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Quality Update - New Agents of Culture Change

Summer 2010

New Agents of Culture Change

Date: July 23, 2010

Trained in patient safety at Johns Hopkins, two young physicians take strategies home to Mexico.


Last fall, Karla Patricia Pacheco Alvarado was eager to introduce strategies for preventing surgical site infections during the final year of her residency at the Monterrey Institute of Technology in Mexico. She had just spent three months immersed in the science of safety during a rotation developed by the Johns Hopkins Center for Innovation in Quality Patient Care.

Informed of the alarming infection rate at a local public hospital, Pacheco urged caregivers there to take preventive measures. They were receptive to her recommendations. But when she encouraged them to speak up if they spotted a nonsterile practice, some doctors responded, No, no, no, we can’t do that, she recalls.

“We don’t have a well-developed culture of speak up,” Pacheco says of the health care system in Mexico. “We are working on it.”

The mixed response to Pacheco’s request drove home the challenge that the hospital—like many others—faces in building a workplace culture that embraces safety. The Hopkins rotation gave Pacheco and her classmate, Armando R. Aguilar Cano, the tools to help move that culture in the right direction.

Through the patient safety fellowship, participants take part in hospital processes, including adverse-event analysis, identifying and creating solutions for safety flaws and helping to create safety action plans for units. They observe safeguards in action, such as presurgical time-outs, and sit in on meetings of safety teams.

As graduate students in the Monterrey Institute of Technology’s health care quality improvement program, Pacheco and Aguilar were the first caregivers outside of Hopkins to take part in the program. (This summer, Monterrey Tech sent two more graduate students to the program.)

Their exposure to Hopkins’ broad array of safety tools has provided them with the opportunity to “incrementally influence safety and quality in their workplace so that it is stronger and hopefully securing support from their colleagues,” says their mentor, Paula Kent, patient safety coordinator for The Johns Hopkins Hospital.   

During the rotation, Pacheco and Aguilar had the chance to drill down to the source of patient hazards. For instance, by analyzing adverse event reports and responses to a questionnaire about safety attitudes, they found that a persistent communication gap existed for patients when they were handed off to the perianestheia care unit after surgery. Patients sometimes came to the unit with orders that lacked details on pain control medications, fall risk and other factors. 

Aguilar, quality and patient safety coordinator in a private hospital at Monterrey, says he learned volumes simply by observing medical practices at Hopkins. For example, he paid close attention to the protocols for tracking medications as they are stored, prescribed and administered. The double- and triple-checks Aguilar witnessed as a drug made its way from the pharmacy to bedside were a far cry from common practice in Mexico’s hospitals, where he says accountability halts once a drug is prescribed. “Watching what others are doing, trying to understand why they are doing it and how they are doing it ,was very important,” he says.

His experience at Hopkins taught Aguilar that culture change happens gradually and with sensitivity to the ingrained habits of hospital practitioners and staff. “You have to communicate,” Aguilar says. To encourage hospital caregivers to speak freely without fear of reprisal, for example, he purposefully asks them and other hospital staff about adverse events in a nonthreatening manner.

In the final months of her residency, Pacheco launched a time-out process in her hospital’s operating room and initiated a surgical site infection prevention program in concert with the hospital’s adoption of the World Health Organization’s safe surgery checklist. Now in Mexico City, she works for the federal government to develop measures to reduce maternal mortality.

Kent was thrilled to know that both Pacheco and Aguilar launched safety projects upon their return to Mexico. “That made the difference for me,” Kent says. “They didn’t just keep their knowledge to themselves. I hope that’s what anybody who comes here to observe will do—learn something they can take back with them.”

The Patient Safety Fellowship program is tailored to individual needs and typically ranges from three months to a year, but shorter stays of one to two weeks are available. Details: innovations@jhmi.edu or (+1) 410-614-3567.

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