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Stand Up Standout: Fairview Health Services

Posted By Administration, Tuesday, August 23, 2016
Updated: Wednesday, August 24, 2016

The Stand Up for Patient Safety Program is an organizational membership program that supports patient safety initiatives.

This is part of a series of member profiles.  


by Joanna Carmona 


Susan Noaker (middle left) and Pat Schlagel (middle right) 

of Fairview Health Services accepting the Stand Up for Patient Safety Award

at the 2016 NPSF Patient Safety Congress in Scottsdale, Arizona.

 

Fairview Health Services and their collective commitment to a culture of excellence in their hospitals is what stood out to the National Patient Safety Foundation when awarding this year’s Stand Up for Patient Safety Management Award. This award is given each year in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management.

 

Fairview Health Services, consisting of six hospitals within Minnesota, aimed to prevent errors in specimen management to make care safer for their patients. Fairview identified specimen mismanagement as a “never event” and thus started the complex process of reducing the risk of mishandling.  

 

According to the Agency for Healthcare Research and Quality (AHRQ), mislabeling errors are one of the most common preanalytic errors in laboratories. Many initiatives were put in place, including Fairview’s use of specimen label printers which made a big difference in specimen management. As a result of system-wide changes, including standardizing processes of surgical debriefing, handoffs, and labeling, there was a 70% decrease in the risk of specimen mismanagement.

 

Here’s what Fairview Health Services had to say about this important work.

 

What were the biggest challenges involved in a project such as this?

Our two biggest challenges were information technology issues, including getting various programs to talk to each other and making our electronic medical record more user-friendly, and standardizing processes. Initially, we assumed our processes varied widely from site to site, but after mapping out processes across our system, we learned we had more in common than we previously thought.

 

What surprised you about the process, either in regard to the way the project team worked or in regard to something you learned about the processes that you did not already know?

“Learning that labels and specimens were labeled and logged by hand, which is not best practice, reinforced our drive to improve. We knew we could do better for our patients. On the plus side, our team became highly functional very quickly. We used multi-voting techniques to prioritize the work so that all voices were heard, not just those belonging to squeaky wheels.”

 

You mentioned that patients are often unaware of the life-altering consequences of error in specimen management. How do you explain the importance of specimen management to your friends or family (i.e., someone unfamiliar with this topic) and what it means for their safety? 

“If a specimen—something we obtained from a biopsy—is lost, we may not be able to make a diagnosis in a speedy manner. We may need to repeat the biopsy. Furthermore, some specimens are so unique that they are irreplaceable. A lost specimen of that type may mean losing essential information about the patient’s health. It may not sound all that important, but proper specimen management is utterly essential to helping us drive a healthier future for our patients.”

 

What are some ways to successfully engage physicians in the problem-solving process?

“We know physicians appreciate seeing data that proves the need for change and demonstrates the likelihood that the change will result in improved patient outcomes. Also, like most employees, physicians want to be asked for their input and know that their contributions are valued and acted upon.”

 

What are two tips you would offer others undertaking similar projects that might help them succeed? 

“First, system-wide changes require system-wide representation. In addition to the appropriate subject matter experts, you should also include people who provide support services, such as IT, Operations, Communications, and Human Resources. These team members help the group think of broader implications of a proposed change, and can often contribute to coming up with corresponding solutions.

 

Second, getting people to agree to serve on yet another committee or workgroup can be tough. Show participants you value their time by creating unusual, but effective meetings. Get people up and moving by breaking into small groups spread out across the room. Record ideas on flipcharts and draw process flow maps on white boards. Award small prizes for attending. Improving patient safety is serious work, but by engaging employees and physicians in different ways, we can often come up with better solutions.”

 

Could you talk in general about lessons learned from this process?

“It’s important to obtain the support of an executive sponsor—someone at the highest levels of leadership. This indicates to everyone involved that the project is a high priority and reinforces the urgency of successfully completing the change. Get IT involved in the project from the start and know who to turn to when you need to escalate concerns. Use a system team of stakeholders that is truly representative of all entities and divisions. Be aware of unintended consequences. When you change one part of a process, there may be unintended negative consequences. Be open to discovering, and correcting this. In fact, embracing a spirit of discovery can make all the difference for improving the health of our patients.”

 

Responses from Beth Thomas, DO, Fairview interim chief medical officer & Susan Noaker, PhD, LP, Fairview project manager, surgical services 


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Have you worked on a similar improvement project at your organization? Comment on this post below.

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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at jcarmona@npsf.org.

 

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Tags:  2016 NPSF Congress  specimen management  Stand Up for Patient Safety 

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