ABSTRACT
Delivering radiation therapy in an oncology setting is a high-risk process where system failures are more likely to occur because of increasing utilization, complexity, and sophistication of the equipment and related processes. Healthcare failure mode and effect analysis (FMEA) is a method used to proactively detect risks to the patient in a particular healthcare process and correct potential errors before adverse events occur. FMEA is a systematic, multidisciplinary team-based approach to error prevention and enhancing patient safety. We describe our experience of using FMEA as a prospective risk-management technique in radiation oncology at a national network of oncology hospitals in the United States, capitalizing not only on the use of a team-based tool but also creating momentum across a network of collaborative facilities seeking to learn from and share best practices with each other. The major steps of our analysis across 4 sites and collectively were: choosing the process and subprocesses to be studied, assembling a multidisciplinary team at each site responsible for conducting the hazard analysis, and developing and implementing actions related to our findings. We identified 5 areas of performance improvement for which risk-reducing actions were successfully implemented across our enterprise.
Subject(s)
Cancer Care Facilities/standards , Hospitals, Proprietary/standards , Medical Errors/prevention & control , Radiation Oncology/organization & administration , Radiation Oncology/standards , Risk Management/methods , Humans , Medical Records/standards , Medical Staff, Hospital/education , Neoplasms/radiotherapy , Patient Identification Systems , Patient Safety , Prospective Studies , Radiation Dosage , Risk Assessment , Risk Management/organization & administration , Treatment Failure , United StatesABSTRACT
There are many steps to consider when making the move to become an innovative health care organization. Take a look at the people and processes to have in place.
Subject(s)
Diffusion of Innovation , Efficiency, Organizational , Health FacilitiesABSTRACT
In order to focus on and improve key aspects of patient satisfaction in its behavioral health programs, Catholic Health East (CHE) enhanced its measurement methodology. In an effort to be consistent with the federal government's movement from measuring patient advocacy programs to measuring patients' perceptions, CHE transitioned to behavior-based questions. These questions give clear targets for program goals and initiatives by objectively measuring whether certain events and desired staff behaviors occurred during treatment, rather than subjectively ranking attributes of institution-defined service. Through this change in approach, CHE may better align its care and services with patients' wants and needs, as illustrated by four case examples.
Subject(s)
Behavioral Medicine , Health Care Surveys/methods , Patient Satisfaction , Humans , Multi-Institutional Systems , Organizational Case Studies , United StatesABSTRACT
This article describes a knowledge-transfer process developed by Catholic Health East (CHE), headquartered in Newtown Square, PA, and focuses on improving resident safety in the skilled nursing or long-term care setting. How the health system customized and implemented an electronic medical event database to identify opportunities for improvement to prevent future occurrences of adverse events is outlined. The database customization and subsequent discussion of results is conducted under the auspices of CHE's quality and patient safety department in collaboration with 18 of CHE's long-term care facilities.