NPSF Perspectives

I’ll admit I was a little nervous about the National Patient Safety Foundation meeting and the live twitter. The entire social media – twitter/blog thing is very new to me and I’m still learning. It’s a strange world, cyberspace, and I’m feeling a little vulnerable. After all, these are my thoughts and my experiences and I can and will only speak for myself.

So, here is my impression of the NPSF conference. I think it went well. I think that having an industry organization that is dedicated to “subject matter” rather than to a particular clinical role is special. It invites people from every role in a caregiver setting to work in partnership around one thing – keeping patients safe. With that said, I believe that some of the most important points from the conference are as follows:

1.) The Role of Technology – Since the advent of the Stimulus Package, there has been much buzz around the importance of HIT and its impact on patient safety and hospital efficiency. There is no arguing the power of technology and the need for hospitals to enter the 21st century and get moving on IT adoption. However, if the implementation of large IT investments are not managed properly and thoughtfully (with the buy-in from all clinical areas) this could actually increase the amount of medical errors. The Joint Commission issued a Sentinel Event Alert (link) on the dangers of poorly designed or implemented healthcare information technology.

2.) Physician Collaboration – My colleagues and I attended an NPSF luncheon that included Lucian Leape Institute members David M. Lawrence, MD, CEO (retired), Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, and Paul O'Neill, former Chairman and CEO, Alcoa, 72nd Secretary of the US Treasury, and Founding Co-Chair, Pittsburgh Regional Healthcare Initiative. It was an open forum to ask questions about anything. And one of the questions was around physician participation while executing quality initiatives and the “attitude barrier”. I was interested to hear the panelists explain the role of physician training and how physicians are trained to take ownership of the care and do anything to retain it. Even if it means kicking quality improvement teams out of the operating room.

Following the luncheon, I had a great conversation with Donna Woods, EdM, PhD who is currently Research Assistant Professor at the Institute for Healthcare Studies in the Feinberg School of Medicine at Northwestern University. She was telling me that one of her research projects revealed that only 10% of medical schools offer even one text book that is dedicated to patient safety. Only 10%. - in the entire country (eyebrows up everyone).

3.) Looking at the Process – I’ll be honest, this is my favorite. Of course I am biased, but I still think this is not well understood and I’m psyched to hear any attention given to process improvement. Anywhooo, I sent a live twitter during our Thursday morning presentation and all it said was, “standardize, standardize, standardize” and a colleague back at our headquarters text messaged me, “standardize what?” (I told you I was new at this). What I meant was standardize your processes. Look at how nurses are using the automated dispensing cabinets (or not using them), find out the barriers to proper use and waiting times, find a better way, and standardize it. Even if it means figuring out a better place to put the automated dispensing cabinet. Addressing processes is the step before large HIT investments. Want barcodes? Get your process standardized to use them properly. Want less nurse interruptions? Improve your process and standardize them. Want the budget to execute process improvement project? See number 4.

4.) Role of Executive Leadership – I ran into Dr. John Combes, M.D. President and Chief Operating Officer for the Center for Healthcare Governance while I was running up the escalator. I’ve only had a few conversations with him and attended a presentation that he gave at the American College of Healthcare Executives around the role of executive leadership and hospital boards. His main message – executive leadership and hospital board members must play a significant role in patient safety and quality initiatives. They must invest in system improvements and they must involve patients in the process. I heard these same messages echoed at this years NPSF conference.


Our individual presentation Creating Rapid & Innovative Improvements Outside of the Capital Budget went really well.

Michelle Mandrack from the Institute for Safe Medication Practices gave a really great presentation around the impact of medication distribution on nursing workflow in “the last 100 feet”. Kathy Rapala from Aurora Health Care talked about the “One Aurora” model and how it drives high reliability. Mary C-D from Aurora talked about a particular process improvement project that looked at setting up the workflow to better support barcode readiness.

They all did an incredible job.

I would love for anyone else who attended this year to comment on other messages they feel resonated this year. I’d also love any feedback you have on the live twitter – things that worked and made sense, things I can do better. I’ll be sending out live twitter feeds at other presentation throughout the rest of the year and obviously want to make these worth while to my twitter followers. So, please, let me know what I can do better.

I want to give a quick thank you to Kathy Rapala, Director of Clinical Risk Management, Aurora Health Care, Mary Cieslak-Ducheck (aka Mary C-D), Director System Nursing Integration, Aurora Health Care and Michelle Mandrack, Director Consulting Services, Institute for Safe Medication Practices. Your passion and dedication to your work is inspiring. I know I can speak for everyone at AmerisourceBergen and say that it is a pleasure to work with you and your organizations. We look forward to future collaborations.

I believe in my work.

Claire