Mary Blegen, director of the Center for Patient Safety in the UCSF School of Nursing, speaks with Robert Wachter, professor and chair of the Division of Hospital Medicine and Lynne and Marc Benioff Endowed Chair in Hospital Medicine.
Patient safety is hardly a new concern for hospitals, but incentives in the Patient Protection and Accountable Care Act elevate this critical issue.
Mary Blegen, RN, PhD, FAAN, director of the Center for Patient Safety in the UCSF School of Nursing, is an internationally recognized expert in nurse staffing and patient safety. A professor in Community Health Systems, Blegen focuses her research on the organization of health care institutions and how that affects the work environment and the quality and safety of patient care.
At UCSF, Blegen works with colleagues, including Robert Wachter, professor and associate chair of the Department of Medicine and a national leader in patient safety.
UCSF has been on the front lines of transforming how hospitals prevent medical errors by improving systemwide procedures, developing clinical and academic patient safety experts, and building a culture that encourages teamwork and learning from mistakes.
In this interview, Blegen describes the importance of interdisciplinary teamwork in improving patient safety in the nation's hospitals.
Q: Please describe some of the patient safety successes to date and what they teach us about how to move forward.
A: There have been some very dramatic success stories like the reduction in pressure ulcers, which is related directly to nursing care. It shows what happens when nurses have the time to do an initial assessment and create a prevention plan. That time requires institutional support — and one lesson is that sometimes it’s external pressure that forces institutions to change and reprioritize. In this case, hospitals moved when CMS [Centers for Medicare and Medicaid Services] decided to halt reimbursement for hospital-acquired pressure ulcers.
Decreases in central line infections and the early detection and treatment of sepsis are two other successes. Both show that interdisciplinary teamwork is critically important — something we confirmed in the Triad for Optimal Patient Safety study. The study found interdisciplinary training had both staff and patients perceiving an improved safety culture: better teamwork, better patient-clinician interactions and better discharge planning.
Mary Blegen, RN, PhD, FAAN
These improvements have also been linked to higher nurse-patient ratios, as we also found in our Interdisciplinary Nursing Quality Research Initiative study on quality of care on inpatient units.
Q: Have nurses led these successful initiatives?
A: Nurses take the lead in care to prevent pressure ulcers, and have been shown to be key participants in the use of checklists to reduce central line infections and in the implementation of practice change for early detection and treatment of sepsis. However, any patient safety effort needs to involve collaboration among all providers.
That said, one of the more prominent success stories is the nursing-led movement around care coordination and transition planning. There have been numerous models, including one developed by Mary Naylor at Penn that has been modified and tested in a variety of different ways and has shown a clear impact on the number of days staying out of hospital, quality of life and quality of care. That model is behind initiatives at a number of Bay Area hospitals.
Q: What are the barriers to improving patient safety?
A: The biggest barrier is that we still deliver care in this enormously complex system with so many competing demands: Patients have demands; the different disciplines have demands; there’s the external demand for efficiency and the sometimes conflicting demand for increased quality. Working through those competing demands is the biggest challenge.
Q: How can nurse leadership best contribute to overcoming those barriers?
A: As more measures of quality and safety are developed, nurses — often in the role of patient safety officer — are the ones extracting data from patient charts, making sense of it and presenting it to other people. That’s an important role. Those nurses are often master’s-prepared. For example, in our master’s in leadership program at UCSF, students learn about data, data sets and presenting data clearly. Many other nurses learn these skills on the job.
“Nurse leaders can promote safety by modeling and encouraging teamwork across disciplines.”
Equally or more important, nurse leaders can promote safety by modeling and encouraging teamwork across disciplines because there’s a fair amount of data that shows interdisciplinary communication can prevent adverse events.
Q: What does that modeling look like?
A: When [clinical leaders] appear in public or even in private, the nurse leader needs to have equal say or equal input. Though sometimes it’s just a matter of personality, training can help, as can the willingness of the non-nurses to solicit and listen to this input. Ed O’Neil [PhD, director of the UCSF Center for the Health Professions] makes these points.
Also, both nurses and physicians need to accept that each has a separate, different and unique perspective that is valuable. For nursing — and these are tired, old phrases — our perspective is more holistic. Nurses determine the care needs of patients beyond the diagnosis and treatment of the primary admitting problem on which the physician is focused. The nursing focus then leads to the very important care that prevents falls, pressure ulcers and hospital-acquired infections, and avoids medication errors. Until our perspective is viewed as having equal value to what physicians bring, the communication won’t work as well.
Q: How do patient safety improvements get off the ground?
A: Often it is external forces. CMS mandates have made a huge difference. But to be lasting, there has to be an internal culture change that fosters a teamwork approach.
I do have a sense that both physicians and nurses are stepping up in this regard. The rhetoric is changing everywhere and there is much more training across the disciplines. I’m a senior scholar for VA Quality Scholars, which opened up to nurses just two years ago. It’s been fascinating to watch the younger physician and nurse fellows and their willingness to engage — very encouraging for the future of health care.
Photos by Elisabeth Fall/fallfoto.com