Raising the bar of safety for your medical staff.

No matter if you are in an executive or a management role at an academic center or a private practice hospital, as a physician leader you want your medical staff to not only understand the principles and theories of the quality and safety movements, but also to put them into practice.

Though there may not yet be a burning national safety platform, for the best organizations the train has truly left the station. For leaders of health care organizations, it is not a question of if, but how to facilitate improvement in patient safety among medical staff. Changing people's behavior is difficult and education alone is not enough.

In 1999, Children's Hospitals and Clinics of Minnesota began a journey to improve patient safety. Our CEO at the time, Brock Nelson, had an epiphany that year that changed our organization and how we operate.

Nelson had been advised by our attorney not to disclose to a family that our pathologists made an error in a diagnosis. Nelson went against the advice and further decided that Children's would always disclose the full truth. In addition, Children's hired a world expert in patient safety--Julie Morath--as our chief operating officer. With these two key events, Children's of Minnesota had begun the effort to change our culture.

We then developed a specific agenda that included readiness, accountability, infrastructure changes, empowerment of all employees and staff, high reliability training, and new safety technology.

Children's medical staff not only concurred with the agenda but also took leadership roles in its development, through the vice president of medical affairs, the elected chief of staff, the chiefs of divisions, and by adding a new position, medical director of patient safety.

Over the past seven years, we have continually updated and revised our patient safety agenda to expand and enhance its effectiveness.

One recent enhancement is a relatively unusual commitment made by our medical staff: All members who are appointed (and at reappointment) will continue to have to meet traditional conditions such as maintaining their licenses, getting continuing medical education credits, showing competencies in their fields, and being good citizens.

In addition, each member must also pass a test that demonstrates understanding of safety and quality principles. At appointment, staff is now given a package of critical communication components to absorb, followed by a test of 10 questions. The medical leadership of Children's of Minnesota took this step in order to raise the bar on safety. Medical staff members will not be appointed or reappointed without passing this test.

How we did it

In 2004, as Children's vice president of medical affairs and chief medical officer, I recommended to the professional executive committee that we commit to an expectation of patient safety knowledge before allowing appointment to our medical staff.

The recommendation further stated that upon staff members' application for reappointment every two years, Children's would offer updated information and knowledge about patient safety, and members must renew their commitment by taking a test again.

The recommendation was supported by the leadership of the professional staff, including the chief of staff, division chiefs, community physicians and Children's boards of directors.

With the guidance of our director of patient safety, Children's created a package of critical communications that focused on nine areas of patient safety:

1. Stop the line policies

2. Chain of command

3. SBAR communications

4. "Do not use" abbreviations

5. Verbal order read backs

6. Rapid response teams

7. Medical accident reporting

8. Universal protocol

9. Disclosures

These recommendations were instituted in 2006. The new process began with all of Children's employed physicians, followed by all of the private-practice (community) physicians and advance practice nurses who apply for appointment on a two-year cycle.

[ILLUSTRATION OMITTED]

The requirement can be fulfilled electronically or on paper. We have also created a CD-ROM with the information available for individuals to review the necessary communication skills.

Here's a look at the test:

Children's Professional Staff Patient Safety Training Questionnaire

Please circle the correct choice.

1. If someone invokes the "Stop-the-Line" rule:

A. All participants will immediately stop and respond to the request by re-assessing the patient's safety.

B. Assistance by any means most expedient shall be sought.

C. Emergency interventions may be initiated without prior express physician order.

D. They are acting in a manner sanctioned and supported by Children's professional staff.

E. All of the above.

2. The chain of command policy is a Children's policy that describes how an employee or professional staff member is expected to escalate an issue of concern depending upon the patient's acuity.

A. True

B. False

3. The obligation to provide disclosure does not require that harm has occurred.

A. True

B. False

4. At Children's, the Universal Protocol refers to which of the following expectations:

A. Pre-procedural verification of patient identity, planned procedure, side, site, and the availability of any special equipment/implants/diagnostic images.

B. Marking the procedure site with an indelible marker that will remain visible after the skin is prepped and draped.

C. A time-out immediately before starting the procedure to verify patient identity, planned procedure, side, site and the availability of any special equipment/implants/diagnostic images.

D. All of the above.

5. Prohibited abbreviations may not be used in any hand-written or typed medical record documents including progress notes, H & Ps, telephone/verbal orders, prescriptions, labels, and diagnostic test reports.

A. True

B. False

6. Improving the reliability of communication at transitions and transfers of care is a continuing organizational priority because:

A. Communication breakdowns are causally linked to the majority of sentinel events.

B. Communication breakdowns include both oral and written communication.

C. During the day, communication breakdowns are commonly seen during physician rounds and at changes of shift.

D. All of the above.

7. Many of the strategies employed in medicine to improve the reliability of communication (verbal order readback, prohibited abbreviations, S-BAR) were borrowed from high reliability organizations (HROs) such as aviation, nuclear power, and the military.

A. True

B. False

8. To transfer attending responsibilities to another physician, the patient's attending physicia must ensure the following:

A. The attending of record or his/her designee has spoken to the receiving attending physician of record.

B. The receiving physician has agreed to become the patient's attending physician.

C. The transferring physician has recorded a notation regarding the transfer in the medical record.

D. All of the above.

9. The use of verbal orders should be restricted to times when a practitioner is physically unavailable to respond to a patient care need in an appropriate manner because:

A. Verbal orders are vulnerable to misinterpretation and may inadvertently cause harm.

B. Verbal orders must be signed and dated within 24 hours to be compliant with Minnesota law.

C. Verbal orders must be signed and dated by the physician issuing the order.

D. All of the above.

10. S-BAR:

A. Is a type of structured communication designed to make sure that decision-makers are reliably provided with all necessary information to make the most informed decisions possible.

B. Is an acronym derived from the words Situation, Background, Assessment, and Recommendation.

C. Establishes the clear expectation that staff members are to convey their own assessments and opinions of what they need, or actions that they would like to have considered.

D. Training is one of the 2005 organizational goals.

E. All of the above.

I attest that I have read and understood the materials in Children's Professional Staff Patient Safety Training Packet and am prepared to comply with these policies and protocols.

Name (Printed): ______

Date: ______

Signature: ______

At Children's of Minnesota, we believe that unless we "hard-wire" expectations into our infrastructure, there will be no lasting changes in behavior or culture. Leadership must continually, conspicuously demonstrate its commitment to patient safety, and one way to do that is by accepting people on our staff only when they understand and commit to these principles, too.

Phillip M. Kibort, MD, MBA, is vice president of medical affairs and chief medical officer at Children's Hospitals and Clinics of Minnesota in Minneapolis/St. Paul. He can be reached at 612-813-6165 or [e-mail]

[ILLUSTRATION OMITTED]

By Phill Kibort, MD, MBA