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Quality Update - Inspiration, Then Action

Summer 2010

Inspiration, Then Action

Date: July 23, 2010

A New York Health System decides to create a patient safety program—and travels to Johns Hopkins for guidance.


D'Amico and Gangemi
Improving new-parent education on the proper use of infant car seats is one of the safety projects spearheaded by staff on the labor and delivery unit at Rochester General Hospital. In the program, safety efforts are championed by hospital leaders, such as Christine D’Amico (second from left) and Richard Gangemi (second from right).

"What are you going to do when you get home?"

For three days, 14 physicians, nurses and administrators from Rochester General Health System had visited the Johns Hopkins medical campus for training in how to develop and sustain a patient safety program. They met with a wide range of experts, such as a medication safety officer and Hopkins Health System leaders. They sat in on meetings of unit-based safety teams, saw firsthand how the hospital handles reports of adverse events, and learned about tools for reengineering broken systems, among other activities.

But as their visit neared its end, Hopkins facilitators urged the Rochester team to turn their enthusiasm into concrete actions.

A year later, a culture of patient safety is starting to take hold at Rochester General. While the organization admits that its journey has just begun, it has generated substantial momentum. From frontline staff to the trustees, more are playing a role in preventing harm to patients. And the health system has already achieved wins in certain areas, such as reducing mislabeled specimens.

The Hopkins workshop "really had a huge impact on the group," says Kristin Opett, patient safety officer for Rochester General.

Unlike typical conference presentations, the workshops are designed by the Center for Innovation in Quality Patient Care so that visiting hospitals have time to map out their next steps.   

"These hospitals tell us that there's something about coming to Hopkins as a group, something palpable about being here," says Stephanie Peditto, the center's director of innovation, who facilitates the workshops. "By being together in a way that they wouldn’t normally be, they have conversations they wouldn’t otherwise have. They go home with a plan that they believe in, and they keep meeting."

Before visiting Hopkins, Rochester General didn't have a patient safety program per se, notes Opett, who was a nurse manager for five medical practices at the time of the workshop.

"Patient safety wasn't in our verbiage," she says. "Our verbiage was quality and regulatory—the things we had to do."

During the visit to Baltimore, the group saw how Hopkins treats safety as everyone's responsibility and how frontline staff often drive improvement.

But the goal isn't to have other hospitals mimic every strategy that Hopkins uses to reach that level of involvement.

"Hopkins realizes that what works there isn't necessarily going to be transplanted someplace else," says Lisa Comella, nurse manager in the Emergency Department at Newark-Wayne Community Hospital, an RGHS affiliate. "They're interested in your processes, your beliefs, your history. They're willing to truly listen rather than say, Here are the tools, here's what you need to do."

Richard Gangemi, chief academic and medical officer for Rochester General Health System, says he returned from Baltimore "very emotionally inspired" by what he had seen. "We also came back with a much clearer direction of where we wanted to go."

After its visit, Rochester General took steps to make more of an organizational commitment to patient safety. The system created a new institute for patient safety and clinical excellence, which is separate from but integrated with performance and quality improvement functions. The health system's board of trustees now starts off every meeting with a 30-minute discussion of safety and quality. And it created a "science of safety" presentation, which was delivered to 650 of its organizational leaders.

Excitement is also rising at the unit level, where three safety teams have formed.   

The Emergency Department at Newark-Wayne Community Hospital zeroed in on mislabeled specimens. While the group works on technological fixes, increased staff awareness has produced results. As of June, the ED had gone three months without a labeling error.

At Rochester General Hospital's labor and delivery unit, the safety team has worked on several efforts, such as new-parent education about proper use of infant car seats. The unit also held a photo contest in which staff captured images of safety hazards. For example, one photo showed several parts missing from a step stool, which nurses often stand on during delivery. Hospital leaders immediately replaced all of the unit’s stools with new ones.  

"People are getting involved and they're no longer just reporting safety issues," says Diana Drake, a nurse educator and safety champion on the unit. "They're taking the initiative to see that the problems get resolved."

The Center for Innovation will host a workshop in creating a patient safety strategy for your hospital on September 27-29, 2010. Register: regonline.com/safetystrategy. Agendas tailored to your organization are also available. Details: innovations@jhmi.edu

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