exemplifies Dr. Smith’s dedication and commitment to patient safety, who works to communicate the importance of making patient safety an organizational priority, and who serves as an outstanding role model for those working to enhance the safety of patients throughout our entire healthcare delivery system.

Our 2015 Richard M. Smith, MD Patient Safety Award Nominees:

RENA SORENSEN | Cincinnati Children’s Hospital Medical Center

MEDICATION SYSTEM REDESIGN TEAM | Dearborn County Hospital: Pam Brown, Kevin Burns, Kim Swanson, Jennifer Copple, Angela Scudder, Pam Will

KIM SEXTON | Highland District Hospital

RACHEL WHITE | Margaret Mary Health

LINDA SUTHERLY | Oncology Hematology Care, Inc.

GARY BLANK | St. Elizabeth Healthcare

DENISE PAGE | St. Elizabeth Physicians

QAPI TEAM | The Beechwood Home: Mike Branam, Megan Randolph, Tom West, Patricia Clark, Belinda Rose, Janet Murphy, Mayer Rosen

KIM PICKENS-BAUGHMAN | The Christ Hospital Health Network

NICOLE BARNETT | The Jewish Hospital



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