NAVIGATING PATIENT SAFETY IN THE RURAL HEALTHCARE LANDSCAPE

by David Allison, CPHRM, System Patient Safety Director, PeaceHealth

As those who work in them know well, running a rural healthcare facility can pose unique challenges. Transitions of care such as helicopter transfers and pathways to access are of extra importance, with long distances and waterways separating patients from treatment centers. Critical access hospitals, ambulatory settings, and outpatient clinics in remote regions must think critically about how to meet complex patient population needs often while facing provider shortages and competition from large urban facilities. PeaceHealth has the distinct challenge of running not one, but a whole system of facilities in rural communities spread across the Pacific Northwest, from the small historic town of Cottage Grove, OR, all the way to the shores of Ketchikan, AK. David Allison, CPHRM, PeaceHealth’s Director of System Patient Safety, shares some of the work he and his team have been implementing to address these unique rural needs.

About PeaceHealth: A Truly Regional Health System

PeaceHealth includes 10 hospitals in Washington, Alaska, and Oregon – 6 of them being critical access hospitals. Also included in the system are 60+ ambulatory clinics with 800+ physicians and allied health providers.

Patient Safety is a department within the Quality Division, led by a physician Patient Safety Officer and a Patient Safety Director; my role. Hospitals and the Medical Group are served by Chief Medical/Patient Safety Officers, or other Medical Staff Leaders, and Patient Safety Consultants.

Tailoring Patient Safety Structures That Work for Your Setting

In the PeaceHealth System, we have been focused on building functional patient safety structures in our critical access hospitals and in the medical group. In doing this, we have found that a patient safety program and structure based on the function and resources of large, acute care hospitals does not serve the needs of critical access hospitals and ambulatory clinics – as many of us know, these programs are not one size fits all.

To address this, PeaceHealth patient safety leaders have met with leaders from all our critical access hospitals, and with medical group leaders, to assess whether the needs and proposed structures were in harmony. The feedback we received from these leaders is what has enabled us to adapt and improve on these structures, ultimately making them more functional. For example, our critical access hospitals do not have Chief Medical Officers. We agreed to ask the Chief of Staff or other medical leader to participate.

“…these programs are not one size fits all.”

We also heard from our critical access hospitals that their patient safety teams were overlapping with the quality management committee. To address this, we structured the process to match the resources. The quality management committees now approve corrective action plans from root cause analyses and address barriers to their implementation, making a separate committee and meeting unneeded. The critical access patient safety team schedules vary based on need, from monthly to weekly to an as-needed basis. We also add meetings as events dictate.

To keep the ball rolling in structural improvements, a monthly system-wide Serious Safety Event Review meeting was also established. Administrative, Medicine and Nursing Chiefs all participate, along with system support such as Risk Management, Quality, Organizational Integrity, Performance Improvement, and Clinical Education. This ongoing meeting includes membership from our critical access hospitals and medical group clinics, as well as the larger acute care hospitals, offering us the chance of sharing the outcomes of root cause analyses in critical access hospitals and medical group clinics, identifying similar risks across the system and spreading action plans to reduce the risk of similar events.

Through this valuable process, patient safety was identified as a core value of our organization. This has led to roles and responsibilities for patient safety being clarified. Patient safety is to lead efforts to reduce and prevent harm. Quality leads in performance in the best outcome being achieved. a patient safety plan being documented, and relevant metrics being identified and reported. Some metrics, such as the rate of serious harm, are common across settings. Others are specific to the setting. For example, metrics for the medical group include enrollment in an electronic portal, and management of InBasket messages.

“Adapting Patient Safety function and structure to meet the resources and needs of critical access hospitals and ambulatory clinics is vital to success.”

Outcomes

What were the primary outcomes or impact of this work?

• A Medical Group Patient Safety Team was formed, with members including the Medical Group Patient Safety Officer and Network Quality Committee Chairs, as well as leaders from Risk Management, Quality, and Patient Safety divisions. The team triages events for potential review by Root Cause Analysis or other processes, assesses harm levels, reviews action plans, and supports the spread of Action Plans across the Medical Group. Events and action plans are shared in the System Serious Safety Event Review.
• Patient Safety Teams were also formed in all Critical Access Hospitals. Members include the Chief Administrative Officer, Director of Nursing, Quality Manager, Risk Manager, Medical Staff representative, and Patient Safety leaders. Teams triage events for review, review and approve Action Plans, and monitor their completion. Events and Action Plans are shared in the System Serious Safety Event Review. Since the inception of the System Serious Safety Event Review in November 2015, 12 Medical Group Action Plans have been reviewed and spread. Eleven Action Plans from Critical Access Hospitals have been similarly shared and spread.

What were the largest “lessons learned” in this effort?

A number of specific lessons learned from Root Cause Analyses have been spread. We are working to hard wire the use of briefs, times out, and debriefs in ambulatory settings as well as in surgery. This requires identifying best practice for the clinic setting, and adapting to fit the workflow in dermatology or imaging, for example. In addition, the structure has allowed addressing events in transitions of care. Standardization and more robust education are underway for clinic triage, and systems are being developed for tracking discharged patients on critical medications. Improvements are also underway in the process for referral from primary to specialty care. Sharing lessons learned from Serious Safety Events has increased levels of transparency, and collaboration. We expected when we began our monthly event reviews that communities might be hesitant to share their stories, but we are pleasantly surprised to have found that there is a collective sense that working together we can better improve safe patient care.

What were the reactions of patients, families, and/or staff effected by the work?

Patient/Family advisors participate on Root Cause Analysis teams. Their feedback has included the importance of following through on Action Plans and spreading lessons learned from events. It is a goal to add a Patient/Family Advisor to the monthly System Serious Safety Event Review meeting. Participants in the monthly call, including Chief Administrators, Chief Medical Officers, Chief Nursing Officers, Quality Leaders, Risk Management Leaders and Patient Safety Leaders have expressed encouragement and support.

If another organization took on a similar project, what would be your biggest suggestion?

Adapting Patient Safety function and structure to meet the resources and needs of critical access hospitals and ambulatory clinics is vital to success. We have collaborated with our critical access and medical group leaders to match patient safety function to the structures they have in place. It looks different than the structures in our acute care hospitals, but still accomplishes the triage and investigation of events, approval and tracking of action plans, and supporting the spread of these across our system.

About the Author

David Allison has served as the PeaceHealth System Patient Safety Director since November 2014, working closely with their System Patient Safety Officer. He has been with PeaceHealth for 28 years in a variety of roles, including Risk Management and managing the Inpatient Psychiatric Unit in Eugene, OR.

dallison@peacehealth.org
541-359-5260