# Presentation: 723325

## Creating a Culture of Safety in the Hospital Setting

- Marge Keyes, M.A.
- Patient Safety Team Leader
- AHRQ
- E-mail:  _[mkeyes@ahrq.gov](mailto:mkeyes@ahrq.gov)_
- Phone:  301-427-1333
- June 7, 2005

***The Patient Safety Improvement Corps***

## PSIC: Concept Development

- John Eisenberg, MD (2000)
- States’ needs (2000-01)
- Filling the gaps – not duplicating
- Feasibility study (2001-02)

## PSIC: Feasibility StudyQuestions

**What content should be included?**
**Are there existing models for a program?**
**What are their advantages/disadvantages?**
**How long should the program run?**
**Should mentorships be established?**
**What eligibility requirements should be developed?**
**Who should select the applicants?**
**What, if any, professional training affiliation should be put in place?**
**What linkages to other programs should be established?**
**Should there be an out-placement program?**
**How should the program be implemented?**
**What evaluation criteria should be used for the program?**
**What cost/content tradeoffs should be considered?**

## PSIC: Feasibility Study

- RTI/UNC (2001)
- Time span
- National Advisory Committee
- Paul Barach		Ronald Cervero
- Robert Crane		Jerod Loeb
- Fred Heifel		Michael Silver
- Steve Solomon	Mary Wakefield

## PSIC: Feasibility Study

- Models
- EIS
- Naval School of Aviation Safety
- IHI Breakthrough Series
- Cooperative Sate Research Education & Extension Service
- Baldrige National Quality Program

## PSIC: Delivering and Implementing the Program

- What content?
- Which organization?
- Which mechanism?
- Student recruitment
- Team development
- Organizational commitment

## PSIC: Stakeholder Feedback

- Conference calls (2001)
- State
- Hospital

## PSIC: Goals

- Conduct effective investigations of reports of medical errors (e.g. close calls, errors with and without patient injury) by identifying their root causes with an emphasis on underlying system issues
- Prepare meaningful reports on the findings
- Develop/implement sustainable system interventions based on report findings
- Measure and evaluate the impact of the safety intervention
- Ensure the sustainability of effective safety interventions by transforming them into standard clinical practice

## PSIC Content

- Phase I
- Patient safety science
- Evaluation
- Human factors
- Measurement
- Organizational theory
- Safety culture
- Change implementation
- Medical errors reporting/analysis
- Medical/legal issues
- Tools (e.g., RCA, HFME, PRA, PSIs)
- Web enable the program (2005)
- Phase II
**Train-the-Trainer**

## PSIC: Eligibility Criteria

_**2003-06**_ Participants eligible for this program are teams of State staff in the field (e.g., patient safety officers or those responsible for patient safety reporting and analysis as well as intervention initiatives) and the State’s selected hospital partners_ (this includes critical access hospitals)_
_**2003-06**_ QIOs
_**2005-06**_ limited to States that have not previously participated
**Alabama****	****	****Arizona****	****Arkansas****	**
**Colorado ****	****	****Delaware****	****Illinois**
**Iowa****	****	****	****Kansas****	****	****Louisiana**
**Maine****	****	****Montana****	****Nevada**
**New Hampshire****	****New Mexico****	****Oklahoma**
**South Carolina****	****Wyoming**** **

## PSIC:  2003-04 & 2004-05

- Year 1 teams
- Year 2 teams
- Years 1 and 2 teams  (yellow and green)

## PSIC:  Participants

- Organizations
- DPH
- Hospitals/hospital systems
- Long term care
- Prison health care
- Legal (state attorneys general)
- QIOs
- Education/profession
- BA/BS/BSN, MA/MS/MPH/MSN, PhD, JD
- RN, MD

## PSIC: Projects To-Date

- Standardizing transfer documents (emphasis on medication)
- Identifying barriers to reporting events
- Increased detection & mitigation
- High risk meds		-- Falls
- Decubitis ulcers		-- Correct site
- 					    surgery
- Models for evaluating RCA processes
- Creating a just culture
- Training programs (e.g., RCA, HFMEA)

## PSIC:  Team Members

- AHRQ
- Marge Keyes 	-- Kerm Henriksen
- Denise Remus	-- Ernie Moy
- VA
- Jim Bagian		-- Caryl Lee
- Tina Nudell		-- John Gosbee
- Joe DeRosier	-- Erik Stalhandske
- Scott McNight	-- Mary Burkhardt
- Rodney Williams	-- Ed Dunn
- Consultants
- John Grout		-- David Marx
- Veronica Nieva	-- John Reiling
- Gregg Meyer