Reflections from the 2015 NPSF Congress
by Lorri Zipperer, MA
Large multidisciplinary conferences offer individuals the opportunity to attend sessions focused toward very specific interests as there are so many topics and perspectives represented. As an attendee of the 2015 NSPF Congress in Austin, I sought to soak up examples demonstrating the intersection of evidence, information, and knowledge (EI&K) with transparency. This strategy fed off of my take on the NPSF Lucian Leape Institute report Shining a Light: Safer Care through Transparency.
The authors define transparency as “the free, uninhibited flow of information that is open to the scrutiny of others.” The report calls for a sense of urgency to situate transparency as an integral element of safe care. The idea of a “magic pill” was used to describe its potential. I wanted to gather insights to elucidate how health care organizations could optimize their use of EI&K in their safety work.
Now, I am the first to admit that evidence, information, and knowledge are murky terms (Zipperer 2014). The ambiguity works against EI&K being established as measurable contributing factors to safety improvement. To simplify the discussion here I’ll build on definitions drawn from my previous work (Zipperer 2011) to differentiate the elements as a touchpoint for the discussion below:
Evidence: “The scientifically sound, fully researched and validated information and collected data that has been analyzed to gain understanding and validation of a hypothesis.”
Information: “Data that is processed and repurposed and printed for distinct use.
Knowledge: “What an individual knows [sic].” It is broader deeper and richer than information or data. It is multifaceted, dynamic in nature, context-specific, and embedded in the actions of experts. Its value emerges over time and is influenced by the individual processing it.
To explore the role of EI&K in transparency, I attended two talks I felt could illustrate the value of robust identification, use, and sharing of EI&K to create safe practice:
Building Risk Management/Patient Safety Bridges: This panel presented activities building on a collaborative funded by CRICO Risk Management Foundation (RMF). Representatives from member institutions shared avenues for ambulatory patient safety improvement. The three-year CRICO grant enabled the collective development of initiatives to share learnings, build tools, track improvements, and mitigate risk across 10 organizations representing more than 300 ambulatory sites.
Operationalization of a Meaningful Sentinel Event Process: This session featured a University of Michigan Health System effort to change its sentinel event review process and improve patient engagement in the activity. The challenges to achieving this goal were discussed. To further improvement, the organization applied the Plan-Do-Study-Act method to prioritize strategies to enhance patient involvement. The session discussed the use of this rapid cycle improvement tool to improve patient and family communication opportunities after sentinel events making them effective, engaging, and earnest.
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External Transparency to Support Improvement
The risk management in the ambulatory setting panel described collaborative activities that could be enhanced through robust EI&K sharing. Although they didn’t explicitly discuss evidence, their work illustrated how being open and transparent can help teams and organizations recognize a need to access evidence to feed improvement work, to generate interest in doing research, and to fill evidentiary gaps. Organizations can be transparent by facilitating the exchange of information (i.e., educational and communication initiatives) and packaging information so it is useful to staff engaged in improvement initiatives.
This collaborative transferred knowledge from one environment to the other by creating a leadership group that was accountable for distributing knowledge. The individuals in the group were explicitly charged with sharing experiences from the risk management collaborative at their own organizations. The local knowledge and status of these champions helped to make the translation of that experience meaningful to their direct peers, who could easily act on the knowledge and apply it in their daily work. The session demonstrated the value of organizational leadership and empowered risk managers to approach adverse event investigations transparently.
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Internal Transparency to Innovate and Learn
The sentinel event review process session set the stage for an exploration of evidence use. Though, again, it was not explicitly discussed, I saw that evidence could be used as a foundation for improvement building off of sentinel event reviews. For example, in the case of a wrong-site surgery, the team investigating the sentinel event might choose to inform their Plan-Do-Study-Act work by first conducting a literature review of wrong-site surgery improvement interventions in similar settings. This strategy could illuminate action based on concrete measures of improvement, and also open the door to enhancing transparency through identifying experts who could be contacted to share their experience (i.e., knowledge) via conversation and dialogue.
More explicitly, the program discussed the use of an established information tool for patient safety: Joint Commission Sentinel Event Alerts. The speaker reviewed information strategies to highlight new alerts through internal efforts to format the information into assets that are easily usable and distributed. The problems uncovered during the internal review process were then translated for organizational distribution through usable materials such as newsletter articles, graphs, and presentations. The methods described also demonstrated how a culture of knowledge sharing supports a transparent sentinel event review process. The effort to tap into the knowledge of the analysis team and the experiences of those close to the event—including patients and families—helped to generate effective strategies to proactively prevent occurrences of sentinel events.
Building on Austin Insights
In order for health care professionals to optimize use of EI&K, they need to ask relevant questions about how the three links come together to support transparency, patient safety, and improvement.
Evidence, while not discussed explicitly, was an undercurrent of the highlighted programs. How can teams reviewing sentinel events or implementing progressive risk management programs more reliably use evidence? If staff and clinicians aren’t enabled and encouraged to access, read, or apply evidence, can their work be efficient, effective, and safe?
Information is the element of EI&K that most of us are apt to use to support transparency on a daily basis. How can organizations use information—like sentinel event alerts or the Institute for Safe Medication Practices newsletters—to respond to risks and generate a sense of urgency for action and enable clinician, leadership, and patient and family engagement in safety improvement?
Knowledge as a contributor to safe care is the hardest element of the three to pin down. How do organizations capitalize on the knowledge present in stories, sharing, and discussion, to shape conclusions and next steps after incident analysis to create contextual understanding of factors that could contribute to sentinel events? How does your organization encourage sharing of knowledge in a transparent way?
Is your organization taking advantage of evidence, information, and knowledge to help make the magic pill of transparency easier to take? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.
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Zipperer L, ed. 2014. Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. London, UK: Gower Publishing.
Zipperer L. 2011. Knowledge services. In: The Medical Library Association Guide to Managing Health Care Libraries. Bandy MM, Dudden RF, eds., 2nd Edition. New York: Neal-Schuman, New York. p 302.
About the author:
Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in patient safety and knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives.