© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
VIEW FROM THE TOP
Quality Officer Takes on Patient Safety Challenges
How does your experience as a critical care nurse inform your current position as a chief quality and safety officer?
It’s important to understand the nature of the work that is done in order to improve it. Working on the front lines of patient care in the intensive care unit uniquely prepared me for my current position. I have seen the risks up front, and, having performed that work, I understand the many burdens and interruptions that staff taking care of patients have to endure.
identify the common process failures. One could also argue that the absence of the safety culture in healthcare is our biggest challenge. How is your facility trying to address that challenge?
My organization is trying to address that challenge by implementing a just culture, teaching team training, and trying to create a safety culture with transparency and open discussion about the challenges of providing highly effective and safe care.
Could you give me a sense of what a typical
What do you see as the greatest advancement
day at work is like for you?
in patient safety over the past decade?
A typical day, unfortunately, is going from meeting to meeting. A lot of the communication is via e-mail where we discuss adverse patient events or processes that need to be put into place to prevent adverse events. A day may be spent in planning projects or participating in executive meetings where regional decisions are being made and quality and safety considerations can be put on the table to influence those decisions.
There is significant awareness of the issues, such as where many of the failure points occur— handoffs, along with medication prescribing, dispensing, and administering. The concept of human error, drift, and at-risk choices inform the process substantially, as well. There is an enormous amount of research that’s being generated on a weekly basis, giving us direction and guidance into where to make improvements.
What do you see as the biggest threat to
We’re living at a time when it’s possible to
patient safety today?
collect more information about patients than
The biggest threats to patient safety today are the multitude of single points of failure, the lack of standard work, and our inability to
Nancy Pratt, RN, MSN, is senior vice president and chief quality and patient safety officer for St. Joseph Health in Orange, CA. She had more than 20 years of experience as a critical care nurse in a variety of settings before joining St. Joseph Health.
ever before. Is that information being used effectively? If not, what are the obstacles?
No, it is absolutely not being used effectively—yet. It’s what everybody wants to have Biomedical Instrumentation & Technology July/August 2014
277
© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
but we’re just emerging in terms of understanding of how to use it. We don’t capture enough timely, process-sensitive information to use this to drive patient safety fixes, yet. Do you think it’s possible to have too much data? I suppose I’m asking if you believe hospitals have lots of data, but too little knowledge.
It is possible to have lots of data that’s not very useful. And that’s what we have today in our incident reporting systems. There are lots of stories, but they are not informed by the process details that would help us fix them. That’s one of the biggest challenges we have today in patient safety.
What is the biggest challenge you faced during the transition and how did you overcome it?
Well, I wish we had it all set up already so I could tell you how we overcame our challenges but we are in the midst of many of those challenges. Chief among those is having data and information on what’s happening with patients in order to intervene with the right resources at the right time. We are connecting those dots today in data systems so the hospital, home health, and ambulatory care providers—along with any other providers in the mix—can all see what’s happening with the patient. You began your career in the U.S. Navy in the
Much has been written in the last few years
Nurse Corps. What lessons did you take away
about population-based care delivery models.
from your time in the military that you use in
Can you explain the term and tell us about your
your current role?
role in facilitating St. Joseph Health’s transition to such a model?
Population-based care delivery models are about taking care of the patients throughout their lifespan across multiple areas and levels of care delivery. It’s about breaking down silos between ambulatory care and hospital-based care and helping patients have a smooth process to encourage their health and reduce their illness burden. It is the right direction to be going, and it will be accelerated when the payment models encourage that type of care. As long as providers in organizations still make money from fee-for-service care, it will distract us from doing population-based care. My role at St. Joseph Health is to support this transition by giving input on quality metrics and performance improvement. The case management leaders and operational experts in the ambulatory space are putting systems and structures into place to manage patients proactively.
I certainly learned a lot about standard processes during my time in the Navy. They rely in the military on systematic processes, standard procedures and reducing variation and to a great extent it works. I probably underappreciated it at the time. Your bio says that you are a noted national and international speaker. What is the biggest concern you hear?
People are frustrated with their measurement systems. They can’t get timely, actionable data. Most of what we get is retrospective, fourmonth-old data, and it’s interesting, but not actionable. Some of the other challenges are the unending new regulatory requirements, the punitive nature of the regulatory oversight, and, of course, the overall shifting landscape in healthcare today. Your CV says that you are a Six Sigma Black Belt. What is that, and how do those skills help you with your daily duties?
Population-based care delivery models are about taking care of the patients throughout their lifespan across multiple areas and levels of care delivery.
278
Biomedical Instrumentation & Technology July/August 2014
A Six Sigma Black belt is someone who is certified—for me, by the American Society of Quality—in using a broad set of performance-improvement skills that includes content from engineering and quality. The certification involves applied use of the skills so it’s not, strictly speaking, just textbook learning. There also is substantial use of
© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
statistical analysis. It is a set of tools that attempts to decrease defects in a process to an extremely low number. “Six Sigma” signifies 3.4 defects per million opportunities—that is the goal.
product, it was published, and it made sense clinically. They continue to work together and it is a fine example of competing organizations working together to drive patient safety. Many of BI&T’s readers are healthcare
Tell us about the San Diego Patient Safety
technology management (HTM) professionals.
Council. How has the council’s work helped to
What role do you see them playing in patient
improve patient safety?
safety?
The council worked on several patient safety initiatives that established guidelines of care for ICU sedation, patient-controlled analgesia, and setting limits on dosing high-risk IV medications.
Technology is one of the fundamental tools available to us to improve patient safety. It is also an opportunity to create risk. Professionals who are working in the healthcare space should make themselves patient safety experts. I could go on at length describing both the methods in which technology has helped us produce better results and circumstances in which the technology created the risk. They need to pull the safety experts in when developing products and testing them, or develop the expertise internally in their departments and companies. Quite often it’s a missing function.
It seems as if it would be nearly impossible to establish best practices throughout many hospitals and healthcare systems. How was the group able to manage that so successfully?
The San Diego Patient Safety Council came together under a grant that a physician from the Department of Veteran’s Affairs (VA) wrote. He originally brought the hospitals together to work on patient safety activities. The grant ran out, but people still wanted to work together. CareFusion offered to give us some space and buy the group lunch in order to allow us to continue to work together, as we had no funding. I was asked to facilitate the group, and so began my many years with the San Diego Patient Safety Council. CareFusion subsequently applied for and received a grant from Cardinal on behalf of the safety council, and those funds were administered by the local hospital association. We listened to all of the participants— whether they were from a big health system or small hospital. We used a lot of change management tools to get to consensus. There were many areas that we were basically doing the same things, and only minor changes were needed in order to standardize. We also had some spirited conversations in which people had different opinions, and the literature was not sufficiently developed to inform the decision. The folks who participated came back over and over wanting to do more together, I think because there was a sense that we were accomplishing something. We produced a
Technology is one of the fundamental tools available to us to improve patient safety. It is also an opportunity to create risk.
How can HTM professionals work most effectively with nurses and other clinicians?
There are people who can navigate both sides of the fence, technology and clinical practice. It is critically important to have clinicians who understand technology and technology experts who know how to listen to clinicians to discover what problem they’re trying to solve. I think you can hire and/or train people to work in that gap. Sometimes clinicians decide what solution that they want and ask for it. But people have to ask enough questions to more deeply understand the fundamental problem, because the best solution may end up being completely different from what the clinician is asking for.
Biomedical Instrumentation & Technology July/August 2014
279
© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
Over the course of your career, you’ve seen more and more medical devices and technology come into the hospital environment. What is the one thing you would want manufacturers
connection to the money and realign the incentives to have patients motivated to take care of themselves and healthcare providers compensated for keeping them healthy.
of these devices to know?
I think that we are making very small improvements in patient safety. We’re not standing still, but we are not accelerating fast enough.
It’s important to develop and test the product in the context of the healthcare environment, as it has many products with alarms. I think most technology manufacturers solicit the voice of the customer on the front lines of care. It’s also helpful to understand what problems we are trying to solve, not just what product could be created. Also, there are some fundamental details that would be useful to implement. From a safety perspective, some of this is around having different audible and visual cues or alarms. Imagine that for one day you have the power
Are there any other issues you’d like to address or points you would like to stress?
I think that we are making very small improvements in patient safety. We’re not standing still, but we are not accelerating fast enough.There are a lot of incentives that are being aligned with quality and safety and those are good changes. We’re giving patients more access to information about their own health. We have to figure out how to get them to fully engage and take care of themselves. We have to get the regulators to back off on the use of punishment and financial fines and get better at helping organizations improve. n
to single-handedly change one thing about the delivery of healthcare in this country. What would that be?
Wow, that’s a heavy question. I would disengage healthcare delivery from its
AAMI Guidance for Healthcare Providers Managing Medical IT-Networks ANSI/AAMI/IEC 80001-1:2010, Application of risk management for IT Networks incorporating medical devices—Part 1: Roles, responsibilities and activities Order Code: 8000101 or 8000101-PDF List $140 / AAMI member $84
TIR80001-2-1:2012, Part 2-1: Step by step risk management of medical IT-networks; Practical applications and examples Order Code: 800010201 or 800010201-PDF List $150 / AAMI member $90
TIR80001-2-2:2012, Part 2-2: Guidance for the
TIR80001-2-3:2012, Part 2-3: Guidance for wireless networks Order Code: 800010203 or 800010203-PDF List $140 / AAMI member $84 Technical
TIR80001-2-4:2012, Part 2-4: Application guidance -- General implementation guidance for healthcare delivery organizations Order Code: 800010204 or 800010204-PDF List $110 / AAMI member $66
Information Report
ANSI/AAMI/ IEC TIR800012-4:2012 Application of risk management for ITnetworks incorporating medical devices — Part 2-4: Application guidance — General implementation guidance for healthcare delivery organizations
communication of medical device security needs, risks and controls Order Code: 800010202 or 800010202-PDF List $150 / AAMI member $90 SOURCE CODE: PB
Order your Copy Today! Call 877-249-8226 or visit http://my.aami.org 280
Biomedical Instrumentation & Technology July/August 2014
Columns and Departments
VIEW FROM THE TOP
Quality Officer Takes on Patient Safety Challenges
How does your experience as a critical care nurse inform your current position as a chief quality and safety officer?
It’s important to understand the nature of the work that is done in order to improve it. Working on the front lines of patient care in the intensive care unit uniquely prepared me for my current position. I have seen the risks up front, and, having performed that work, I understand the many burdens and interruptions that staff taking care of patients have to endure.
identify the common process failures. One could also argue that the absence of the safety culture in healthcare is our biggest challenge. How is your facility trying to address that challenge?
My organization is trying to address that challenge by implementing a just culture, teaching team training, and trying to create a safety culture with transparency and open discussion about the challenges of providing highly effective and safe care.
Could you give me a sense of what a typical
What do you see as the greatest advancement
day at work is like for you?
in patient safety over the past decade?
A typical day, unfortunately, is going from meeting to meeting. A lot of the communication is via e-mail where we discuss adverse patient events or processes that need to be put into place to prevent adverse events. A day may be spent in planning projects or participating in executive meetings where regional decisions are being made and quality and safety considerations can be put on the table to influence those decisions.
There is significant awareness of the issues, such as where many of the failure points occur— handoffs, along with medication prescribing, dispensing, and administering. The concept of human error, drift, and at-risk choices inform the process substantially, as well. There is an enormous amount of research that’s being generated on a weekly basis, giving us direction and guidance into where to make improvements.
What do you see as the biggest threat to
We’re living at a time when it’s possible to
patient safety today?
collect more information about patients than
The biggest threats to patient safety today are the multitude of single points of failure, the lack of standard work, and our inability to
Nancy Pratt, RN, MSN, is senior vice president and chief quality and patient safety officer for St. Joseph Health in Orange, CA. She had more than 20 years of experience as a critical care nurse in a variety of settings before joining St. Joseph Health.
ever before. Is that information being used effectively? If not, what are the obstacles?
No, it is absolutely not being used effectively—yet. It’s what everybody wants to have Biomedical Instrumentation & Technology July/August 2014
277
© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
but we’re just emerging in terms of understanding of how to use it. We don’t capture enough timely, process-sensitive information to use this to drive patient safety fixes, yet. Do you think it’s possible to have too much data? I suppose I’m asking if you believe hospitals have lots of data, but too little knowledge.
It is possible to have lots of data that’s not very useful. And that’s what we have today in our incident reporting systems. There are lots of stories, but they are not informed by the process details that would help us fix them. That’s one of the biggest challenges we have today in patient safety.
What is the biggest challenge you faced during the transition and how did you overcome it?
Well, I wish we had it all set up already so I could tell you how we overcame our challenges but we are in the midst of many of those challenges. Chief among those is having data and information on what’s happening with patients in order to intervene with the right resources at the right time. We are connecting those dots today in data systems so the hospital, home health, and ambulatory care providers—along with any other providers in the mix—can all see what’s happening with the patient. You began your career in the U.S. Navy in the
Much has been written in the last few years
Nurse Corps. What lessons did you take away
about population-based care delivery models.
from your time in the military that you use in
Can you explain the term and tell us about your
your current role?
role in facilitating St. Joseph Health’s transition to such a model?
Population-based care delivery models are about taking care of the patients throughout their lifespan across multiple areas and levels of care delivery. It’s about breaking down silos between ambulatory care and hospital-based care and helping patients have a smooth process to encourage their health and reduce their illness burden. It is the right direction to be going, and it will be accelerated when the payment models encourage that type of care. As long as providers in organizations still make money from fee-for-service care, it will distract us from doing population-based care. My role at St. Joseph Health is to support this transition by giving input on quality metrics and performance improvement. The case management leaders and operational experts in the ambulatory space are putting systems and structures into place to manage patients proactively.
I certainly learned a lot about standard processes during my time in the Navy. They rely in the military on systematic processes, standard procedures and reducing variation and to a great extent it works. I probably underappreciated it at the time. Your bio says that you are a noted national and international speaker. What is the biggest concern you hear?
People are frustrated with their measurement systems. They can’t get timely, actionable data. Most of what we get is retrospective, fourmonth-old data, and it’s interesting, but not actionable. Some of the other challenges are the unending new regulatory requirements, the punitive nature of the regulatory oversight, and, of course, the overall shifting landscape in healthcare today. Your CV says that you are a Six Sigma Black Belt. What is that, and how do those skills help you with your daily duties?
Population-based care delivery models are about taking care of the patients throughout their lifespan across multiple areas and levels of care delivery.
278
Biomedical Instrumentation & Technology July/August 2014
A Six Sigma Black belt is someone who is certified—for me, by the American Society of Quality—in using a broad set of performance-improvement skills that includes content from engineering and quality. The certification involves applied use of the skills so it’s not, strictly speaking, just textbook learning. There also is substantial use of
© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
statistical analysis. It is a set of tools that attempts to decrease defects in a process to an extremely low number. “Six Sigma” signifies 3.4 defects per million opportunities—that is the goal.
product, it was published, and it made sense clinically. They continue to work together and it is a fine example of competing organizations working together to drive patient safety. Many of BI&T’s readers are healthcare
Tell us about the San Diego Patient Safety
technology management (HTM) professionals.
Council. How has the council’s work helped to
What role do you see them playing in patient
improve patient safety?
safety?
The council worked on several patient safety initiatives that established guidelines of care for ICU sedation, patient-controlled analgesia, and setting limits on dosing high-risk IV medications.
Technology is one of the fundamental tools available to us to improve patient safety. It is also an opportunity to create risk. Professionals who are working in the healthcare space should make themselves patient safety experts. I could go on at length describing both the methods in which technology has helped us produce better results and circumstances in which the technology created the risk. They need to pull the safety experts in when developing products and testing them, or develop the expertise internally in their departments and companies. Quite often it’s a missing function.
It seems as if it would be nearly impossible to establish best practices throughout many hospitals and healthcare systems. How was the group able to manage that so successfully?
The San Diego Patient Safety Council came together under a grant that a physician from the Department of Veteran’s Affairs (VA) wrote. He originally brought the hospitals together to work on patient safety activities. The grant ran out, but people still wanted to work together. CareFusion offered to give us some space and buy the group lunch in order to allow us to continue to work together, as we had no funding. I was asked to facilitate the group, and so began my many years with the San Diego Patient Safety Council. CareFusion subsequently applied for and received a grant from Cardinal on behalf of the safety council, and those funds were administered by the local hospital association. We listened to all of the participants— whether they were from a big health system or small hospital. We used a lot of change management tools to get to consensus. There were many areas that we were basically doing the same things, and only minor changes were needed in order to standardize. We also had some spirited conversations in which people had different opinions, and the literature was not sufficiently developed to inform the decision. The folks who participated came back over and over wanting to do more together, I think because there was a sense that we were accomplishing something. We produced a
Technology is one of the fundamental tools available to us to improve patient safety. It is also an opportunity to create risk.
How can HTM professionals work most effectively with nurses and other clinicians?
There are people who can navigate both sides of the fence, technology and clinical practice. It is critically important to have clinicians who understand technology and technology experts who know how to listen to clinicians to discover what problem they’re trying to solve. I think you can hire and/or train people to work in that gap. Sometimes clinicians decide what solution that they want and ask for it. But people have to ask enough questions to more deeply understand the fundamental problem, because the best solution may end up being completely different from what the clinician is asking for.
Biomedical Instrumentation & Technology July/August 2014
279
© Copyright AAMI 2014. Single user license only. Copying, networking, and distribution prohibited.
Columns and Departments
Over the course of your career, you’ve seen more and more medical devices and technology come into the hospital environment. What is the one thing you would want manufacturers
connection to the money and realign the incentives to have patients motivated to take care of themselves and healthcare providers compensated for keeping them healthy.
of these devices to know?
I think that we are making very small improvements in patient safety. We’re not standing still, but we are not accelerating fast enough.
It’s important to develop and test the product in the context of the healthcare environment, as it has many products with alarms. I think most technology manufacturers solicit the voice of the customer on the front lines of care. It’s also helpful to understand what problems we are trying to solve, not just what product could be created. Also, there are some fundamental details that would be useful to implement. From a safety perspective, some of this is around having different audible and visual cues or alarms. Imagine that for one day you have the power
Are there any other issues you’d like to address or points you would like to stress?
I think that we are making very small improvements in patient safety. We’re not standing still, but we are not accelerating fast enough.There are a lot of incentives that are being aligned with quality and safety and those are good changes. We’re giving patients more access to information about their own health. We have to figure out how to get them to fully engage and take care of themselves. We have to get the regulators to back off on the use of punishment and financial fines and get better at helping organizations improve. n
to single-handedly change one thing about the delivery of healthcare in this country. What would that be?
Wow, that’s a heavy question. I would disengage healthcare delivery from its
AAMI Guidance for Healthcare Providers Managing Medical IT-Networks ANSI/AAMI/IEC 80001-1:2010, Application of risk management for IT Networks incorporating medical devices—Part 1: Roles, responsibilities and activities Order Code: 8000101 or 8000101-PDF List $140 / AAMI member $84
TIR80001-2-1:2012, Part 2-1: Step by step risk management of medical IT-networks; Practical applications and examples Order Code: 800010201 or 800010201-PDF List $150 / AAMI member $90
TIR80001-2-2:2012, Part 2-2: Guidance for the
TIR80001-2-3:2012, Part 2-3: Guidance for wireless networks Order Code: 800010203 or 800010203-PDF List $140 / AAMI member $84 Technical
TIR80001-2-4:2012, Part 2-4: Application guidance -- General implementation guidance for healthcare delivery organizations Order Code: 800010204 or 800010204-PDF List $110 / AAMI member $66
Information Report
ANSI/AAMI/ IEC TIR800012-4:2012 Application of risk management for ITnetworks incorporating medical devices — Part 2-4: Application guidance — General implementation guidance for healthcare delivery organizations
communication of medical device security needs, risks and controls Order Code: 800010202 or 800010202-PDF List $150 / AAMI member $90 SOURCE CODE: PB
Order your Copy Today! Call 877-249-8226 or visit http://my.aami.org 280
Biomedical Instrumentation & Technology July/August 2014
