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Reducing patient harm by learning from each other

EMHS Office of Patient Safety: Organizational Learning Message
By Tina Scott, System Director of Clinical Performance
      Emily Burdin, System Director of Patient Safety
EMHS has made great strides in reducing patient harm since our initial engagement with the Partnership for Patients (PfP), Hospital Engagement Network (HEN 2.0) initiative that began in the fall of 2015. The improvements made by our member organizations demonstrate a high level of hospital engagement and program value. In an effort to highlight the amazing work that is being done across the system, we are showcasing a sample of the successes from two of our member organizations. As we learn from other member organizations, share best practices, and engage frontline staff, we are able to improve patient safety at the bedside.

We are pleased to share that as of the last fiscal year, EMHS avoided 27 cases of catheter-associated urinary tract infections (CAUTIs), improving the incidence rate by 43 percent since 2010. Much of the success is attributable to the team-based learning among member hospitals, addressing barriers and challenges along with sharing failures and successes with one another. CAUTIs are the most common type of healthcare-associated infections, accounting for more than 30 percent of acute care hospital infections. An estimated 13,000 deaths are associated with urinary tract infections (UTIs) each year. Preventing healthcare–associated infections, and catheter-associated UTI in particular, has emerged as a priority in the United States, with government agencies taking a lead role in their reduction.

Sara Donovan, RN, infection preventionist at Inland Hospital, learned from another member hospital of a product called the SureStep Foley Tray System, which has features to help better standardize the catheterization process, thus supporting CAUTI reduction. The manufacturer of the product provided education and training for CAUTI reduction champions at Inland Hospital, which empowered these staff members to conduct training for all nurses on CAUTI reduction and the new product. This tray is now used in all departments at Inland Hospital. EMHS’ participation in Partnerships for Patients has allowed our members to collaborate with a new, organized framework. Sara says, “Having the encouragement and formal structure from our systemwide collaboration was very beneficial and kept us accountable.”

Kyla Trundy, RN, infection preventionist at Eastern Maine Medical Center, was part of the clinical design day held at the EMHS Home Office last spring. Her team wanted to study current catheter practices, find opportunities to improve outcomes, and bring infection prevention to the bedside. Kyla explains, “We wanted to take an honest look at the practices surrounding each CAUTI, compare those practices to our policies, and address any identified gaps.”  Kyla learned of a method on clinical design day called “direct observation,” used to assess a problem’s root cause. She and her team developed a “bedside rounding tool,” which is a checklist used to ensure the safest catheter protocols are used and shared through clinical shift changes. “I have learned,” Kyla reflects, “that it is critical that our new processes become rituals to hardwire high reliability. Best practices are only effective if they are sustainable.”

Reflecting on the past year, many lessons have been identified that EMHS will use strategically to support ongoing improvement. Our system supports a blame-free environment and seeks to promote the reporting of close calls or near misses when it comes to patient harm. Creating this kind of open communications allows us to look at system improvements and ultimately share lessons learned across the system. Next month, we will share with you how all of the work being done across the system to reduce patient harm fits in with our Culture of Patient Safety survey results. Throughout the month of March, the Office of Patient Safety met with the executive and front line leaders from each organization to review their Culture of Patient Safety Survey results and to begin incorporating the components of safety culture into their already established action plans. We will tell you more about EMHS’ journey towards becoming a high-reliability organization. Click here to learn more about CMS’ Partnership for Patients or here to learn about Hospital Improvement Innovation Networks.

About the authors:
Tina Scott is the system director of clinical performance and lead system coordinator for the Partnership for Patients (PfP) engagement. Emily Burdin is the system director of patient safety and data coordinator for PfP HEN 2.0 engagement.