Effective teamwork is critical in creating a culture of patient safety, she said, adding that although the healthcare industry has talked about accountability—the theme of this year’s meeting—in terms of clinical outcomes, it has not talked about accountability of behavior.
Pinakiewicz also said “disruptive behavior” is a big term today in the patient-safety arena and described that behavior as any action that compromises a team’s ability to provide a patient with optimal care. Failing to wash hands or eye-rolling among team members during a “time out” in the operating room would qualify as disruptive, she said.
The meeting, which drew 1,100 to 1,200 participants, also sought to broaden patient-safety efforts beyond the traditional inpatient setting.
“We always knew from the beginning of this work when it began in earnest that we were really only looking at the tip of the iceberg when we looked at the inpatient side,” Pinakiewicz said. “And we focused there because that’s where the studies were first done and because that’s where the complexity is highest so that’s where the big fixes needed to take place first.”
In one breakout session on outpatient safety, Ruthie Goldberg, group leader for Kaiser Permanente’s Southern California Clinical Operations, and Dr. Michael Kanter, medical director, quality and clinical analysis at Southern California Permanente Medical Group, highlighted results from Kaiser Permanente Southern California’s Outpatient Safety Program. The program features “safety nets”—regional programs that identify patients who have outpatient safety risks by using small, centralized teams that have limited clinical scope capacity and clerical support. The areas of primary focus are diagnosis detection, medication monitoring, potentially harmful interactions and necessary follow-up care.
“The first place that’s easiest to start is with tracking abnormal results,” Goldberg said after the presentation. “Every single ambulatory institution has processes for testing people and screening people for things and they all have processes—many of which are paper—to see what the result is,” she added. “And the first place to look is: How do we make sure that if a result is abnormal, we make sure that we follow up with it?” Even if a patient does not initially follow clinicians’ directions, Goldberg said, “I think that’s really the first place to start.”