Quality Report High-Reliability Interventions and Process Improvements
We can't make our employees perfect, but we can develop processes that encourage a level of mindfulness that enables us to catch potential errors before they do harm. Read more about how Memorial Hermann is making healthcare safer and better for patients.
"By moving upstream in the care process, we've taken a more active and effective role in managing the health of the populations we serve."
In July 2007, interdisciplinary teams started to work on the elimination of central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). After the first few months of reduced infections, a culture of patient safety and effectiveness took root and continued to evolve. The cornerstone was team building among all interdisciplinary team members, which we encouraged with transparency of data, sharing of challenges, building trust and relationships, and a united commitment to improve patient outcomes. These unit-based teams became well versed in quality improvement principles and were willing to report safety concerns and drive ideas for future improvement. This level of accountability contributed to significant, sustained decreases in the rate of CLABSIs and VAPs, which were previously assumed to be unavoidable complications of invasive medical procedures. Our healthcare teams began to recognize healthcare-associated infections as a care failure and focused their energy on complete elimination.
Click to enlarge comparison chart
Click to enlarge chart
Led by physicians and clinical and operational system leaders, our System Quality and Patient Safety Council endorsed the use of computer alerts to avoid potential errors in patient care. When an alert causes clinicians to cancel or modify a potentially harmful action, we tabulate it as a "good catch." Good catches, which now occur about 1,000 times a month in our hospitals, form one of the three sides of our Patient Safety Triangle, along with close calls and serious safety events.
The Memorial Hermann Electronic Health Record (EHR) allows secured access to patient medical records within our facilities and across healthcare domains. In 2006, MHMD, the Memorial Hermann Physician Network, recognized that equipping physicians with office-based EHRs enhanced their ability to share clinical data and report quality performance as part of the MHMD Clinical Integration Program. eClinicalWorks, subsidized by MHMD, has transformed the physician practices that have deployed it, allowing physicians to report their quality scores based on nationally recognized measures.
Within the EHR, a Medical Power Plan (MPP) allows physician and nursing ordering, automated documentation and aggregated outcomes. The MPP includes an evidence-based information tool that provides clinicians with up-to-date information about best practices.
MEDSAFE increases reliability at the point of medication administration by providing an electronic double-check that compares, at the patient's bedside, medical barcode information against a verified physician's order. MEDSAFE aligns Memorial Hermann with the National Patient Safety Goals to improve the accuracy of patient identification, improve the effectiveness of communication among caregivers and improve the safety of administering medications.
Our focus on reliable use of preventive measures led us to recognize that iatrogenic pneumothorax and accidental puncture or laceration caused by central line insertion could be prevented by evidence-based use of ultrasound guidance. A system wide effort made ultrasound devices immediately available for central line insertion and ensured that providers inserting central lines were trained to use the devices.
Memorial Hermann has concentrated its focus in the operating room on reducing avoidable harm events. As part of Memorial Hermann's systematic high reliability process, the use of RFID-tagged sponges were implemented for all open surgical procedures. In addition to routine sponge counts, all open surgical patients are scanned with a RFID detection wand before the incision is closed. This process led to the detection and removal of sponges that might have been retained because the sponge count was thought to be "correct." This is an excellent example of a resilient, high reliability process with multiple opportunities for a "good catch." Our physicians and operating room staff also use the Surgical Safety Checklist, modeled after the World Health Organization checklist. Compliance with the checklist process is audited and reported as part of each hospital's Monthly Operating Review.
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