While we can't publish details from our M&M cases given confidentiality laws, we can publish some of the key Patient Safety & Quality Improvement concepts we discussed.
What are some of the core concepts at the heart of Patient Safety and Quality Improvement?
Before diving into an M&M, it's essential to understand the background of the patient safety movement. Before this movement took off nearly 20 years ago (also... yes. 2000 was almost twenty years ago!), it was the norm for the person who made an error to be punished for it.
To Err is Human was a landmark publication that came out in November of 1999. Issued by the U.S. Institute of Medicine, not only did it result in increased awareness of U.S. medical errors: it launched the patient safety movement. It's why we've started basing our processes as a healthcare system on those of high-reliability organizations, such as the airliner industry or nuclear energy.
From these industries, we borrowed the concept of just culture. A just culture is one where there is an atmosphere of trust, where people believe they will not be punished for bringing forward essential information. This doesn't mean that punishments never occur: if someone is acting maliciously or recklessly, punishment will still happen. Rather, it means that those who make honest errors won't be punished.
This is borne of another concept: human error is inevitable. Everyone makes mistakes (no one is immune from human error!) and human error is not a behavioral choice: therefore, no one should be punished for errors. Rather, systems should be built to minimize error.
What is local rationality?
Local rationality is the idea that decisions make sense if you look at them in the environment in which they were created. People make decisions that make sense based on their goals, situational understanding, organizational culture, and focus of attention at the time of their decision. Therefore, to truly understand the system and the decisions made, you MUST understand the full context.
How do we go from an adverse event to a QI project?
We will discuss these steps throughout our conferences this year.
First, you need to analyze the system and come up with areas for improvement. There are several methods to do this (RCA, Gap Analysis, etc.). In our programming today, we discussed both a Fishbone Diagram and The 5Whys?
After you have analyzed the system, choose an area for improvement and create a project aim. Start with a very general aim initially. For example, "my goal is to make it so that critical medications aren’t missed during inpatient admissions."
Next, narrow your focus. For the above example, you could narrow it to something like the following: “I want to improve the process for medication reconciliation when patients are transferred from an outside hospital to Froedtert”.
From here, make your goal a SMART goal. A SMART goal is one that is:
Specific
Measurable
Assignable or Attainable
Relevant
Time-based.
A bad "specific aim" for the above example would be: "I want to make an EPIC template for OSH hospital transfers to get med rec'd". A good "specific aim" would be "By July 1, 85% of outside hospital transfers will have their outside hospital med list reconciled by a pharmacist using an EPIC template within 24 hours of their stay”.
From here, you can go on to design the rest of your project! The next step would be choosing your measures... and we will talk more about that at a future M&M.
Let me know if you have any questions or want to jump ahead with a project of your own.
References
Systems Thinking for Safety/Principle 2. Local Rationality from SKYbrary. Accessed 12/3/2019.
MKSAP 17.
Scott Weingart. EMCrit 249 – You Can Either Learn or You Can Blame – Fixing the Morbidity and Mortality Conference with George Douros. EMCrit Blog. Published on June 13, 2019. Accessed on December 6th 2019. Available at [https://emcrit.org/emcrit/fixing-mm-conf/ ].
IHI's Patient Safety Toolkit
IHI's QI Toolkit
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