{"id":3906,"date":"2015-06-18T11:20:57","date_gmt":"2015-06-18T18:20:57","guid":{"rendered":"http:\/\/www.wapatientsafety.org\/?p=3906"},"modified":"2019-08-02T22:21:40","modified_gmt":"2019-08-02T22:21:40","slug":"a-few-thoughts-from-the-2015-wpsc-conference","status":"publish","type":"post","link":"https:\/\/www.qualityhealth.org\/wpsc\/2015\/06\/18\/a-few-thoughts-from-the-2015-wpsc-conference\/","title":{"rendered":"A Few Thoughts From the 2015 WPSC Conference"},"content":{"rendered":"

By: Miriam Marcus Smith, WPSC Program Director<\/em><\/strong><\/p>\n

The 13th<\/sup> Northwest Patient Safety Conference (May 2015) included several short sessions in the afternoon \u2013 we call these \u201cthe fast and the furious\u201d because the format for each is a short (10-minute) talk followed by about 10 minutes of discussion at the tables.\u00a0 Participants are assigned to mixed tables \u2013 that is, each table has people from different organizations and settings. As organizers, our hope is to provide the opportunity for people to talk with others whom they may not know, and thus have even livelier, productive, and creative (some might say riskier) conversation.<\/p>\n

I want to highlight two of the sessions.\u00a0 One was presented by Seattle Children\u2019s about their experience with including patients and family representatives in root cause analyses.\u00a0 Three questions were posed to the attendees: (1) what is your greatest fear about involving families in this work? (2) what is the biggest issue that is keeping you from involving patients and\/or families? And (3) what\u2019s one step you are willing to take toward the goal of involving patients and families in RCAs?<\/em> Attendees discussed the questions and provided written responses, and I derived the themes from the 33 responses.\u00a0\u00a0 In response to Questions 1 and 2, there were four main themes.\u00a0 Two were what I would call informational or logistic \u2013 concerns about privacy, confidentiality, disclosure, and legal issues; and about developing the process, training, and scheduling.\u00a0 To me these seem relatively straightforward \u2013 organizations can seek out the information they need, and address logistic challenges; there is information available from other organizations that have done this.\u00a0 Another theme was concern about patients, families, and staff \u2013 would they be harmed in some way by this process? Would we frighten patients and families, or cause them more pain? Would their trust be lost? Would staff feel safe?\u00a0 The fourth had to do with organizational leadership:\u00a0 leadership must be on board to increase the likelihood of success. Finally, among the themes of Question 3 (What\u2019s the one step you\u2019ll take toward this goal) the standout was \u201cStart the conversation\u201d \u2013 with patients and families, with leadership, with other departments, and with other organizations.<\/p>\n

The other session was an overview of the serious adverse events that are reported to the Washington State Department of Health, focusing on a \u2018non-zero\u2019 rate of surgical-related events that persists despite significant, ongoing effort by hospitals.\u00a0 The questions put to the attendees were the following: If it were up to you, what would you do differently? What is keeping that from happening?<\/em>\u00a0 We collected and collated the 30 responses.\u00a0 Similar to the prior session, two themes of Question 1 were \u2018mechanical\u2019 or technical:\u00a0 e.g., provide supports such as scribes; and improve the root cause analysis process.\u00a0 Two other themes dealt with communication, culture and leadership.\u00a0 The answers to the second question fell into a single theme:\u00a0 culture. \u00a0<\/strong>The comments include concerns about lack of organizational commitment and follow-through; push for productivity; and a fear of reprisal and punishment for speaking up.<\/p>\n

What do the discussions of these two presentations tell us?\u00a0 First, I am impressed that so many attendees were willing to share their thoughts, opinions, and ideas. These are sensitive topics: involving patients and family members in the processes we use to examine errors can be frightening. Revealing a fear of reprisal at one\u2019s organization \u2013 when we are supposed to be \u2018past that\u2019 – takes trust and courage. \u00a0Second, even while there is great concern about both patients and staff, attendees were willing to start those conversations<\/em> about a challenging topic \u2013 involving patients and families in root cause analyses. Third, despite years of effort on eliminating surgical-related errors, \u2018technical\u2019 issues persist. Why is this?\u00a0 Have we all implemented the surgical checklist and now treat it like a casual four-way stop intersection, without being truly attentive? \u00a0Finally, culture and organizational leadership are critical as both facilitator and barrier. \u00a0Leadership is not a one-time event, a statement in the organization\u2019s mission, or frequent presentations at conferences.\u00a0 It is daily, ongoing work, requiring constant communication up and down the line, truly being there for all <\/em>staff. It is a process, and it is hard.\u00a0 We know when it is absent or ineffective, and it does affect safety.<\/p>\n

The full summaries of both sessions are available on this website in the Selected Past Conference Materials, 2015<\/a>\u00a0(Summaries titled,”Getting to Zero” and “Patients and Families on RCAs”).\u00a0 Would you like to comment on these materials, or submit a guest blog?<\/strong> Please complete a Contact Us<\/a> form on our website.<\/p>\n

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