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West Quality Improvement Award Winner: Adopting a culture of continuous improvement

May 1, 2008
by Jon Zeipen, MSW, LGSW and Christine Lind, RN, BSN, CARN
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Reducing ADEs and enhancing continuing-care activities are part of Hazelden's quality improvement efforts

JAMES W. WEST, MD, QUALITY IMPROVEMENT AWARD WINNER
The Hazelden Foundation is a national nonprofit organization founded in 1949 that helps people reclaim their lives from the disease of addiction. Built on decades of knowledge and experience, Hazelden offers a comprehensive approach to addiction that addresses the full range of patient, family, and professional needs, including treatment and continuing care for youths and adults, research, higher learning, public education and advocacy, and publishing.

Hazelden is a mission-driven organization led by its strategic priorities, which ensure mission effectiveness. A comprehensive measurement system assesses the effectiveness of key processes and functions implemented by a corporate quality department and vetted through quality leadership teams. A quality leadership team that integrates operational business functions with quality improvement leads each clinical site.

In the early 1990s, Hazelden adopted a Total Quality Management (TQM) approach to improvement, using Continuous Process Improvement (CPI) methods to improve clinical processes across the organization. In addition, Hazelden adopted the Model for Improvement developed by Associates in Process Improvement (API), which asks three key questions: (1) What are we trying to accomplish? (2) How will we know that a change is an improvement? And (3) what changes can we make that will result in an improvement and incorporates the Plan, Do, Study, Act (PDSA) methodology?

During this time, Hazelden also developed a Quality Measurement System guided by trainings with the Institute for Healthcare Improvement (IHI), which focused on a learning approach rather than inspection or judgment. These steps began a cultural shift related to process improvement.

Reducing ADEs

Beginning in the mid-1990s, Hazelden began reading publications from the Joint Commission stating that effective reduction of unintended adverse patient outcomes requires an environment in which patients, their families, and staff and leaders can identify and manage actual and potential risks to patient safety. The Joint Commission said that this environment encourages a focus on processes and systems and minimization of individual blame or retribution for involvement in a medical/healthcare error.

This bold position statement by the Joint Commission, in conjunction with the IHI and other leading national organizations, promoted collaborative efforts to redesign culture and processes of medication systems. It triggered an avalanche of responses from healthcare entities across the country. In 1997, challenged by the prospect of redesigning our culture and examining medication practices in order to improve patient outcomes, the nursing leadership team at Hazelden's headquarters in Center City, Minnesota, embarked on a process improvement initiative guided by four aims:

  1. to primarily create a shift in the existing culture from one of “judgment/blame” to one of “learning” regarding the way medication errors or adverse drug events (ADEs) are perceived and reported;

  2. develop a systematic method of tracking and reporting medication errors and ADEs;

  3. stratify and target the most frequently occurring ADE types and causes; and

  4. reduce the number of ADEs while maintaining a culture of learning.

Since many healthcare professionals consider ADEs to be an individual performance issue, research reveals that caregivers tend not to report ADEs, and data collection and analysis often are incomplete. The Hazelden team recognized that changing a culture from one of blame to one in which staff would feel comfortable reporting all errors (and even identifying “potential” errors or near misses) would require the frontline staff to examine their process very differently. This would involve establishing an absolutely “safe” environment in order to obtain genuine buy-in and real cultural change.

The nursing leadership team fostered staff ownership of the idea and shared the vision that absolute transparency is a risk worth taking when patient safety is at stake. To execute a real and sustained culture shift, the leadership team recognized that this process would be an intensive three- to five-year undertaking, and patience, perseverance, staff ownership, and ongoing communication and measurement would be key components.

This journey resulted in an ongoing “living” project continuously being measured and improved. Since the project began in 1997, actual ADEs (defined as any injury caused by a medication) have been reduced by 72% (figure). In addition, the ADE team has reduced errors attributed to wrong medication and wrong dose incidents, which were the targeted and most frequently occurring errors.





Figure. Data are not available for 1998 because the organization was transitioning to a new data collection process and medication administration system

Since the improvements were so successful at the Center City campus, this project has spread to Hazelden's youth residential services at the Center for Youth and Families in Plymouth, Minnesota, and residential adult services at the Springbrook facility in Newberg, Oregon. Data are being collected at both facilities, and similar tests are taking place to improve processes and reduce ADEs.

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