A. Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the following:
1. Describe a healthcare-related situation (S) prompting a systems-level patient safety concern that has the potential to impact multiple patients.
2. Analyze background (B) information about the concern by doing the following:
a. Describe the data that support or would support the need for change.
b. Explain how one or more national patient safety standards apply to this situation.
3. Assess (A) the impact of the safety concern on the patient(s), staff, and the organization as situated in the identified healthcare setting.
a. Explain how the safety concern affects value for the patient(s) and the healthcare setting.
4. Recommend (R) an evidence-based practice change that addresses the safety concern.
a. Discuss how this recommendation aligns with the principles of a high-reliability organization.
b. Describe two potential barriers to the recommended practice change.
c. Identify two potential interventions to minimize the barriers from part A4b to the recommended practice change.
d. Discuss the significance of shared decision-making among the healthcare setting’s relevant stakeholders in implementing this recommendation.
e. Describe an outcome measure that could be used to evaluate the results of the recommendation.
f. Describe the care delivery model currently being used in the healthcare setting.
i. Explain how the current care delivery model in the healthcare setting identified in part A4f would be impacted by the recommended change in part A4.
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
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Organizational Systems and HealthCare Transformation
D221
Mona Y. Shen
Western Governors University
Dr. Kallie Gatzemeier
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SITUATION: (Healthcare-related situations prompt a systems-level patient safety concern that
could impact multiple patients.)
1. Medication errors remain a major health problem in the healthcare system, medication
errors occur every 22.7 hours, and medication errors that adversely affect patient care
outcomes occurred 0.25% of all patients admitted in hospitals a year (Medication Error
in United States hospitals (2001) pubmed.ncbi.nlm.nih.gov/11560102/). In 2016 John
Hopkins released a longitudinal study between 2000 and 2008 of preventable deaths
caused by medication errors. The John Hopkins study calculated over eight years that
more than 250,000 deaths per year occurred due to medical errors making it a third
leading cause (hub.jhu.edu>2016/05/03>medical-errors-third). Medication errors are
preventable and are considered a never event. A never event according to National
Quality Forum (NQF), are errors in a healthcare setting that are identifiable, preventable,
measurable, and should not have happened in the first place.
BACKGROUND:
2a. (Describe the data support the need for change)
Medication errors cost the healthcare system an estimated 3.5 billion dollars annually due to
adverse drug events (ADE) and the estimated 3.5 billion dollars does not include the loss of
wages and productivity (Institute of Medicine, Committee on Identifying and Preventing
Medication Errors. National Academies Press; 2007:124-25).
The benefits of prevention of ADE promote to improve and facilitating zero patient harm, the
trustworthiness of the healthcare system to perform its due diligence in providing the best quality
care and outcomes for the patients, and the monetary savings can be utilized for improvements or
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upgrades in organizational healthcare technologies, software programming system, medical
durable equipment, streamline healthcare operations, additional resources, and support for staff
training, provide the community with health-related resources such as health education in
chronic disease management, or health prevention measures such as community gardening to
promote healthy nutrition lifestyles and provide low impact exercise activities such as Tai Chi.
2b. (Explain how one or more national patient safety standards apply to the situation)
Quality care and patient safety outcomes are the goals of every healthcare provider. However, the
detrimental impact of a never event occurring in a healthcare organization affects the perception
and places a negative stigma of the organization from the community if not corrected. HCAPS
(Hospital Consumer Assessment of Healthcare Providers and Systems) is the voice of the patient
and the patient’s family review and survey of the care they received at the healthcare facility. The
low HCAHPS score will negatively impact the organization’s reputation and limit the amount of
reimbursement from Medicare/Medicaid to the organization. Healthcare is also evolving from
fee-for-services (FFS) to value-based care payment. The FFS is a payment method based on the
quantity of care and not the value of care. Value-based healthcare is based on the quality of care
and the measuring of patient health outcomes. The center for Medicare/Medicaid service is
moving away from FFS to value-based care payment and private healthcare insurance is
following suit. Quality patient outcomes and financial benefits go hand in hand with the
organization’s success in the healthcare industry. It would be imperative for a healthcare
organization to facilitate medication error prevention, to do no harm, and to align with the
National Patient Safety Goals (NPSGs) under the Joint Commission. Who is the Joint
Commission (TJC)? The TJC is a United States-based nonprofit tax-exempt 501(c) organization
that accredits more than 22,000 US healthcare organizations and programs
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(https://en.wikipedia.org/wiki/Joint Commission). The mission and vision of TJC are to
continuously improve health care for the public, in collaboration with other stakeholders, by
evaluating healthcare organizations and facilitating the provision of safe and effective care of the
highest quality and value. TJC’s vision is that all people always experience the safest, highest
quality, best-value health care across all settings. TJC's main purpose is the assurance of
healthcare organizations meet the criteria to ensure policies and procedures are implemented to
safeguard patients’ safety. TJC annually inspects healthcare facilities and makes
recommendations if necessary. If the healthcare organization is not in compliance with the
patient's safety, the facility can incur penalties and monetary fines. The purpose of the NPSGs is
to assist and collaborate with the healthcare facility to improve patient safety, focusing on the
problem of healthcare safety issues, and how to correct and solve the problem.
ASSESS: (Assess the impact of the safety concern on the patients, staff, and the organization)
3a. We do not live in a perfect world void of human errors and mistakes. We must
acknowledge mistakes do happen and what we can learn from them, prevent them from
happening again, and not look to blame. When a medical staff unintentionally causes an error in
an ADE, there is a tendency to prompt our self-assessment and question our ability to provide
quality care, re-evaluating our judgment, skills, knowledge, and feelings of shame and guilt. One
of the best practices of a healthcare organization is to facilitate and promote a Just Culture. Just
Culture is a concept relating to a system of thinking which emphasizes that mistakes are overall
the product of faulty healthcare organization cultures, rather than solely instituted by the person
or persons directly involved. So, the staff and organization can begin the process of Root Cause
Analysis (RCA). RCA is about what happened, why did it happened, what steps the healthcare
organization can take to prevent it from happening again, and then measure the effectiveness of
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the implemented action. RCA is a systematic approach to assessing the causes of an adverse
event and identifying any system flaws. To pinpoint the area of weakness or root cause of the
problem, to gain a full understanding of the problematic issue or issues it happened, what steps
the healthcare organization can take to prevent it from happening again, and then measure the
effectiveness of the implemented action. To pinpoint the area of weakness or root cause of the
problem, to gain a full understanding of the problematic issue or issues, and take measures to
correct and rectify the problems to prevent them from happening again. The Fishbone diagram
created by Professor Kaoru Ishikawa (please see attached Fishbone diagram) is used as a chart
guide. There are six steps to conducting RCA, first to identify what happened. Second,
determined what should have happened. Third, determine the cause. Fourth, develop statements
about the incident. Fifth, make a list of recommendations. Sixth is the conclusion and
dissemination of the findings and recommendations. The RCA group involves an
interdisciplinary team made up of clinician engagement, eliciting patient involvement upon the
patient’s consent, the patient's family representative that was informed of the medication error,
providing transparency, involvement of risk management, and other stakeholders. The
stakeholders gather documents, assemble timelines, draw out the story from all groups or
individuals that are involved, work together to identify the root causes, identify any gaps in
knowledge, identify any deficiencies in the system’s protocols, standard policies, or technology,
failure of information, identify any environmental sources, such as lack of personnel support or
staffing issues. Once the issues are identified, the process begins in developing a plan of action
for correction that addresses the root causes to improve the quality of the healthcare system and
establish outcome measures. Some findings may be that multi-system level issues have existed.
Such as knowledge gaps, inadequate staff training, work environments such as heavy workloads
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posing a safety risk, distractions, and interruptions. Did the prescriber who ordered the drug
inaccurately express the dosage in the order entry system, did the software program lack warning
alerts for inaccurate dosing, was the dosage and correct medication verified with a second
witness, did the pharmacist who dispensed the medication fail to capture the medication error
due to distractions or was there a software malfunction that dispensed the medication. The main
purpose of conducting the RCA is to find possible near misses that could have harmful effects or
a sentinel event. A sentinel event is defined by TJC as a patient’s safety having been
compromised resulting in death, permanent harm, or severe temporary harm. ADE has a negative
impact and consequences that affect patients’ experience with the healthcare system such as
physical pain, suffering, psychological distress, extended hospitalization, and preventable deaths.
This leads to decreased patient satisfaction and a lack of trust in the healthcare system from the
patients and the patient’s families. The ADE consequences are the extra financial burden for
treatment and rehabilitation expenses from the never event, loss of revenues, and not to mention
the legal ramifications of potential lawsuits.
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Fishbone Diagram Example
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RECOMMENDATION: (Evidence-based practice that changes that addresses safety concerns)
4a. Applying evidence-based practices such as knowledge and performing the 5 Rights.
1st Right patient 2nd Right medication 3rd Right dose 4th Right route 5th Right time. The 5 Rights
are an important integral part of providing patient safety and ensuring patient-centered care.
Taking extra precautions and being proactive to eliminate any potential errors promotes best
practices and promotes patient safety. Healthcare facilities are integrating technology systems to
facilitate protocols and procedures in place to warn and alert staff of look-alike and sound-alike
medications (https://www.nci.nlm.nih.gov/books/NBK2656 / ). Promoting and optimizing the
utilization of best practices throughout the healthcare organization is key for patient safety
outcomes. Most healthcare systems strive to adopt the characteristics of a High-Reliability
Organization (HRO). HRO characteristics involve promoting clinical team training, continuous
learning, and improvement processes, providing a just and safe environment/culture, evaluating
technology, and finding solutions with evidence-based practices, creating innovative partnerships
with stakeholders providing patient safety and value-based care compassionate care. Part of the
HRO has shared decision-making with the patients, and stakeholders. HRO models the focus on
patient-centered care that makes sense to the patients. Including patients to be active in their care
would encourage and motivate the patients to be proactive in implementing the steps they need
to take to enhance their wellness. It leads and initiates patients to offer their valuable input and
suggestions. Patients can provide insights and feedback from their perspective with the
knowledge provided by their care providers. Patients can provide their analysis and assessment
of how effective the healthcare providers’ communication process is perceived by the patients in
comprehending what the healthcare providers are providing. The significance of shared decision-
making encompasses having a conversation between two parties to find common grounds to
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agree on a subject matter. Respecting each other’s differences and valuing each other’s
perspectives.
4b. (Two potential barriers to recommend practice change)
Two potential barriers in implementing plans of intervention are resistance from administration
in support of facilitating change and resistance to change from those who are responsible to
deliver and implement the plan of action. Resistance is natural, it is expected to have some
resistance to change or process, it is the unknown factor resulting the natural occurrence of fight
or flight. Some possible reasonings of resistance from the administration and those who would
be responsible to institute and follow the process of change includes they were not aware of the
never event incident had occurred, so it came as a surprise to the individuals, other possible
reasonings they were not informed or consulted prior to RCA process, they were not prepared to
receive latest information, information was unexpected, conflict with the instability of
leadership, new management’s uncertainty or lack of confidence in the process.
4c. (Identify two potential interventions to minimize barriers)
Some of the following recommendations for intervention to minimize potential barriers;
1) Communicate as early as possible for the rationale of change.
2) Involve and notify the administration, management, team leaders, and the staff early in
the stages of plans for improvement.
3) Provide an opportunity for an open forum that is safe and allows for two-way
communication.
4) Engage staff and stakeholders in the process and change-related activities.
5) Give a clear and concise understanding of the organization’s goals and mission for HRO.
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6) Ensure support and resources are in place to facilitate the activities and are deployable
without hindrance.
7) Provide acknowledgement with positive feedback and reinforcement with support along
the journey
The journey and process to implement change are not void of simplicity, but when an
organization comes in unity and shares the same values for patient-centered care that creates
assurance for patient safety outcomes will allow the process of change to come to fruition
successfully. When we understand that we work together for the greater good and come together
as a team striving for the same mission and goals, we will be able to work cohesively.
4d. (Discuss the significance of shared decision-making among the healthcare setting and
stakeholders in implementing the change)
Everyone has choices and the freedom to choose on how to they go about managing their own
health practices and treatment options. Shared decision-making (SDM) includes the patient,
patient’s family, caregiver, and the patient’s healthcare providers to ensure that patient’s
preferences are acknowledged, respected, and prioritized. Patients who are well-informed and
given reliable, unbiased information can assist the patient to navigate the best options to their
individual preference. A patient’s healthcare provider can provide accurate details of choices,
uncover any myths or assumptions, listen carefully to the patient’s concerns and questions, offer
support, and guide the patient to reach the patient’s anticipated healthcare goals. Patients can also
optimize their pros and cons of treatment options via the utilization of decision aids. Decision
aids are evidence-based medical literature or pamphlets, video, or a website, that can assist the
patients to make informed choices that can lead to better outcomes. The main driver for
stakeholders to implement SDM in the healthcare system is that it is patient centered care. It is
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the right thing to do, acts on behalf of the patient for the individual’s best interest, aid in
preventing health disparities, and can impact the quality, cost, and safety of healthcare delivery
(mghdecisionsciences.org).
4e. (Outcome measure that is utilized to evaluate the results of recommendations)
How does a healthcare facility confirm that the current practice in place is beneficial and
provides positive end results? Answer, perform and compare by benchmarking. The
benchmarking program demonstrates the comparison with other healthcare facilities who are top
notch with high performance ratings of similar processes and applying their tools and processes
for improvement. By applying accurate data to make informed decisions for healthcare practices
can reduce or eliminate mistakes. Healthcare providers gain insights and improve outcomes
through quality measure benchmarking. Benchmarking allows healthcare organizations to
identify best practices in care. By analyzing variation in quality measures, healthcare providers
can identify research opportunities that advance professional knowledge, which informs the
creation of future best practices. Similarly, quality measure benchmarks can be used to
accurately track quality improvement progress.
4f. (Description of current healthcare model being utilized in a healthcare setting)
At the Veteran’s Affairs (VA) ambulatory care clinics (ACC) have a team-based care approach
with integrated care in providing the veterans with all one-stop healthcare needs. The team-based
care at the VA is identified as PACT (Patient Aligned Care Team) that encompasses the MD, RN,
Pharmacist, Nutritionist, LVN (licensed vocational nurse), SW (Social Worker), MSA (Medical
Support Assistant), and PACT working closely with integrated ancillaries such as the specialty
clinics. Specialty clinic providers include Neurologists, Cardiovascular, Pulmonary,
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Gastrointestinal, Endocrinology, Dermatology, Rheumatology, Mental Health, Behavioral
Health, Geriatrics, Orthopedics, Surgeons, Imaging, Laboratory, Physical Medicine, Chaplain,
Education, and in addition with other health-related resources such as the Home Health services,
Telehealth for outpatient monitoring, travel resources, durable medical equipment, and the list
goes on. PACT provides a point of care when a patient comes to the clinic complaining of, for
example, low back pain, the patient is examined, triaged, and given detailed information about
treatment options and preferences. If warranted, the patient may complete imaging, refer to
Physical and Medicine for back brace support, and go to the pharmacy to pick up the medication.
All these healthcare-related activities are done on the same day and completed in the same
building for convenience and accessibility for the patient. The current PACT practice is also
integrated care, and an example of integrated care is when a patient is discharged from the
hospital, the hospital discharge nurse planner notifies the PACT, and the PACT then would
follow up on the patient within 2 days post-discharge. Post-discharge follow-up performance
action from RN includes, but not limited to, is medication reconciliation, which includes
information on any new, discontinued, or held medications from the discharging provider,
reinforcement of discharge instructions understanding, any concerns, issues, or questions patient
may have and address the issues, accordingly, are there any new needs from the patient, such as
dressing supplies, durable medical equipment, ensure there is a scheduled follow-up medical
appointment and if not, we can schedule it at the time of the call. A post-discharge follow-up call
is vital to help facilitate the transition from hospital to home, provide support for recovery and
prevent complications.
4i. (Explain how the current care delivery model identified in A4f would be impacted by
the recommendation change in part A4)
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Teamwork is an essential component of HRO as demonstrated by the VA ACC with PACT
model. The PACT model in which a group of healthcare professionals, led by primary care
providers, work collaboratively with patients to provide all the patient’s healthcare needs. PACT
coordinates care with other qualified healthcare specialists as needed, automated point-of-care
delivery, point-of-care health literacy dissemination. The VA healthcare system puts the patient’s
goals and needs at the center of the treatment decision-making process. The PACT model also
encourages patients to play a more active role in managing their health and healthcare needs. The
PACT model focuses on partnerships with the patients, allowing patients to access care using
diverse methods, coordinated care among team members, and team-based care with patients as
the center of their PACT. Patients’ access to care and the choice of in-person visits with their
healthcare provider (HCP), telephone visits, secure text messaging, or video connection visit.
The study suggests the adoption of PACT reveals significantly associated with a lower risk of
avoidable hospitalization (Yoon J, Rose D, Canelo I, et al.)
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Reference
1. Medication Error in United States hospitals (2001pubmed.ncbi.nlm.nih.gov/11560102)
2. hub.jhu.edu>2016/05/03>medical-errors-third
3. Institute of Medicine, Committee on Identifying and Preventing Medication Errors.
National Academies Press; 2007:124-25
4. https://en.wikipedia.org/wiki/Joint Commission
5. https://www.nci.nlm.nih.gov/books/NBK2656
6. Yoon J, Rose D, Canelo I, et al. Medical home features of VHA primary care clinics and
avoidable hospitalizations. Journal of General Internal Medicine. September
2013;28(9):1188-1194.