MedStar Health: Moving Patient Safety Into The 21st CenturyPosted: September 26, 2012
Yesterday, I introduced the multi-disciplinary team at MedStar Health System led by Terry Fairbanks MD/MS, Director of the National Center for Human Factors Engineering in Healthcare and his team’s proposal for an Integrated Patient Safety Transformational (PST) Model to prevent and mitigate harm to patients. A description of the model, and a proposed plan for dissemination, follow. Comments are always welcome!
The team’s PST model is based on the clinical concept of primary, secondary and tertiary disease prevention–where interventions are first targeted at disease prevention, and then finally at mitigating disease if/when it occurs. The example the team provides is for Cardiovascular Disease Prevention:
- Primary prevention includes things like encouraging a healthy lifestyle or smoking cessation programs.
- Secondary prevention encompasses screening for risk factors and then controlling those risk factors.
- Tertiary prevention includes strategies employed post heart attack or optimizing congestive heart failure management.
The PST model for patient safety improvement takes a novel approach by shifting the typical focus of healthcare’s medical error management from “after the fact” to the primary and secondary areas of opportunity. The model is designed to proactively identify existing hazards and marginalize them before error occurs, and enhances the management of error if it does occur, through transparent disclosure when appropriate (tertiary prevention). These efforts will not only protect patients from preventable harm, but also have the potential to provide considerable cost savings to the health system.
Five “best practice” modules were selected to address these three areas of prevention with the ability to design additional modules if a need arises. Each module will be measured for its individual efficacy, as well as the efficacy of the model as a whole. The flow of the proposed PST model will include:
- Primary prevention: Module 1 (Proactive Risk Assessment), Module 2 (Enhanced Patient & Family Satisfaction), Module 3 (“Warm Handoff” including team dynamics and physician-patient communication strategies)
- Secondary prevention: Module 4 (Hazard Alerting Loop which reports hazards and collects, analyzes, trends, and feeds back hundreds of reports to staff)
- Tertiary prevention: Module 5 (Trains a “Go Team” to immediately address medical error through disclosure/apology/compensation (where appropriate), support staff involved and immediate initiation of systems-safety based event review)
The team is striving to apply the model within MedStar health operations, but is awaiting AHRQ’s review of their grant proposal which, if awarded, will allow an intensive implementation in the emergency medicine setting. Of importance to note, is that MedStar has a unique proving ground within their system. The five EDs where they hope to test the model reflect the diversity and breadth of the urban, suburban and rural areas in Maryland and the District of Columbia. Several of MedStar’s community hospitals, along with the larger teaching and tertiary care centers, serve diverse patient populations and present an opportunity to provide research that is inclusive of many patient populations.