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Evidence, Information, and Knowledge as Components of Transparency

Posted By Administration, Thursday, November 12, 2015
Updated: Thursday, November 12, 2015

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 informationlike 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.

Tags:  knowledge management  transparency 

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Leadership, Culture, and Patient Experience Take Center Stage

Posted By Administration, Thursday, September 24, 2015
Updated: Thursday, September 24, 2015


     Afternoon keynote speaker Dr. Skip Campbell
A video tribute to Dr. Lucian Leape
kicked off the evening program.

    Dr. Sands (left) with panel participants (from left): Dr. Richard Whyte;
Dr. Pat Folcarelli; Mary Fay, RN; Jeff Catalano, Esq.;
and Nancy Watson, JD.


The 8th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner touched upon issues that are the keys to moving the patient safety agenda forward.

by Patricia McTiernan, MS


Would your hospital allow a news reporter to follow along as the leadership team conducted WalkRounds? What does your hospital do to provide support to clinicians involved in medical errors? Would you ever hesitate to recommend your physician or hospital to a friend or loved one?


These questions may not come up in day-to-day patient safety work, with its focus on numbers, data, protocols, and checklists. But they are among the thoughts provoked by the presentations at this year’s NPSF Lucian Leape Institute Forum & Keynote Dinner, held in Boston last week. Leadership, culture, patient experience, and workforce safety took center stage as the event’s presentations demonstrated the value of transparency in health care and the importance of leaders in influencing behavior within our health care organizations.


The Institute’s most recent report argues that greater transparency in health care – at all levels – can fuel better, safer care. With that report as the backdrop, Dr. Darrell “Skip” Campbell shared experiences from his work as a surgeon, researcher, and chief medical officer as well as from his current role as director of the Michigan Surgical Quality Collaborative.


Dr. Campbell pointed to research that showed that staff who had participated in Leadership WalkRounds were more likely than those who had never participated to say they would speak up when faced with a potential or actual medical error. During his time at University of Michigan Health System, Dr. Campbell was so confident in the promise of WalkRounds to drive improvement, he invited a news reporter to observe the ritual.


In his role as director of MSQC, Dr. Campbell works on a different level of transparency—between providers. MSQC is certified by the Agency for Healthcare Research and Quality as a patient safety organization and is made up of 73 member organizations across the state that agree to share data on surgical outcomes and not compete on safety.


MSQC works to identify top performers through the analysis of data; visits them, talk to them, and figures out what it is that they are doing to achieve the good results; and then distributes that information to the other members. One of their early successes has been a state-wide decrease in surgical site infections after colectomy.


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Breakout Knowledge

Dr. Gary Kaplan, chairman and CEO of Virginia Mason Health System and chair of the NPSF Lucian Leape Institute noted in his opening remarks that there are challenges and opportunities around the issue of transparency, as well as significant barriers. The Institute’s current focus is on translating its recommendations into action.


In breakout sessions, forum attendees discussed these issues. Rick Boothman, JD, chief risk officer at University of Michigan Health System and a member of the NPSF Board of Directors summarized the key points of consensus from the groups:

  • The single biggest area of concern is leadership’s role and the widespread failure to set expectations to create and support a safety culture.
  • Education is valuable, but it needs to be done correctly and embedded in the organization’s behavior.
  • Transparency can be powerful tool, but it needs to be used responsibly, with data that make sense and are delivered in useful ways.
  • There is a lack of appreciation for engagement by boards of directors in the issue of patient safety; board education on the issue is needed.
  • Provider-to-provider sharing of data and information is difficult to achieve, but is essential for progress.
  • Everyone in the organization needs to support the core mission of patient and workforce centricity – whether they are a housekeeper or a lawyer.
  • Information without action is not productive. It is the responsibility of the person reporting substandard care to be accurate, fair, and thorough, and the responsibility of the receiver to listen and understand the problem with the goal of fixing it if possible.

Where Does Apology Come In?

The afternoon concluded with an overview of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) and a panel discussion featuring staff of Beth Israel Deaconess Hospital in Boston, an organization that helped pioneer the MACRMI roadmap to respond to adverse events and suspected medical errors.


Dr. Alan Woodward was instrumental in starting MACRMI in 2005, when he was president of the Massachusetts Medical Society. “We were beating our heads against the wall with tort reform,” he said. “But we wanted to do something about patient safety.” He met with Rick Boothman at the University of Michigan, and eventually formed an alliance of hospitals in Massachusetts. Dr. Kenneth Sands, chief quality officer of Beth Israel Deaconess, served as principal investigator of MACRMI’s study, funded by the Agency for Healthcare Research and Quality, to identify the major impediments to apology and disclosure and strategies to overcome them. This work led to the MACRMI roadmap, known as CARe—communication, apology, and resolution following medical injury.


Dr. Woodward described CARe as a proactive process to review the case, advocate for the patient’s medical needsand if the injury was found to be avoidable, their financial needs—and to render appropriate apology, which he said, "is therapeutic for both clinicians and patients.”


Dr. Sands facilitated a panel discussion of a case that was handled through the CARe process. In the case presented, a communication breakdown led to a delayed cancer diagnosis. Speaking via a video, the patient explained that she found out she had cancer only after persisting in telling her doctor that something wasn’t right after her gallbladder surgery. “Patients shouldn’t have to figure this out for themselves,” she said.


In an important part of the process, the patient met with the vice chair of the department of surgery, who explained what happened and how, and what the organization was doing to prevent it from happening again.


Pat Folcarelli, RN, PhD, director of patient safety at BI Deaconess said that “physicians usually leave such a meeting feeling very positive. We prepare them beforehand, [telling them] that it is a critical meeting to communicate openly about what happened. Despite anxiety, most leave thinking they’ve been given a gift in terms of interaction with the patient and family that they hadn’t had before.”


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Making It Personal

Dr. Jonathan Perlin, the evening keynote speaker, began his talk, "To Care Is Human," by asking the question, “Would you ever hesitate to recommend your physician or hospital to a friend or loved one?” A former, long-time member of the NPSF Board of Directors, current chair of the American Hospital Association, and chief medical officer of Hospital Corporation of America, Dr. Perlin argued that patient safety and patient experience go hand-in-hand. He told four patient stories, each through the lens of the HCAHPS survey (Hospital Consumer Assessment of Healthcare Provider and Systems).


Would you ever hesitate
to recommend your physician or
hospital to a friend or loved one?

Two of the cases involved breaches of hand hygiene. In one case, the patient, a retired nurse, did not speak up to the anesthesiologist because she knew “for the next four hours, my life would be in his hands.” In another case, speaking up to a clinician about hand hygiene led to a rebuke about how “disruptive visitors can be asked to leave.”


Apart from noting that the most common mode of transmission of pathogens is via the hands, and that there are roughly 80,000 hospital acquired infections each year, Dr. Perlin also fixed on the patient’s perceptions: how would those patients respond to HCAHPS survey questions such as “Would you recommend this hospital?” and “How would you rate the nurses’ response to concerns or complaints?”


A noted expert in health information technology, Dr. Perlin suggested that better use of data could also help providers improve care and safety. “If each of us read two articles per night, we’d only be behind by 10,000 articles,” he said. “Care informs care.” More effective use of the digital records we are creating can be part of a learning health system.


Making it personal, Dr. Perlin concluded by saying that each patient he had discussed was a member of his own family. “Patient experience isn’t just about being nice,” he said. “Patient safety is inextricably linked to patient experience. It involves culture and leadership, with the patient at the center.”

Have you done work to improve the culture or the patient experience in your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  apology  Boothman  Campbell  communication  culture  Gandhi  Kaplan  leadership  Leape  Sands  transparency 

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How Risk Management and Patient Safety Intersect: Strategies to Help Make It Happen

Posted By Administration, Tuesday, March 24, 2015
Updated: Tuesday, March 24, 2015

This article describes the journey of integrating patient safety and risk management and reports a 62% overall reduction in hospital professional liability premiums over 10 years that has occurred as a result of the integration and a dramatic increase in the reporting culture.

By Jamie Leviton, MHA, CPHQ, and Jackie Valentine, MHA, Rph

Engaging health care professionals and staff around reporting errors to reduce risk and improving the safety culture is a crucial but difficult task for many organizations. Unless staff members are engaged, feel safe to speak up, and are enabled to learn from the occurrence of preventable medical errors, poor patient outcomes will likely continue to occur. How organizational leaders respond to safety events and communicate to staff, patients, and family members following such events is key to building high reliability organizations and enhancing safety cultures.


A report published by the NPSF Lucian Leape Institute, Shining a Light: Safer Health Care Through Transparency, describes transparency as the most important element among the Institute’s recommendations necessary to transform the health care industry. In most organizations, the risk management and patient safety departments are separated in goals, scope, and leadership. In 2006 Virginia Mason chose to integrate the risk management function into the patient safety department and since then have utilized the Virginia Mason Production System (VMPS) management methods, to continuously improve the patient safety system by enhancing transparency in reporting, disclosing, mitigating risk, and improving patient safety.


This article shares the journey of integrating patient safety and risk management and reports a 62% overall reduction in hospital professional liability premiums over 10 years that has occurred as a result of the integration and a dramatic increase in the reporting culture.


The Patient Safety Alert System (PSA system) is the cornerstone of safety and quality for staff and patients at Virginia Mason. The PSA system began in 2002 and has been the focus of an on-going initiative to:

  • Encourage reporting and a culture of safety
  • Produce a rapid and standardized response to identified concerns
  • Empower managers to address issues close to the source
  • Promote greater transparency

The PSA system requires any employee who encounters a situation that has harmed or has the potential to cause harm to a patient to report a PSA and take actions to “stop the line.” Approximately 800-1000 PSAs are submitted per month via the online incident reporting system. Each PSA is reviewed by a patient safety specialist, who makes an assessment of the severity of the PSA based on whether there was harm or potential harm to a patient. The assessment by the patient safety specialist determines whether the PSA will be handled by the manager of the operational area or by a higher level administrator. For those PSAs that require a more intensive review, the patient safety specialist partners with the accountable executive and a multidisciplinary team to facilitate a root cause analysis and corrective action plan.


At Virginia Mason, risk management and patient safety are not separate, they are one in the same. We believe our patient safety program is our most effective risk management tool and have structured our department to focus on identifying safety risks and mitigating them quickly which allows for improvements to safety for patients while reducing risk to the organization at the same time.

There are 3 key strategies for how patient safety work is leveraged to reduce risk:

  • Culture of safety that encourages reporting of events
  • Leadership training and engagement
  • Early notification and collaboration with risk management (disclosure, support, etc)

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Culture of Safety

The first strategy is the culture of safety. While Virginia Mason has a relatively good degree of reporting, there are opportunities to improve communication around patient safety events and develop a culture where staff feel safe to speak up. The safety system should not be perceived as punitive, and staff members should be engaged in the solutions to identified safety issues. Armed with the VMPS management method and the support of dedicated team members, Virginia Mason has explored new and innovative ways to approach safety. The first step was to create a shared vision of patient safety at VM. A group of staff and leaders was brought together to come up with a vision statement: “To be inspired and prepared to take the right action, at the right time, with the right resources.” In addition to developing the vision statement, the team developed a future-state model and a three-year Kaizen plan, or work plan that has provided the roadmap for accomplishing the vision.


Critical concepts of the vision include:

  • Safety is deliberate.
  • Safety work utilizes VMPS and is aligned organizationally.
  • Safety starts and ends on the front line.
  • Engaging in safety is simple, fast and intuitive.


Five strategies are used to accomplish these goals: prevent, detect, respond, analyze, and learn/teach.

Communicating with staff about safety and celebrating success is critical to maintaining the culture, encouraging reporting, and normalizing the behaviors of speaking up and taking actions to improve safety.

All leaders at VM are expected to discuss safety issues with their staff regularly at huddles and staff meetings and ask for their ideas on how to improve systems and processes. Engaging the teams in discussing the problems and developing solutions gives them ownership and pride in improving safety every day. Safety is communicated at not only the local level, but also the organizational level, through a communication plan developed to raise awareness of patient safety and publicize some of the successes resulting from safety work.


The Good Catch Award is a celebration of a staff member who reported a PSA that had a compelling story which led to system improvements. The winner is presented with a certificate and a logo baseball signed by members of the quality oversight committee and is recognized on the website and at several leadership meetings. This award helps to stimulate conversation about safety and encourages staff to report safety issues. It is also used to publicize some of the great improvements that have been initiated as a result of those reports.

Reaching out to physicians and engaging them in safety and reporting is a critical element to building and maintaining a culture of safety. One strategy used at VM to engage physicians is PSA Pointers, a series of succinct educational presentations designed for the busy practitioner. Each PSA Pointer is created by the Continuing Medical Education office and is based on an actual Patient Safety Alert involving a gap in knowledge. The story of the PSA and the educational lesson is highlighted in fewer than 5 minutes through a video presentation. Each time a new PSA Pointer video is created, clinical staff receive an email notice with links to the video site.

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Leadership Training and Engagement

In order to ensure that the leadership across the organization shares the same mental model of patient safety, a patient safety orientation for all new leaders was developed. The training covers the history of patient safety at Virginia Mason, the expectations for leaders around communication with their staff related to safety, and the commitment to a non-punitive environment that provides tools and resources they can use to investigate and resolve safety concerns. Each leader is partnered with a patient safety specialist to mentor them through their safety journey and serve as a resource and team member.

Integration of Risk Management Function

At Virginia Mason, we do not have a risk management department. The function of managing claims is done within the patient safety department by claims specialists, but our philosophy is that the patient safety work is our strongest risk management tool.


All of the work related to improving culture and engaging leaders and staff in patient safety is key to the success of our risk management function. The patient safety department works closely with the claims team to ensure that they are notified early of any potential risk-related events. The claims team is able to evaluate potential risk events early, support providers and teams through disclosure, and work proactively to resolve patient complaints. Learning about potential risk events early allows the claims team to act sooner to mitigate that risk and not only protect future patients, but improve on the experience of the patient affected. In addition, the patient safety staff has worked closely with the patient relations team to develop a program for synchronized ongoing support (SOS) to respond to unexpected incidents such as reportable events and unanticipated deaths. We created a process available 24/7 that leverages our current resources including patient relations as well as spiritual care for staff and patients, patient safety, and leadership. This program serves to provide immediate and ongoing support for our patients, families, and team members and to initiate the investigation for process improvement.


To evaluate the impact of the safety initiatives, the number of PSAs reported per month was measured. At baseline, there were 430 PSAs reported each month; recently the numbers have increased to the goal of 1000 PSAs per month. More PSAs are not an indication that we are less safe, but that our teams feel safer to report—which is the ultimate goal. In addition to incident reports, culture metrics are measured. Each year staff at VM take a safety culture survey. The survey includes questions assessing the degree to which staff feel they are informed about errors on their unit, receive feedback about changes put into place based on incident reports, and participate in discussions to prevent errors from happening. Spot checks of the safety survey results have been favorable.


Finally, reported malpractice claims have fallen by approximately 50% at the same time PSA reporting significantly increased. There has been a 62% overall reduction in hospital professional liability premiums since 2006. The results show that the investment in a culture of safety and process improvement related to staff-identified safety concerns, coupled with robust communication and leadership training, can really impact the bottom line—which is good for patients and for the organization.

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Do risk managers and patient safety staff collaborate at your organization? Comment on this post below.


Jamie Leviton is manager, patient safety, at Virginia Mason Medical Center. Contact her at Jackie Valentine is director, patient safety, at Seattle Children’s Hospital. Contact her at

Tags:  risk management  transparency 

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