Allina Center for Patient Safety

Background

Patient safety is a critical issue for America's health care system. Adverse health events result in patient harm and increased costs.

Allina is developing a Patient Safety Center to proactively improve systems and impact unit cultures that will increase safety. The center will provide an in-depth analysis of the causative factors relating to adverse health events, known patient outcome-related events and claims to determine the overall impact to patients, families, staff and the health system; and strive to change practices and cultures by supporting grassroots projects that form performance improvement strategies for change.

Intent

Consistent with its strategic vision, Allina has made significant strides in improving patient safety. However, we believe with the right resources and leadership focus, we can take our performance to a new level.

Operationally, the Center for Patient Safety will provide a platform for functioning more as a system, recognize the importance of patient safety in all we do, and create a model for addressing ongoing quality, service and cost performance issues.

The aim of the Center for Patient Safety is to demonstrate our commitment to exceptional care through the elimination of harm to those that entrust us with their care through staff members closest to the care delivered.

Desired outcomes

Patient safety in our hospitals

The outcomes to be realized by Allina include:

the ability to become a national role model for patient- and family-centered care by, in part, highlighting the safety agenda among patients and families
increasing the knowledge and skill level in patient safety across the system with care givers and leaders developing the basic foundation of skills to implement change
establishing the discipline to target known high risk areas for patient care for innovation of care design with a focused and funded effort for success
establishing linkages with employee health and safety aspects for safety with grassroots support for change.

Approach

First, Allina will develop a comprehensive agenda for safety for Allina. A comprehensive bundle of services will be designed that is known to support change and address the issues that surface in patient safety.

Educating staff on the fundamentals of safety, targeting specific safety efforts that impact patient care and measuring success over time are known ways health care systems have made improvements to safe patient care delivery. For example, communication continues as the number one issue in patient safety events.

Educating staff and leaders on known issues and strategies for change begin to put the foundational science of safety into practice. Currently, strategies are attempted however without foundation knowledge are often not sustained over time.

Allina's comprehensive approach will support cultural aspects of teams and local units that have a strong influence on making change successful, as well as providing foundational education in the science of safety.

Specifically, the Center for Patient Safety will pursue a four-pronged approach:

1. Education: Allina Patient Safety University

Allina will assess existing health care-provider supported "university" models to understand structure, funding, and content. By December 2008 Allina will design a curriculum to be offered at Allina Patient Safety University. The format will include basic courses of science of safety, human factors, teamwork and communication, and measurement and analysis of data using a performance improvement model of care.

As part of the process, we will determine market/industry expertise needed to supply the foundational material and course content. Specialty-specific sessions will be tailored to align to known high risk behaviors in care communities. Using Allina data, industry knowledge, expertise and local resources, we will develop sessions with targeted action plans and outcomes. Participants will come with a problem to solve to make the effort not only educational, but also action and results-oriented.

Over time, the curriculum will be integrated into Allina's Center for Learning and Innovation to ensure information is shared across all settings and staff. Allina Patient Safety University will continue to evolve the next generation of curriculum based on theories and ideas for change needed at Allina to improve on the objective of safe delivery of care.

2. Local safety initiatives: Grassroots for patient safety

Over the next six months, we will identify targets and conduct deep-dive analysis of the top three to five factors impacting the delivery of safe patient care. We need to first define the issues and barriers that stand in the way of enhanced patient safety. Using the six-month window of time with focus on the data, literature, costs and outcomes, we will be in a position to provide the necessary rationale and background information for change.

This will be focused through an evaluation of care process for high reliability in systems related to AHE and other known risk factors such as outcomes related to obstetrical care. Using culture survey data, and other tools for this evaluation, a report will be generated with a defined change action plan that will be crafted with the local leaders at each site. This will form the basis for the targeted areas for change.

3. Consistent change model: Implement change action plans

We will utilize John Kotter's model for change to develop strategies for spread, actions for implementation and measures for success. The aim is to connect the passion of front line staff to Allina's safety agenda, initiating change and transforming care by harnessing ideas in a way that enables the staff to explore the problem and new ways to change care delivery.

The Center will solicit requests for proposals (RFPs) from staff and review them against specific criteria that impact one of three high risk safety concern areas: Obstetric care, safe site surgery/ procedures, and reduction in harm from falls. The Center will help determine the work that merits funding and will work with staff to enable problem identification, tests of change, measurement for improvement and spread best practices.

4. Advocacy with patients and families: Patient safety steering committee

Throughout the remainder of 2008, we will develop an Allina-wide patient safety steering council. This council will provide oversight and direction to the development of the safety agenda for Allina and will be staffed with a multi-disciplinary team from both internal and external clinical staff, community leaders and patients and family representatives.

Funding

In 2009, The Center for Healthcare Innovation at Allina invested $133,000 in the Center for Patient Safety to further develop the program, hire a project leader and complete planning to fully implement initiatives in 2009 and beyond.