From metaphor to model: the Clarian Safe Passage Program.

The most important stakeholders in patient safety are alert and mobilized frontline health care staff. At Clarian Health Partners, Indianapolis, IN, clinicians in the Safe Passage Program work jointly with unit staff, physicians, and other departments to continuously improve the level of patient, employee, and visitor safety. Medical error reporting at Clarian has tripled. The enthusiasm and passion of Safe Passage clinicians is both inspiring and energizing. IN THEIR RECENT ARTICLE, "Five Years After To Err is Human What Have We Learned," Lucian Leape and Donald Berwick state that the most important stakeholders in patient safety are alert and mobilized frontline health care staff [Leape & Berwick, 2005). We agree. From an administrator's view, truly engaging the frontline of patient care in patient safety is difficult to accomplish. Frontline participation takes time and money, and does not show clear and measurable results as a Six Sigma or performance improvement project would. Some successful frontline applications, such as crew resource management, can be expensive and difficult to apply throughout an organization. To address this need for frontline patient safety experts, Clarian Health Partners has developed the Safe Passage Program. Based on the concept that patients experience "safe passage" through the health care system, the Safe Passage clinician is not only alert and mobilized, but also trained to understand and apply patient safety concepts. The role of the Safe Passage clinician, and how the role fits into the concept of a high reliability organization [HRO), is explored. Key Elements of a HRO Reliability is defined as the measurable capability of a process, procedure, or service to perform its intended function in the required time under commonly and uncommonly occurring circumstances (Berwick & Nolan, 2003). An HRO is an organization, such as an aircraft carrier or nuclear power plant, that is reliable and safe in even the most hazardous of circumstances. The HRO can teach health care many lessons. Unlike HROs, however, the health care work environment is highly complex, more diverse, and constantly changing. Additionally, due to individual practice issues, different patient and family constellations, and differing health care infrastructures, health care is difficult to standardize. From professional organizations to state legislatures, external organizations have answered the call to improve patient safety. The Joint Commission on Accreditation of Healthcare Organizations, the Institute for Healthcare Improvement, Leapfrog and the National Quality Foundation, among others, have implemented major national patient safety initiatives. Additionally, many states have mandatory error reporting requirements. All reporting requirements are evidenced based and can actually improve reliability within a health care organization. However, these reporting requirements demand resources. Although necessary and helpful, mandatory reporting alone does not speak to all patient safety issues within a health care organization. The challenge is to balance and understand reporting requirements while attending to internal patient safety issues. HROs hold a key to balancing patient safety mandates, design, and measurements. Gaba (2003) states that HROs have four key elements which may be used as criteria to balance a health care organization's patient safety initiatives. 1. Intact systems, structures, and procedures conducive to safety and reliability; for example, mandatory and voluntary patient safety reporting. 2. A culture of safety permeates the organization; this is the foundation of any patient safety program. 3. Safety and reliability examined prospectively for all the organization's activities; organizational learning by retrospective analysis of accidents and incidents is aggressively pursued as seen by Root Cause Analysis and Failure Mode Event Analysis. 4. Intensive training of personnel and teams takes place during routine operations, drills, and simulations (for example, crew resource management and mock codes). A Culture of Safety Permeates the Organization: The Safe Passage Program The term "safe passage" is coined from the American Association of Critical Care Nurses (AACN) Synergy Model of Patient Care. This model matches patient characteristics with nursing characteristics for optimal care. Its key outcome is that the patient experiences safe passage through the health care system (Curley, 1998). Clarian has implemented the AACN Synergy Model of Patient Care systemwide. The Safe Passage Program grew from an idea to put a "safety nurse" on every patient care area. It was soon apparent that for a frontline, staff-driven program to work, the staff needed to understand key patient safety areas of study. Concepts such as work complexity, technology, communication, and teamwork are among those taught to new Safe Passage clinicians. The Safe Passage clinician, designated by the unit to become the local safety expert, works jointly with unit staff, physicians, and other departments to continuously improve the level of patient, employee, and visitor safety. Goals of the Safe Passage Program include: • Providing nurses with a patient safety knowledge base, including the most current patient safety information available. • Providing a communication network from top to bottom and bottom to top; preventing errors through planning for change and identifying gaps. • Creating a mechanism to analyze and learn from errors. • Increasing work efficiency and effectiveness. • Providing a mechanism for process improvement through evidence-based practice. When these goals were first outlined and adopted, they seemed daunting. However, in the course of 4 years, the Clarian Safety Passage Council developed and incorporated these goals. Infrastructure is key to the function of Safe Passage. Safe Passage members participate in a Clarian system-wide monthly meeting. This meeting provides an opportunity to share experiences and issues across units and departments and also acts as a vehicle for knowledge dissemination. Each Safe Passage member participates in a local monthly Safe Passage Council meeting. Safe Passage Councils include mother/baby, emergency and trauma center, Riley Children's Hospital, Indiana University Hospital, and Methodist Multi-specialty and Intensive Care. Educators, managers, and frontline staff facilitate the Safe Passage Councils. Other methods of communication include a listserv, newsletter, and Safe Passage Emergency Alerts. Once the infrastructure and schedule were established, Safe Passage clinicians began to share near misses and error reporting across the Clarian system. Sentinel events and root cause analyses were discussed. Up-to-date research, patient safety news, and articles were shared and disseminated. Stakeholders from key initiatives requested time on Safe Passage agendas, not only to explain processes but also to receive feedback from the frontline perspective. Safe Passage clinicians were selected for team memberships based on patient safety knowledge, systems thinking, and frontline perspective. The link to operations is a work in progress. Safe Passage clinicians sit on Clinical Practice Councils and have time on unit agendas. Some unit newsletters include a "patient safety column" with up-todate patient safety information. Knowledge Driven CareTM Clarian internal initiatives are producing a body of knowledge that helps identify opportunities for improvement in patient safety issues. This organization-specific knowledge, paired with evidencebased practice, allows improvements in care and is referred to as Knowledge Driven CareTM. Knowledge Driven CareTM represents a shift from reactive thinking and retrospective analysis to proactive planning and design. Safe Passage clinicians are able to anticipate patient safety issues based on need, experience, and expertise. One of the hallmarks of an HRO is deference to expertise, with leadership deferring to experts at the point of care (Weick & Sutcliff, 2001). Frontline staff see the patient safety landscape from a different level than leadership. Coupled with the Synergy Model of Patient Care, staff anticipate the needs of the patient based on nursing and patient characteristics. Additionally, to achieve reliability, design must be linked with reliability science and human factors research. Berwick and Nolan (2003) state that there are three levels of safe systems of care: (a) to design the system to prevent failure; (b) to make failures visible so they may be intercepted before causing harm; and (c) to mitigate the harm caused by failures when they are not detected or intercepted. Proactive Thinking on the Front Line Kathy Shields, BSN, RN, is the Safe Passage clinician on the infant intensive care unit at James Whitcomb Riley Hospital for Children. After attending core curricula and the Riley and Clarian Safe Passage Councils, she returned to the unit in search of a project. Ms. Shields made rounds of the rooms and talked to her peers. Ms. Shields noted that several rooms did not have the correct spare tracheostomy tubes cleaned and ready for use at the bedside. Although available in the unit, it is safer and quicker to have a set at the bedside. She further noticed that some of the rooms not only had the clinical alarms set in different ranges but also at limits that were either too high or too low to be helpful or safe. Based on this information and other safety issues, Ms. Shields created a checklist and started raising awareness by discussing the issues in the unit newsletter. She and other staff members audited the checklist and posted the results in the newsletter and on the unit. In a short time, the unit achieved 100% compliance. After several months at 100%, Ms. Shields noted that this was now a unit practice firmly imbedded in the culture. Now she occasionally monitors the safety list to check compliance; each spot check has