Patient Flow E-Newsletter
Volume 3, Issue 2
Thursday, August 3, 2006

Innovations
Creating a ‘Culture of Safety’ in Maryland’s Emergency Departments: A Profile of the Maryland Patient Safety Center & Its ED Collaborative

 As hospital leaders nationwide know, everything changed with the Institute of Medicine’s (IOM) 1999 report, ‘To Err is Human.’ The report brought a tidal wave of media coverage that questioned hospital procedures, ushered in an era of increased government scrutiny and caught the attention of top brass at hospitals across America. Nervous patients in every state were assured that despite the report’s sometimes shocking findings, their local hospital’s quality improvement programs were well-oiled and working.

“The IOM report was groundbreaking, because before then, hospital errors were really not on the national radar. People were dying every year due to errors, but it simply wasn’t being talked about or written about,” said William Minogue, M.D., Director of the Maryland Patient Safety Center (MPSC). “When the report was first issued, there was actually some high-profile denial, because most errors had previously been perceived as complications.”

Experts agree that Maryland was one of the first states to tackle the hospital error issue head-on. On the heels of the IOM report, a group of leading health care professionals joined with legislative leaders to form the MPSC. Before long, the state’s Health Care Commission and General Assembly got involved, and in 2003, legislation was enacted mandating that hospitals report errors resulting in death or permanent disability to the state – two years before Congress passed similar federal legislation. The law also directed the Maryland Health Care Commission to create a patient safety center. “Near misses” and adverse events that do not do permanent harm are voluntarily reported to the MPSC.

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“The events of the last three years have put us ahead of the curve, so the eyes of many other states are on us here in Maryland,” said Dr. Minogue, who regularly gets calls from states as diverse as California, Michigan, North Carolina and New Mexico, asking for advice on how the MPSC was established.

A collaboration of the Maryland Hospital Association and Delmarva Foundation for Medical Care, Inc., the MPSC is a voluntary, non-regulatory initiative that unites the state’s healthcare providers to discuss the root causes of unsafe medical practices and determine how to put evidence-based improvements in place to reduce them. Three-year funding of the MPSC began in June 2004. Within three months, education and training activities were up-and-running to:

• Create awareness of the need to improve patient safety and the potential for achieving it
• Foster the cultural changes required to yield significant improvements
• Ensure that healthcare leaders and professionals have the competencies essential for safety improvement
• Disseminate patient safety solutions and better practices

In November 2004, the MPSC kicked off its Safety Culture Collaborative Series, a program to facilitate sharing of information and encourage the implementation of safety innovations among hospitals statewide. Because a hospital’s sickest patients most prone to death due to error are those in intensive care, the series began with an intensive care unit (ICU) collaborative involving 37 hospitals.

ED Collaborative Exchange Establishes a Statewide Culture of Safety

Although the IOM report detailed errors that occur throughout hospitals, some emergency department officials felt they were under particular scrutiny, with the study coming amidst reports of crowding and inefficiencies that were seen as bellwethers of an error-prone environment. So when the MPSC achieved early success helping ICU leaders reduce errors, the Maryland chapter of the American College of Emergency Physicians was waiting in line.

“They laid out why Maryland’s emergency departments simply had to be next,” said Dr. Minogue. “They were very eager for their own program to share information and safety innovations. It is hard to deny that emergency departments are in crisis, so we agreed they should be the focus of our second collaborative.”

Approximately 30 Maryland hospitals signed on for the ED collaborative, which held its first meeting this past February. It’s a mix of Baltimore’s urban teaching hospitals, suburban community hospitals located just outside of Washington, DC, and rural hospitals that serve the state’s Eastern Shore.

“The collaborative quickly honed in on what is so unique about the ED – the element of time,” said Minogue. “Unlike other areas of the hospital, timeliness and errors go hand in hand in the emergency department. If a patient doesn’t get antibiotics within the first few hours after arriving in the emergency department, that in itself can be an error, and they can quickly mount.”

The ED Collaborative’s Hospital Teams

To participate in the ED collaborative, hospitals are required to assemble teams to work together internally and share lessons learned with the other hospitals. Most well-integrated teams include:

• An executive sponsor, ideally someone at the vice president level or above who will ensure that the institution remains committed to the collaborative
• An emergency physician advisor
• An improvement leader, typically the hospital’s director of process improvement or the vice president of quality improvement
• A handful of team members who represent all positions within the ED, including physicians, triage nurses, registration staff, etc.

The most successful hospital teams commit more staff and resources than the collaborative requires, including members of the radiology, pharmacy and other departments.

Participants say that communication throughout the collaborative is the key to success. Hospitals are required to send members of their team to three day-long sessions; develop monthly action plans; participate in regular conference calls; use provided data collection tools; and submit data measures regularly through a collaborative web portal. Most of the hospitals are currently working on a flow exercise, which involves randomly tagging 30 patients as they arrive and having a hospital volunteer ‘shadow’ them to record exactly how long every step in the ED process takes.

“Each hospital team is doing this for its own knowledge. They cannot fail this exercise because they are only in competition with themselves,” said Kathryn Schulke, Vice President of Strategic Deployment and New Initiatives. “There is no carrot and stick associated with the collaborative. Instead, it requires that every team must believe that if we all commit to this, hold each other accountable and work really hard at improvements, we all will benefit.”