Kellogg is keeping an eye on patient safety
Michigan Medicine recently kick-started its journey to zero harm, in partnership with Healthcare Performance Improvement, to improve patient safety and reduce the incidence of harm that reaches patients.
Part of this journey focuses on creating a culture of safety across the organization and implementing new projects that prioritize patient safety and look to reduce patient harm events. One area already working toward this goal is the Kellogg Eye Center (KEC), which has implemented several initiatives over the last year to drive improvements in patient safety.
Analyzing the current state
Cataract surgery is one of the most common surgical procedures performed in the U.S., with more than 3.5 million surgeries performed yearly. With advances in modern instrumentation and techniques, the procedure has become highly efficient, but the inherent complexity of cataract surgery means there are many potential opportunities for an error to occur.
Faculty and staff at KEC recently embarked on a comprehensive review of all steps involved in cataract surgery, from preoperative consultation all the way through the day of surgery, in order to maximize patient safety and ensure the highest possible quality of care.
Together with colleagues from the U-M Center for Healthcare Engineering & Patient Safety (CHEPS), a team from KEC conducted a Healthcare Failure Mode & Effect Analysis (HFMEA) to review current processes in cataract surgery.
An HFMEA is a type of proactive risk assessment tool that analyzes and diagrams each individual step of a process to identify potential sources of error that could result in patient harm. The team spent several months mapping out every step involved in planning and performing a successful cataract extraction, with no detail too small for review.
Through this comprehensive assessment, the team identified 36 action items to address potential points of error.
“Following the HFMEA, our team created a new protocol designed to proactively address areas of possible error to make sure our system is as fail-safe as possible,” said Jennifer Weizer, M.D., associate professor of ophthalmology and visual sciences. “This will allow us to focus on improving patient outcomes and reducing harm.”
Improving communication through huddles
Simultaneously, KEC started to implement daily huddles in all 15 of its outpatient clinics.
“We used the existing concept of team huddles widely performed on inpatient units in the hospital and modified the content to make it as relevant as possible to our ambulatory clinic settings at Kellogg,” said Philip Lieu, M.D., instructor in ophthalmology and visual sciences at the U-M Medical School and a faculty member of the retina and uveitis service. “When we first started huddling I would ask our staff what was the biggest thing preventing them from having a good day in the clinic. This gave them an opportunity to raise issues of any kind from equipment or building-related problems to patient safety events. The huddles grew from there and now address these same topics but also include time for team-building, employee recognition and any other areas that a particular clinic needs to focus on.”
Every huddle includes a “safety moment” where the team discusses any safety events or near misses that occurred the day before and a running tally of “days without a safety event,” consistently recognizing the continuous hard work required to maintain patient safety and zero harm.
Staff at many of the clinics agree that these huddles have improved transparency around patient harm events and have encouraged greater communication and collaboration among team members.
“Prior to the huddles, we were often so busy and absorbed in individual responsibilities that it was hard to recognize what our fellow team members were experiencing,” said Lieu. “Now, we feel more like a cohesive unit striving for the same uncompromising goals of delivering highest quality care with maximum patient safety – but with better communication. One result of the huddles that I am most proud of is providing a platform that empowers every one of our team members to voice issues, concerns or give compliments to other members of the team.”
Committed to safety
KEC also created a patient safety committee, led by Weizer, that has representation from all roles (allied ophthalmic personnel, patient service associates, nurses, and physicians) and meets every six weeks.
Every patient safety event is reported to the Patient Safety Event Team, and the KEC patient safety committee is committed to reviewing every event that occurs in the clinics. For events that require a full multidisciplinary review, every person on the committee is trained to lead a root cause analysis (RCAs) in order to fully understand what happened, why it happened and prevent it from happening again.
“The committee was established as a way for us to hold ourselves accountable to our patients and ensure we are meeting our safety goals,” said Weizer. “The Office of Patient Safety helps us coordinate larger, multidisciplinary reviews, but our committee uses root cause analysis techniques to conduct safety reviews to be sure that we are being thorough in reducing opportunities for harm to occur.”
The team discusses any current RCAs being conducted and gives a status update to the full committee once it has been completed. All results are reported back to Paul Lee, M.D., chair of the Department of Ophthalmology and Visual Sciences and the F. Bruce Fralick Professor of Ophthalmology.
The team from KEC recognizes that these improvements would not have been possible without the hard work of colleagues across the organization and would like to thank the following individuals for their dedication to the projects:
- Joseph M. DeRosier, P.E., C.S.P., program manager, Center for Healthcare Engineering and Patient Safety
- James Bagian, M.D., P.E., director, Center for Healthcare Engineering and Patient Safety
- Kevin Noble, performance improvement coach, Michigan Medicine Quality Department, Continuous Improvement
- The entire KEC Retina team, and
- All members of the KEC community, without whom all of this safety work would not be possible