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Original Research |
1 Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC
5031, 3333 Burnet Ave., Cincinnati, OH 45229-3039.
2 Department of Pediatrics, Cincinnati Children's Hospital Medical Center,
Cincinnati, OH.
3 Department of Quality Improvement, Cincinnati Children's Hospital Medical
Center, Cincinnati, OH.
Received November 11, 2008;
accepted after revision December 19, 2008.
Presented at the 2009 annual meeting of the Society for Pediatric Radiology
where it received the Caffey Award for Outstanding Clinical Research
Paper.
Abstract
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MATERIALS AND METHODS. A comprehensive safety program implemented in a department of radiology included error prevention training for all employees, a safety coach program, safety awards, Crucial Conversations training, and operational rounds with radiology leaders. The number of serious safety events (events with deviation from best practice, patient harm, and causation) that in part involved radiology were compared for 2 years after implementation of the program and the previous 2 years (baseline). A U.S. Agency for Healthcare Research and Quality safety culture survey was distributed to radiology employees, and the responses were compared for periods early in the program and after full implementation of the program. Fisher's exact test was used to evaluate for statistically significant differences (p < 0.05) in the survey responses and the frequency of serious safety events.
RESULTS. Before introduction of the safety program, radiology contributed to a serious safety event an average of once every 200 days as opposed to once in 780 days after implementation of the program (one event in more than two academic years) (p = 0.37). Improvement was found in all 12 dimensions of the culture survey after implementation of the program. Radiology scored higher than hospital averages in 10 of 12 dimensions of the survey.
CONCLUSION. The safety program had a positive effect on safety culture. Although it is early in the process and proving statistical significance for rare events such as serious safety events is difficult, the mean number of days between serious safety events has increased from 200 to 780. We conclude that the program is having a positive effect on safety performance.
Keywords: patient safety • safety program
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One can argue that the focus on general aspects of patient safety in radiology has lagged behind that in general medicine. Most of the safety-related issues addressed in the radiology literature have focused on specific issues, such as MRI safety, contrast reactions, and radiation dose protection [15]. It can be argued that radiology has contributed to improved safety and quality through improvements in the rate of reporting and storage and access to images through PACS [16]. There have been very few publications, however, on overall programs to improve the general safety in the radiology department [15-17]. We are not aware of publications that document improved patient safety related to deployment of a comprehensive patient safety program in radiology. We evaluated the effects of a safety program on both the frequency of serious safety events and the safety culture in the radiology department of a pediatric hospital.
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Error Prevention Training
Error prevention training consists of a mandatory 2-hour program for all
employees involved in clinical care and for nonclinical employees who have
patient contact. Training is mandatory for new employees and available for
nonclinical personnel with an interest in safety. The training defines safety
terminology, gives examples of safety failures and institutional baseline
safety performance, and describes the institutional approach to safety. The
overall goal of error prevention training is to have all clinical staff
practice low-risk behaviors in high-risk situations. Emphasis is on conveying
the important features involved in creating a culture of safety: First, that
all employees, regardless of level within the hierarchy, feel comfortable
about speaking out in the face of uncertainty and, second, that patient safety
is everyone's responsibility. At the core of the error prevention training are
three behavioral expectations and error prevention techniques that can be
practiced by employees to enhance the behavioral expectations: making a
personal commitment to safety, communicating clearly, and paying attention to
detail.
Safety Coach Program
A safety coach program was implemented in the department of radiology. The
goal of the program is to reinforce expected safety behaviors and techniques.
Safety coaches are volunteers re cruited during error prevention training
classes. The only requirement is a passion for safety. It was decided that the
coaches would self-select within the group; that is, those unable to or
uncomfortable in meeting the commitments of a coach would not volunteer to be
coaches. Safety coach volunteers include radiologists, technologists, nurses,
customer service representatives, informatics employees, and administrative
personnel. As of this writing, the department of radiology had 20 safety
coaches.
Safety coach responsibilities include attending a 1-hour safety coach training, acting as a safety role model by consistently practicing error prevention techniques, performing 16 safety observations per month, and attending the monthly 1-hour safety coach meeting. Safety coaches must complete the 1-hour training before becoming active. The training consists of a 15-minute didactic review of error prevention techniques, instruction and elaboration on five-to-one feedback (five positive comments reinforcing safety behaviors for each coaching moment), and instruction on filling out a behavioral observation tool. The rest of the training consists of presentation of scenarios specific to the radiology department with which to practice coaching moments. The practice is reinforced by group critique of the presentations.
Safety coaches meet once a month. At each meeting, updates from the hospitalwide safety coach meeting are presented. Coaches share experiences, both positive and negative; identify barriers to coaching; and support one another. An example of a barrier identified is discomfort in speaking up while coaching peers and coworkers on a higher level in the hospital hierarchy. This barrier was consistently identified not only in radiology but also throughout the medical center. In an effort to expand the communication skills and comfort of safety coaches, hospital leaders supported the decision to test the use of Crucial Conversations training of a group of safety coaches. Radiology safety coaches were included in this pilot group.
Crucial Conversations Training
Crucial Conversations training is described in the research publication
"Silence Kills: The Seven Crucial Conversations for Healthcare"
[18]. The research was
conducted by the authors of the book Crucial Conversations: Tools for
Talking When Stakes Are High
[19] in conjunction with the
American Association of Critical Care Nurses. The trainees learn critical
communication skills for situations in which stakes are high, emotions are
high, and opinions differ. Implementation of the training requires a strong
commitment in both money and time away from clinical areas (16 hours). The
expected outcome is an increase in the ability of those trained to hold
difficult conversations about safety. Because radiologists and clinical
managers are informal safety leaders, the radiology department chose to train
not only safety coaches but also all clinical managers and interested
radiologists.
Safety Award Recognition
The radiology safety award was established so that radiology department
leaders and safety coaches could recognize those within the department who
exhibit an outstanding commitment to safety. Each quarter, safety coaches or
managers may nominate an employee for the radiology safety award by briefly
describing the nominee's contributions to safety. Safety coaches then vote to
determine the winner. The award recipient receives a certificate, a safety
hardhat filled with candy, and the $25 gift card of their choice. The award is
presented during work hours in front of peers and coworkers. It is announced
with a brief description of the recipient's accomplishments to all department
personnel via e-mail and on the radiology Web page. Photographs of the
recipient receiving the award are posted on the Web page for the entire
quarter.
Operational Rounds With Radiology Leaders
Operational rounds is a process by which radiology leaders visit with the
area managers, front-line technologists, radiology division chiefs, and key
radiologists and other employees in specific imaging divisions (radiography,
MRI, CT, ultrasound, nuclear medicine, interventional radiol ogy, radiology
nursing, and satellite imaging locations). The goals of operational rounds
include demonstration of radiology leaders' commitment to safety, improved
safety culture and performance, emphasis on behavioral expectations and
concepts taught during error prevention training, and identification of areas
of improvement according to information from front-line workers. A culture of
speaking out in circumstances of uncertainty, evaluation of systems, and
avoiding individual blame for unintended human error is emphasized.
Operational rounds have been previously described in detail
[20]. Each division is visited
twice annually, and rounds are conducted at the site of care. The radiology
leaders who participate in operational rounds are the radiologist-in-chief,
radiology compliance and education coordinator, chief technologist, manager of
radiology informatics, and radiology business and administrative leaders
(assistant vice president, depart ment of radiology, and director of finance,
department of radiology).
Minutes of operational rounds are posted online and on the department intranet and are organized in tables that include columns for description of the issues raised by front-line staff, person responsible for a plan of action, actions planned and taken, and the date the issue was resolved. Employees can check on updates on issues in their respective areas, and technologist managers can evaluate issues in other divisions to see whether the same issues may also need intervention in their areas. Safety issues identified through operational rounds have been previously described [20].
Process for Serious Safety Event Action Plan Debriefing
All institutional serious safety events are subjected to root cause
analysis by means of a defined standardized mechanism. The output of this
process is an action plan that details recommended corrective actions for
preventing similar events. To increase awareness of the related safety issues,
a defined process is in place for communication of the content of the action
plan to the department. For all serious safety events to which the radiology
department has contributed, a summary of the event, the identified root and
contributing causes, and the action plan are presented by the
radiologist-in-chief to the radiologists at the monthly faculty meeting, to
radiology division managers and other administrative leaders at the monthly
management council meeting, and to the department employees during periodic
department updates. As for all institutional serious safety events, a
description with identifying information removed is posted on the hospital
intranet as a safety actions notice.
Lessons Learned Program
Our institution has a hospitalwide safety lessons learned program. Twice a
month, stories about safety lessons learned are posted on the medical center
home page. These stories are examples of instances in which employees improved
safety by practicing error prevention techniques. Numerous stories have been
contributed by department of radiology employees. Stories from throughout the
medical center also are posted. The purposes of the lessons learned program
are to produce a transparent environment within the organization with regard
to safety and to facilitate learning among staff through the sharing of safety
narratives.
In addition to participating in the hospitalwide lessons learned program, radiology has devised a lessons learned program of its own. The purpose is to share safety incidents and narratives with faculty and staff that are specific to the department of radiology. Quarterly radiology safety incidents reported through the safety reporting system are compiled and shared with faculty, fellows, and residents at a regularly scheduled conference. Subsection clinical managers are invited to attend. Incidents are rated on a severity scale from 1 (potential to cause error) to 9 (death). All incidents with a severity rating of 4 or higher are reviewed in detail, and process changes are discussed. Each presentation ends with a discussion of incidents targeted by category or by radiology division. Managers share information specific to their divisions with front-line staff at monthly staff meetings.
Measures
The safety program was launched in July 2006, and components of the program
were initiated between July 2006 and June 2007. Two areas of measured
parameters were compared for the periods before and after implementation of
the safety program. Safety performance was measured in number of serious
safety events, and safety culture was measured in responses to a U.S. Agency
for Healthcare Research and Quality (AHRQ) safety survey
[21] performed before and
after implementation of the program. The AHRQ safety survey is a standardized
tool used by medical institutions to evaluate safety culture.
The number of serious safety events that in part involved radiology in the 2.5 years after implementation of the program (July 2006-November 2008) was compared with the number of events in the 2 years before implementation of the program (July 2004-June 2006), the baseline. The outcome measure evaluated was mean number of days between serious safety events. A serious safety event was defined according to the Healthcare Performance Improve ment definition: an event that entails deviation from best practice care, patient harm, and causation. An example would be a case in which a chest radiograph was obtained to evaluate the position of a peripherally inserted central venous catheter, and the tip was correctly identified and reported to be within the right atrium; the radiologist did not communicate these issues orally; the information was not found by the caregivers; and the catheter lacerated the atrium, causing the death of the patient. If it had been agreed that not orally communicating such critical results to caregivers is deviation from best practice and it was found that the lack of oral communication was the cause of the patient's death, this instance would be considered a serious safety event. The definition of a serious safety event is broader than and includes all of the "never events" defined by the National Quality Forum [22]. A Fisher's exact test was used to evaluate for statistically significant differences in mean number of days between serious safety events and in culture survey responses between the two time periods.
AHRQ safety culture survey responses by radiology employees were compared in surveys performed early in the program (January 2007) and after full implementation of the program (January 2008). Each survey was offered to all institutional employees, including all radiology employees. The survey consisted of 42 questions divided into 12 dimensions. The dimensions included teamwork within hospital units, organizational learning, hospital management support for patient safety, supervisor and manager expectations and actions promoting safety, overall perceptions of safety, communication openness, staffing, feedback and communication about error, frequency of event reporting, teamwork across hospital units, nonpunitive response to error, and hospital handoffs and transitions. The number of institutional and radiology employees who completed the survey was recorded. Statistically significant changes in survey results were measured with a two-sided Fisher's exact test. Statistical significance was defined as p < 0.05.
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The AHRQ survey results are summarized in Table 1 and Figures 1 and 2. Eighteen of the 42 questions (43%) on both surveys showed statistically significant increases in positive responses (Table 1). There was improvement in all 12 categories and statistically significant improvement in nine of 12 categories of the culture survey after implementation of the program (Fig. 1). Categories in which 50% or more of questions showed statistically significant change included organizational learning with continuous improvement, hospital management support for patient safety, supervisor and manager expectations and actions promoting safety, overall perceptions of safety, and staffing. Categories in which less than 50% of questions showed statistically significant change included teamwork within hospital units, communication openness, feedback and communication about error, frequency of event reporting, teamwork across hospital units, nonpunitive responses to error, and hospital handoffs and transitions. Radiology scored higher than the hospital average in 10 of 12 categories (Fig. 2). Perceived performance of radiology in hospital handoffs and teamwork across hospital units were lower than the hospital averages.
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The safety survey showed improvement in all categories evaluated and statistically significant improvement in 18 of the 42 specific questions (43%). These findings show definite improvement in the culture of safety in the department. Improvement was more evident in some categories than in others (Table 1). Investment by institutional and departmental leaders in the safety agenda is a key factor to driving improvement. Statistically significant change was found in most responses in the categories of hospital management support for patient safety, supervisor and manager expectations and actions promoting safety, and overall perception of safety. These findings showed that institutional and departmental efforts to give safety the highest priority in the organization are having an effect. Significant change in continuous improvement in organized learning and staffing shows the institution's commitment to safety. Other key areas to improving safety culture that may take more time to change culturally and in which survey results showed less significant change include developing a nonpunitive response to error, feedback and communication about error, and communication openness. Continued efforts are needed in these areas.
No statistically significant change was found in the category of frequency of event reporting. This finding is interesting because the frequency of incident reporting has increased dramatically. We believe that the perception shown in the survey responses may be related to the fact that the incident reporting system is cumbersome, time-consuming, and unpopular. Other areas in which there was less significant positive change included teamwork with and across hospital units and hospital handoffs and transitions. These areas might have shown less change among radiology employees because of the often complex issues around communication and transport of patients from medical floors to the radiology department and despite ongoing efforts toward improvement.
In 2003, a National Quality Forum publication [4] emphasized that the most important action for improving patient safety is establishing and improving a culture of safety. Designing and implementing the safety program and enrollment of all trainees in error prevention training helped to emphasize the importance of patient safety among our radiology care providers. The safety coach program, safety awards, operational rounds, and mechanism for providing feedback concerning action plans about serious safety event action plans all help in continuing to emphasize the importance of safety.
There are multiple important messages in creating a culture of safety [1-17, 20]. These include making sure that health care providers realize that patient safety is an issue in the health care system in which they work, that both system level and individual failures exist in care delivery processes that jeopardize patient safety, the expectation that all health care providers see patient safety as their responsibility, that health care providers are comfortable speaking out in situations of uncertainty regardless of their position in the medical hierarchy (and the position of the others involved in the situation), and that health care providers perceive leaders as involved and dedicated to improving patient safety. Many of the cultural aspects are introduced and reinforced through error prevention training and the safety coach program.
Walk rounds have become a widely used method for promoting patient safety and showing executive and institutional commitment to safety [5-8, 20]. We believe that involvement of the radiologist-in-chief, division leaders, and other department leaders in operational rounds shows broad leadership support of the importance of patient safety in the department. In addition, the posting of actions taken on the basis of issues raised in operational rounds shows the commitment of the department to acting on the concerns of health care providers [20] and motivates all employees to identify and voice concerns about safety issues.
Effective communication has been emphasized as key to improving patient safety [1-14]. National movements have begun to improve professionalism and effective communication in medicine in general and within radiology [23]. Effective health care delivery systems rely heavily on high degrees of skill in communication. In this patient safety program, effective communication is emphasized in behavioral expectations and behavioral tools. Crucial Conversations training enhances acquired communication skills and teaches new skills. Communication at the end of the process is also important. This program emphasizes communication about the results and actions of issues identified by use of serious safety event root cause analysis and at operational rounds.
One of the other key issues in our success has been the involvement of radiologists, technologists, support staff members, and business administrators in the development and implementation of the program. A review of the literature [1-14] showed that safety programs often are created and run by hospital administration and nursing departments. Sometimes one physician is involved, often a chief safety officer or chief of staff. Most often, the physicians at these institutions are housed in separate administrative units and are not engaged in establishment or implementation of the program. Often the physicians see the program as an additional regulatory bureaucracy. We believe that having all members of the radiology team actively engaged in the process has been integral to its success. At our institution, all subspecialty physicians are hospital employees and organized into administrative structures with physician, nurse, and business manager leadership. We believe this administrative simplicity has advantages in the patient safety process.
This study had several limitations. First, we are still early in the process of improving safety performance. Our program has been in place for only 2.5 years. Because serious safety events are uncommon, we were not able to show statistically significant improvement in mean number of days between serious safety events. Another limitation was that the components of the program were phased in over a 1-year period. We have no data on the independent value of the individual components of the program, so we cannot state which parts are and which are not of value.
We conclude that use of a comprehensive patient safety program can improve safety culture in radiology. Although it is early in the process and proving statistical significance for rare events such as serious safety events is difficult, the mean number of days between serious safety events increased from 200 to 780. We believe the program is having a positive effect on safety performance and that we are moving in the right direction. Safety improvements in radiology should include and emphasize overall patient safety in addition to radiology-specific safety issues such as MRI safety, radiation dose exposure, and contrast reactions.
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0.05 for 2008 versus 2007.