The Department of Diagnostic Imaging at Rhode Island Hospital (RIH) in Providence has won Healthcare Technology Management ’s first-ever Best Practices in Healthcare Technology Management Awards.
The group’s prize-winning achievement, good for $500, involved tapping into the expertise of a range of departments and individuals so as to establish and sustain, in the words of the entry, a “culture of safety.” At the project’s outset, with safety issues abounding, the hurdles appeared formidable—yet the process of attacking the troubles head-on ended up transforming the reputation and, indeed, the very identity of the department within Lifespan, the Brown University-affiliated health system of which 719-bed RIH is the flagship facility.
With our congratulations to all at RIH who participated in implementing the best practice or preparing the contest entry—or both—we present the winning entry in its entirety, lightly edited for clarity and conciseness:
In March of 2009, upon reviewing the R.I Department of Health reportable errors (events), RIH’s Department of Diagnostic Imaging (DI) identified pervasive safety concerns. Data collected for events from 2007 to 2009 showed an average 17 events per year. Simultaneously, to identify and track trends, the department was collecting data for near misses. Analysis of this data identified significant problems with accuracy of orders for exams and discovered that these errors had been generated at all points of the process, from beginning to end.
Our conclusion after this exhaustive review led us to decide that the DI department needed to transform itself through a specific focus on the process of ordering and executing exams. Accomplishing this successfully would require the involvement and engagement of physicians and allied health professionals, as well as clinical and operational support staff.
Leadership of the DI department requested the assistance of Lifespan Learning Institute (LLI) to evaluate existing practices and identify areas of improvement. In March and April of 2009, the director of LLI interviewed section coordinators, staff members and the attending radiologists from each modality.
DI leadership then appointed six members to our Culture of Safety Task Force, whose goal was to review the findings from the LLI director’s assessment, identify areas of improvement, and provide recommendations to the department’s Patient Care and Oversight Committee. Members of the task force include the former and present director of DI, the programs administrator for RIH’s School of Diagnostic Imaging, the radiology section coordinator, the CT scan section coordinator, the DI nurse manager and the DI quality assurance and research coordinator, along with the LLI director.
The Culture of Safety Task Force identified three opportunities for improvement: physician engagement and collaboration, root-cause analysis (RCA), and education, communication and training of staff on policies and procedures.
Data collected from 2007 to 2009 showed that the average 17 events per year spread out evenly throughout the year. In March of 2009, five reportable errors occurred. Leadership decided to investigate the psychological factors behind the errors, enlisting the help of LLI. The director of LLI’s goal was to identify the current culture of patient safety and identify any underlying causal concerns.
During the staff interviews, recurrent themes and conclusions emerged, including:
- The importance of safety: Errors can lead to adverse outcomes and undermine satisfaction and confidence of patients and families.
- Alignment and engagement: Physicians, allied health professionals and clinical and operational supportive staff across all sections of DI is critical to fostering a culture of safety.
- Response to errors: It is imperative to be ready with an array of responses (consoling, coaching, educating, counseling); to improve communication and training on policies and procedures; and to apply corrective actions consistent and fairly.
- Compliance: Staff must have a clear understanding of their duties, supported by reviews of systems and behaviors.
From these interviews, a process map was developed to summarize the findings.
- A review of near-miss data revealed a disproportionate number of near misses (60 percent) compared with overall exams in two other high-volume, highly complex clinical areas;
- One-third of the near misses generated were from 12 of 141 referral