PARENT PERCEPTIONS OF PATIENT SAFETY CULTURE IN THE NEONATAL INTENSIVE CARE UNIT

Background: Understanding and promoting a positive culture of patient safety within neonatal intensive care units (NICU) has been to shown to decrease threats to patient safety. Parents are an integral part of the NICU culture, yet little is known about how they perceive patient safety and what role they would find meaningful and appropriate for engaging in safety promotion activities in the NICU. Therefore the purpose of this study was to determine how neonatal parents conceptualize patient safety and their role within the Neonatal Intensive Care Unit (NICU). Methods: Using an ethnographic qualitative approach, semi-structured interviews and field observations of parent interactions within the NICU were conducted from January to November 2014. A purposive sample of twenty-two neonatal parents from a large tertiary NICU was selected for interviews. Data were initially coded according to parent perceptions from interview transcriptions and observed parent interactions. A content analysis of the coded data revealed themes relevant to the study aims. Exemplars of these themes were verified as congruent with the analysis through peer debriefing. Results: A model of parent involvement in NICU patient safety was developed. To neonatal parents, safe care was evidenced by the presence, intention and respect of clinicians and staff in their actions. Patient safety was characterized by adherence to security and infection control procedures, interactions with their baby, and effective communication with parents. Parents saw their role as advocate, caregiver, decisionmaker, learner and guardian in partnership with clinicians to promote safe care. Conclusions: This model of parent involvement could inform practice and further research about patient safety in the NICU. Parents provided valuable insight impacting the assessment and further study of NICU safety culture. Promoting a culture of partnership between clinician and parents was integral to parents engaging in actions to promote safe care for their infants

Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS)

BACKGROUND: To create a theory-informed survey that quality improvement (QI) teams can use to understand stakeholder perceptions of an intervention. METHOD: We created the survey then performed a cross-sectional survey of QI stakeholders of three QI projects. The projects sought to: (1) reduce unplanned extubations in a neonatal intensive care unit; (2) maintain normothermia during colorectal surgery and (3) reduce specimen processing errors for ambulatory gastroenterology procedures. We report frequencies of responses to survey items, results of exploratory factor analysis, and how QI team leaders used the results. RESULTS: Overall we received surveys from 319 out of 386 eligible stakeholders (83% response rate, range for the three QI projects 57%-86%). The QI teams found that the survey results confirmed existing concerns (eg, the intervention would not make work easier) and revealed unforeseen concerns such as lack of consensus about the overall purpose of the intervention and its importance. The results of our factor analysis indicate that one 7-item scale (Cronbach\u27s alpha 0.9) can efficiently measure important aspects of stakeholder perceptions, and that two additional Likert-type items could add valuable information for leaders. Two QI team leaders made changes to their project based on survey responses that indicated the intervention made stakeholders\u27 jobs harder, and that there was no consensus about the purpose of the intervention. CONCLUSIONS: The Stakeholder Quality Improvement Perspectives Survey was feasible for QI teams to use, and identified stakeholder perspectives about QI interventions that leaders used to alter their QI interventions to potentially increase the likelihood of stakeholder acceptance of the intervention

Developing the Improving Post-event Analysis and Communication Together (IMPACT) Tool to Involve Patients and Families in Post-Event Analysis

The analysis of harmful errors is typically led by a team within the hospital and includes clinicians and staff who were involved at the time of the event. However, the patient and family are often left out of this process and are not asked to participate in the investigation. Because little guidance is available for facilitating patient input, an interprofessional team convened to develop a semi-structured tool to be used in eliciting patient feedback. Some 72 persons who had experienced adverse events were interviewed. Using a thematic analysis approach, the team learned that 51% of the interviewees preferred to participate in event analysis directly through an interview and 47% recommended that patients and families should be offered the opportunity to provide their views immediately (within 24-48 hours of the event). The resulting tool, IMPACT, incorporates a conversational flow of questions that allows patients to tell their story, focus their attention on specific causative factors, and give recommendations to improve healthcare in their institutions or to prevent further harm

A Quiet Revolution: Communicating and Resolving Patient Harm

Good patient care includes not only avoiding error and injury but also acting honestly and constructively should it occur. Communication and Resolution Programs (CRPs) commit the sponsoring institution to vigilant detection of error, full disclosure to patients and families, and timely redress. CRPs also seek to incorporate the perspectives of patients and family members into safety improvement activities. This chapter explains the principles underlying CRPs, traces their history, and describes current best practices for physicians, provider organizations, and the legal and regulatory environment. Transparency about error and proactive response to injury lagged other professional commitments to patient self-determination because of the emotion and politics surrounding medical malpractice. However, recent generations of physicians, patients, and policymakers have engineered a “quiet” revolution. Silence and secrecy are no longer ethically acceptable responses to medical error. Although additional research is needed on how CRPs affect safety, patient and provider satisfaction, and cost, the American College of Surgeons in 2014 declared CRPs to be, on balance, the most promising approach to medical liability reform

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm

INTRODUCTION: Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm. METHODS: Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives. RESULTS: Participants (N = 67) completed pretraining and post-training surveys. Training scores (0–10 scale) improved from an average of 4.45–7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations. CONCLUSIONS: Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives

Structuring Patient And Family Involvement In Medical Error Event Disclosure And Analysis

The study of adverse event disclosure has typically focused on the words that are said to the patient and family members after an event. But there is also growing interest in determining how patients and their families can be involved in the analysis of the adverse events that harmed them. We conducted a two-phase study to understand whether patients and families who have experienced an adverse event should be involved in the postevent analysis following the disclosure of a medical error. We first conducted twenty-eight interviews with patients, family members, clinicians, and administrators to determine the extent to which patients and family members are included in event analysis processes and to learn how their experiences might be improved. Then we reviewed our interview findings with patients and health care experts at a one-day national conference in October 2011. After evaluating the findings, conference participants concluded that increasing the involvement of patients and their families in the event analysis process was desirable but needed to be structured in a patient-centered way to be successful. We conclude by describing when and how information from patients might be incorporated into the event analysis process and by offering recommendations on how this might be accomplished

Patients as Partners in Learning from Unexpected Events

Importance Patient safety experts believe that patients/family members should be involved in adverse event review. However, it is unclear how aware patients/family members are about the causes of adverse events they experienced. Objective To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. Design We interviewed patients/family members using semistructured interviews to understand their perceptions about why these adverse events occurred. The adverse events occurred between 1991 and 2014. Setting Participants described adverse events that occurred in various types of health care organizations (i.e., hospitals, ambulatory facilities/clinics, and dental clinics). Participants We interviewed 72 patients and family members who each described a unique adverse event. Eligibility requirements were that patients/family members spoke English or Spanish and were aware of an adverse event that happened to them or a loved one. Intervention(s) for Clinical Trials or Exposure(s) for Observational Studies N/A. Main Outcome(s) and Measure(s) The main outcome was determining whether patients/family members could identify at least one contributing factor they perceived as related to the adverse event they described. Results Each participant identified at least one contributing factor and on average identified 3.67 contributing factors for their event. The most frequently mentioned contributing factors were Staff Qualifications/Knowledge (79 percent), Safety Policies/Procedures (74 percent), and Communication (64 percent). Participants knew about the contributing factors from personal observation only (32 percent), personal reasoning (11 percent), personal research (7 percent), record review (either their own medical records or reports they received in their own investigation; 6 percent), and being told by a physician (5 percent). Finally, patients/family members were able to provide recommendations that address each of the nine contributing factors we examined. Conclusions and Relevance Patients/family members identified contributing factors related to their adverse event. Given that these contributing factors might not be known to health care organizations because most participants stated that they were not involved in the analysis process, opportunities for organizational learning from patients are potentially being missed. Health care organizations should interview patients/family about the event that harmed them to help ensure a full understanding of the causes of the event