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Stand Up Stand Out: Baylor Scott & White

Posted By Joanna Carmona, Tuesday, June 27, 2017

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read about what one Texas health system 

is doing to improve palliative care. 


 

Baylor Scott & White Health, a not-for-profit health system based in Texas, is a founding member of the IHI/NPSF Stand Up for Patient Safety program and has recently partnered with Ariadne Labs to roll out their Serious Illness Conversation and Care Planning Program across their system. Robert L. Fine, MD, FACP, FAAHPM, Clinical Director, Office of Clinical Ethics and Palliative Care at Baylor Scott & White Health, spoke to us about the genesis of the palliative care movement and how the program has initially influenced patient safety across their health system. 

 

Why did Baylor Scott & White partner with Ariadne Labs to implement their

Serious Illness Conversation and Care Planning Program?

The easy answer is that they had a complete, scalable, evidence-based product ready to go to help improve communication between patients and providers.

 

The deeper story, however, is the collective cumulative experience that led to the development of palliative care in first place. One of the earliest studies to suggest such a need was the SUPPORT study, published in JAMA in 1995. This study involved 9,000 seriously ill patients with a six-month mortality rate of 50% admitted to five major teaching hospitals. These weren’t hospice appropriate patients—at least not on admission—these were people with a 50% chance of survival and, in fact, half did survive. However, for the 50% of patients who died, the study revealed glaring care deficiencies leading to significant confusion about goals of care (with much unwanted treatment provided) and significant suffering. The SUPPORT study thus revealed a special sort of patient safety concern and care deficit.

 

At the root of this care deficit was poor communication. Many of us focusing on end-of-life care via ethics or hospice consultation came to understand that hospice could not serve patients in common circumstances like those found in the SUPPORT study until very late in the patient’s journey, and ethics consultation could largely work on only the moral dimensions of care. Some other sort of service not necessarily tied to definite terminal illness or ethical uncertainty/discord was required.

 

The notion of palliative care as distinct from hospice was just starting to evolve at that time and the SUPPORT study lent great credence to the need. In fact, I attempted to start a small palliative care program at Baylor University Medical Center in 1995, but the program was terminated before we could serve our first patients. It would be several more years before we could get our palliative care service line established. Palliative care as a specialty is now growing rapidly, but we’ve all realized that we can’t train palliative care doctors, nurses, and other professionals fast enough to serve every seriously ill patient who might benefit. We must help non-palliative care professionals develop better primary palliative care skills, such as better communication skills.

 

So, how can we do that? The reality is that busy physicians aren’t going to take a multi-day training to do it and non-palliative care specialty training will never include the intense communication training that is so much of the focus of a palliative medicine fellowship. However, non-palliative care professionals can and will participate in shorter training with role-play exercises over a few hours accompanied by ongoing coaching. BSWH chose the program from Ariadne Labs because they had the evidence-based solution we were looking for.

 

What does the Serious Illness Conversation and Care Planning Program consist of?

There are three basic components:

  • Tools that provide a scripted checklist approach to guide the clinician who isn’t comfortable with having these types of serious conversations;
  • Education for health care professionals using the tools; and
  • Systems change to help identify appropriate patients and to build the tools into the EMR so that any practitioner can look at the chart and be both guided in the conversation and see what has been previously discussed by others following the same conversational script.

It has been demonstrated that patients and doctors like the tools, it helps make conversations more complete, and the data are retrievable. This is a pretty big systems change and Ariadne has never taken it to a system as big as ours—this will be the first.

 

How are you rolling the program out across your system?

Systems change and EMR implementation is critical. It would frankly be easier in a system that has one EMR, but at Baylor Scott & White we have two different major EMRs. Another challenge is our sheer size and geographic spread. We are also one of the larger nonprofit systems in the country, the largest in Texas, and we have thousands of physicians, advance practice nurses, and others to be trained.

 

At the same time that we have been building the necessary tools into our EMRs, we are also training our palliative care experts to train others in the use of the SICP tools and process. I’ve observed that just because a palliative care professional is an expert communicator with patients of families, that doesn’t guarantee they will be an expert trainer, so the notion of “train the trainer” is very important. Each trained facilitator can then train three learners in three hours. Of course, the trainer needs to be available going forward to provide ongoing coaching when needed. It is a bit daunting given our size, but we see it as a perpetual task that we are slowly and deliberately weaving into the fabric of our organization. It is a project in perpetuity and we want this program to be self-sustaining.

 

What has been the reaction among team members to the new program?

We don’t teach much about end of life in medical school, especially not the differences in communication between those with less serious illnesses versus more serious illnesses, and this training is benefiting both palliative care professionals and those who may not be as comfortable having these conversations. The palliative care professionals, even though already skilled in serious illness conversation, are very excited. Some have said that it has actually shortened their goals-of-care conversations because the script helps to focus the conversations. We are also starting to hear from some early adopter non-palliative care professionals we have trained saying that they don’t need the palliative care team as often to have these conversations. I think some palliative care professionals might see that as a threat, but at BSWH we don’t!

 

Out in the community of doctors, there are those who haven’t been trained but are excited to be trained ASAP. There are others who feel they don’t have time to learn this right now, but we are working on how to encourage everyone to take the time for trainings.

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How do you think this program will impact patient safety across your system?  

It has already. When it comes to the structural impact, you see it by being able to open up the EMR and having a link at the top of the patient banner directly to the SICP script and answers. All you have to do is click to see what answers the patients gave. This is the beginning of real cultural change.

 

It is so vitally important because a lot of programs from the mid to late 1990s on have emphasized preventing  bad death, meaning a patient who received unwanted treatment, was separated from their family at death, experienced emotional and spiritual distress, had poorly treated pain, and experienced many other treatment deficits as well. That is a patient safety problem. If death comes, we should ideally provide what I refer to as “safe passage.” For example, if someone says ‘When I die, I want to go to heaven without your machines’ then we ought to be able to know that and offer them a safe passage to heaven or whatever their wishes may be. We use the idea of safe passage frequently with patients and families facing mortality because it is an idea that people get.

 

We recently had a palliative care physician say to us, "I found all this information that I normally don’t have when I’m consulted. It was in the SICP section of the EMR.  When I was called in as a consultant, the information present allowed me to sit down with the patient and family and say 'Based on the information you gave to your oncologist, I can suggest we do the following…'" The information not only gets to the right person at the right time, but it also gets dispersed to the whole team. We see this program continuing to influence patient safety as time goes on and the amount of trainers and trainees grows.

 

Read other Stand Up Stand Out stories.

 

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How does your organization encourage conversations with patients who are experiencing serious illness? Comment on this post below.

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Tags:  Stand Up for Patient Safety 

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Stand Up Standout: Improving Communication, Engaging Patients

Posted By Administration, Wednesday, April 5, 2017
Updated: Wednesday, April 5, 2017

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read how one New York City health center
is making strides to overcome low health literacy.


by Patricia McTiernan, MS

 

The National Patient Safety Foundation has long advocated for patients and family members to be regarded as integral members of the health care team. When patients are actively engaged, they can help improve patient safety and experience better outcomes.

 

Yet getting patients engaged in their care is more challenging than it might appear. Barriers to engagement are still common at many levels of the health care system, with a 2014 report from the NPSF Lucian Leape Institute citing low health literacy as one of the chief barriers.

 

Health literacy has been defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”


The most commonly cited data suggest that only 12% of English-speaking adults in the U.S. are at a proficient level of health literacy. That means many of us struggle to comprehend care plans, medication regimens, and follow-up instructions.

 

To ensure that patients are able to understand important health care information, it is critical that providers recognize the nature of patients’ health literacy challenges and implement strategies to promote clear health communication. Ask Me 3, a program of NPSF, is designed to improve the lines of communication among patients, families, and health care professionals. The program encourages patients to ask the following three specific questions of their health care providers to better understand their health conditions and what they need to do to stay healthy.  The program encourages health care providers to use this framework to be prepared to answer the questions.

 

The Ask Me 3 program is one of the
tools being used at NYC Health +
Hospitals/Cumberland to improve
communication between patients and
health care providers.

1.     What is my main problem?

2.     What do I need to do?

3.     Why is it important for me to do this?

Through the use of these questions, Ask Me 3 empowers patients to become more involved in their health care, organize the provider-patient conversation, focus discussion on the answers to key questions, and help patients acquire the information they need to take care of their health. 

 

Staying Focused in Brooklyn

NYC Health + Hospitals/Cumberland, a Gotham Health Center, in Brooklyn, NY, is one of many health care organizations that have implemented the Ask Me 3 program to address health literacy. As part of NYC Health + Hospitals, the largest public health care system in the country, Cumberland has more than 57,670 patient visits every year from all walks of life and cultural backgrounds. Marlene Dacken, RN, patient safety officer, points out that “empowering patients to be active members of the patient/provider relationship and ensuring that communication is clear are essential components of patient safety.”

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The hospitals under the auspices of NYC Health + Hospitals have been long-time members of the NPSF Stand Up for Patient Safety program. As part of a larger effort to engage patients in their care, Cumberland introduced the Ask Me 3 program in adult primary care clinics, specialty care departments, and pediatrics.

 

Overall, approximately one-third of patients at Cumberland have used the program, according to Cynthia Boakye, MD, medical director. “For adult medicine, we try to give it to every patient,” she says. “Those who choose to use it fill out the form and organize their thoughts before they see the provider.”

 

Before rolling out the program, the Cumberland team ensured that all staff members were on board by providing training on health literacy and the program. The program has become a part of the culture of care at Cumberland with ongoing training of staff and all new hires.

 

A nurse or nursing assistant explains the program to the patients and provides them the questions on a form. Physicians refer to the form during the visit and are able to correlate the information they want to tell the patient to the patient’s questions.

 

“Staff members believe that the program really helps the patient get focused on what they want to ask the physician during the encounter,” says Ms. Dacken. “This helps outline their process to keep focused on what their concerns are.

 

“I started to use it myself, because even as a nurse, sometimes you do forget or you lose focus,” she adds. “As a patient, the communication is often physician-directed, the provider asking all the questions, but there are questions not on the health provider’s radar that may be on the minds of patients.”

 

The team has also developed a program called Take the Pledge, Take Your Meds, to improve medication adherence, another common issue in outpatient care.

 

Results of these efforts are so far anecdotal, with patients and staff both reporting positive feedback. “The patients think that it’s a good idea,” said Dr. Boakye. “It helps them focus on what they have to ask the physician and keeps everything in alignment so they are not diverted.”

 

NPSF offers complimentary Ask Me 3 materials and resources to organizations interested in implementing the program. Posters and fliers in English and Spanish are provided, along with an implementation guide and other materials. In addition, a new educational module is now available to help educate clinicians and staff regarding health literacy and the Ask Me 3 program.

 

Some 2,000 individuals have downloaded the materials in the past year, and the Ask Me 3 program continues to be one of the most frequently visited areas of the NPSF website.

 

“We are very pleased with the growing interest and use of this program over the past few years,” said Patricia McGaffigan, RN, MS, senior vice president for program strategy and management and chief operating officer of NPSF. “We see it as a very useful addition to other tools organizations may be using with both patients and health care professionals to better engage and communicate with their patients.”

 

To learn more and download complimentary materials, please visit www.npsf.org/askme3.

 

Ask Me 3 is a registered trademark licensed to the National Patient Safety Foundation.

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What steps does your organization take to improve communication between patients and health care providers? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Patricia McTiernan is editor of the P.S. Blog. Contact her at pmctiernan@npsf.org.

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Tags:  ask me 3  health literacy  Stand Up for Patient Safety 

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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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