The implementation of the Affordable Care Act (ACA) has been a catalyst for healthcare organizations to reexamine care practices and delivery models of services to meet the demands of healthcare reform mandates and goals. The basic goals of the ACA are to decrease the number of uninsured individuals nationally, eliminate insurance discrimination of preexisting conditions, improve access to care, transition from fee for service to accountable care through pay for performance, and incorporate individual and employer mandates for healthcare insurance coverage. The bottom line is that healthcare organizations will be paid for performance, will need to increase quality and safety of patient care services provided at a reduced cost, and will need to attract and retain healthcare consumers. During this time of challenging healthcare transition, visionary nurse executives and professional staff nurses are integral in ensuring that the needs of patients, colleagues, and professional standards of nursing practice are not compromised.
Professional nursing incorporates a special set of unique tenets associated with a focus on quality patient care. Nurse leaders must not only be effective strategic planners and financial managers, they must also be patient safety advocates. Nurse leaders and staff nurses in dermatology have a key role in promoting a culture of quality and safety within the healthcare work environment whether it is at a large teaching facility, outpatient clinic, or private practice. The healthcare environment is an extremely complex system that is challenging for those who are providing care, treatment, and services to consumers within it. The culture within the healthcare setting is critical and directly related to patient outcomes, satisfaction, safety, and quality of care provided. The Just Culture (2012) Community Healthcare Overview states that "as healthcare providers, we are entrusted with the care of a nation. It is our culture that will influence how well we fulfill that trust" (p. 2). Dermatology nurses at every level have an integral role in promoting a work environment that is conducive to a trustful, safe, and high-quality care experience for dermatology patients and colleagues. This article will review work environment culture of safety dimensions, Just Culture, and a procedural/ambulatory surgery safety checklist as a valuable quality and safety practice tool.
CULTURE OF SAFETY
Many healthcare organizations and clinics across the nation are implementing initiatives that promote a fair or just culture and commitment to patient safety. The Just Culture model focuses on a "shared accountability between leaders and staff to support error disclosure and organizational learning from mistakes" (Vogelsmeier, Scott-Cawiezell, & Miller, 2010, p. 289). Successful organizations globally acknowledge that errors and crisis will occur in the healthcare work environment. These organizations actively educate, plan, and train employees to prevent and manage events to minimize impacts of unintended situations. Human factors of behavior variability, lapses in judgment, forgetfulness, and at times, negligence are unfortunate inheriting behaviors of human beings. The Just Culture (2012) Community Healthcare Overview reflects:
Not only do humans err, but we drift away from safe behaviors as well. As our perceptions of risk fade and we try to accomplish more with fewer resources and less time, we can begin to drift away from the procedures we have been taught. (p. 6)
Flawed organizational systems, processes, and technologies that are not designed to withstand human factor errors contribute to safety risks for consumers in healthcare. Patient safety and care quality outcomes are directly linked to ACA mandates and pay-for-performance guidelines and will directly impact healthcare organizational financial sustainability. The combined complexities of managing human error, system and process failure, demanding technologies, fluctuating customer volumes, and crisis situations are not issues of healthcare alone. Managing error has been studied on U.S. Navy nuclear aircrafts carriers, nuclear power plants, and the airline industry. The landing of U.S. Airways Flight 1549 on the Hudson River without harm to passengers or crew is a prime example showcasing a team of individuals collectively managing a crisis. The airline industry's Crew Resource Management program was cited as preparing the crew members successfully with communication, teamwork, workload, and threat and error training (Gordon, Mendehall, & O'Connor, 2013). The good news is that, through innovative research and evidence-based practice exploration, many successful methodologies, resource tools, and educational curriculums have been identified to assist healthcare organizations in cultivating a resilient team culture of trust and safety.
CREATING A CULTURE OF SAFE BEHAVIORS
It is crucial for organizations to clearly define the safe behaviors and primary team values that each and every member of the organization/clinic must display in all daily work activities. These actions are the cultural behaviors expected to be enacted by all staff members in the organization in order for the mission, vision, and patient care outcomes to occur at the safest highest quality level possible. Creating a culture of safety focuses on everyone to create a workplace environment that is inclusive to Fair and Just Culture model concepts, harm prevention, and promotion of safe and high-quality patient care outcomes through heightened individual and team awareness. The author will share five safe commitment to safety behavior principles embraced at a prominent tertiary healthcare organization. The concepts include pay attention to detail, communicate clearly, have a questioning and receptive attitude, hand off effectively, and support each other.
Pay Attention to Detail
The dimension of paying attention to detail impacts about everything we do as professional nurses and healthcare team members. Ensuring patient identity, labeling biopsy specimens accurately and not losing them, administrating medication correctly, and identifying correct anatomical site of planned procedural or treatment intervention require a great attention to detail. Paying attention to detail incorporates an intentional focus without distractions on a task at hand to prevent error. A misplaced biopsy, an inaccurately labeled specimen, a wrong procedure, a preventable laser malfunction, or an intervention performed on the wrong patient are all unfortunate errors that most of us have either witnessed or heard about in the specialty of dermatology. The impact of these errors to patients, families, and the healthcare team can be detrimental to all involved.
Critical to promoting a culture of safety in this dimension includes the ability of individual team members to speak up regardless of their role when details are not clear, when distractions are occurring, or when patient/planned procedure information is ambiguous. Dermatology providers, nurses, and allied team members have a shared responsibility in identifying barriers to paying attention to detail and putting in place system, process, or practice safeguards to limit breaches of attention that in turn can lead to error. A proven successful tool in the healthcare setting to help individuals be skillful in paying attention to detail is the stop-think-act-review model in decision making. A southern healthcare system initiated this decision-making model in their quest for becoming a high-reliability organization and to simultaneously create a culture of safety. During this initiative, Woterman and Shabot (2011) stated that "among other safety behaviors, employees were trained to take a one-second stop before taking an action like injecting a medication, because a one-second stop has been proven to reduce errors by 90%. That behavior is called STAR for Stop, Think, Act and Review" (p. 1). This behavioral methodology is focused on individual accountability to briefly pause in a critical process step to reflect on their action or next behavior needed. During this pause, individuals think about if there are any alternatives to their actions that are better and what are the consequences of the action taken. The third step in the model is for individuals to take full responsibility and accountability of their chosen action. The last step is for a personal review of their action and if they obtained the end goal that was anticipated. If the goal was not obtained, a reflection of how the action chosen created a barrier to the end goal should be noted and remembered for future similar decisions. This simple prevention tool and brief pause can help dermatology care team members during times of performing multiple tasks, working faster, heightened stress, and critical high-risk tasks and interventions. Throop (2011) states that "the mind can only think of one thing at a time. Those who use S.T.A.R. regularly can attest that this tool is helpful to maintain attention to detail" (p. 1).
Communicate Clearly
Communication breakdown is one of the most common causes of errors in the healthcare setting. The Joint Commission's Senior Vice President Paul Schyve (2009) states that "because poor communication is linked to many types of errors in healthcare, it is clear that organizations must collaborate on initiatives to improve leadership and staff communication to help prevent errors and preserve patient safety" (p. 9). Providing clear and concise verbal, written, and nonverbal communication during an exchange of patient care information is integral in promoting patient safety and care quality. Displaying mutual respect during communication is a key component in the sharing of information and the process of ensuring the recipient is free of any unintentional barriers in comprehension of the information being shared. Communicating respectfully incorporates behaviors such as proper use of tone, awareness of body language, legibility of written information, and minimal use of acronyms and allows time for the recipient of the communication to verify any unclear information.
There are many tools, communication techniques, and educational programs available that can easily be implemented in all dermatology practice settings to enhance communication. TeamSTEPPS training, Crucial Conversations training, Situation-Background-Assessment-Recommendation (SBAR) communication format, and safety checklists are a few resources available to assist organizations, clinics, and staff members in improving team communication in the work environment. The implementation of checklists in healthcare settings has illustrated improvements in staff communication. In a 13-month prospective study, Lingard et al. reported positive field observation result data after the implementation of a preoperative checklist in a general surgical division at a tertiary care hospital. The data illustrated "reduced miscommunication events in the division from an average of 3.95 events per operation to 1.31 events per operation (P < 0.001). The checklist led to a 64% reduction in miscommunications that specifically caused at least one visible consequence" (Lingard et al., 2008, p. 1). A simulation study of 17 operating room teams from both academic and community-based hospitals illustrated that team performance was enhanced by the use of a checklist as a memory aid during crisis event simulation. "When checklists were used, only 6% of steps were missed, whereas 23% of steps were missed when participants had to rely entirely on memory" (Shapiro, Punwani, & Urman, 2013).
Safety Checklist for Clinic Procedures and Dermatology Surgery
In 1999, the World Health Organization developed a research-based surgical safety checklist through efforts led by Dr. Atul Gawande (2009). The safety checklist initiative was in response to the Institute of Medicine report "To Err is Human: Building a Safer Health System." Dr. Gawande's research study focused on eliminating errors during surgical procedures in the perioperative environment. The World Health Organization study "found that using the checklist in eight clinical sites ranging from third-world hospitals to state-of-the-art academic centers resulted in a 4% decrease in surgery-related complications and 0.7% reduction in-hospital deaths for 3,955 consecutive patients" (McConnell, Fargen, & Mocco, 2012, p. 4).
In the past decade, there has been increased attention, research, and evidence-based best practice awareness in healthcare focused on the use of patient safety checklists. This heightened attention in part has occurred to a shift in healthcare practices, technological advances, and a new focus on risk management, which includes the specialty of dermatology. Venkataram and Anitha (2009) state that "possibilities of medico-legal situations and esthetic complications always exist and therefore dermatologic surgeons should adopt checklists and standards of care in their practice" (p. 1). Many procedures and surgical interventions that once were performed in only hospital settings have shifted to the outpatient and office-based clinical settings. The paradigm shift of the surgical and procedural healthcare practice will only continue to expand in the future. Healthcare team members must be prepared to safely manage patients in the ambulatory/outpatient-focused setting. Shapiro et al. (2013) reflect that "as technology advances and more attention is placed on rising healthcare costs, the trend of medical and surgical procedures moving to office settings will only intensify."
The incorporation of checklists into procedural and surgical areas has assisted healthcare organizations in meeting Universal Protocol requirements for the Centers for Medicare and Medicaid Services. Universal Protocol is a national patient safety goal for all accredited organizations and ambulatory care centers. In 2013, the Centers for Medicare and Medicaid Services implemented "a new quality reporting program for ambulatory surgery centers that introduces a structural measure on the use of a safe surgery checklist (ASC-6). This measure is part of payment determination for the calendar year 2015" (Joint Commission, 2012, p. 1).
A patient safety checklist focused on the needs of office-based and ambulatory surgical procedural sites has been developed by the Institute for Safety in Office-Based Surgery (Shapiro et al., 2013). Safety checklist templates can be modified to address key risk areas of outpatient procedures and surgical interventions. Checklists are divided into distinct phases of a procedure/surgical intervention including introduction, setting, procedure, and before discharge and includes a patient and provider/team quality assessment of the care episode (Shapiro et al., 2013). The Accreditation Association for Ambulatory Health Care (2013) Institute for Quality Improvement has a patient safety toolkit for ambulatory surgical and procedural practices that includes a safety checklist example. The Accreditation Association for Ambulatory Health Care patient safety checklist can be viewed at http://www.aaahc.org/Global/pdfs/AAAHC%20Institute%20content/Patient%20Safety%20.
The Association of Perioperative Registered Nurses (AORN) has also developed a comprehensive patient surgical checklist (Figure 1) that can be used by all facility types including clinics and ambulatory surgery practice settings. The AORN checklist "includes the safety checks outlined in the World Health Organization's Surgical Safety Checklist, while also meeting the safety checks within The Joint Commission's Universal Protocol in order to meet accreditation requirements" (AORN, 2013). The Universal Protocol standard and requirement for all accredited hospitals, ambulatory care, and office-based surgery practices were initiated in July 2004 by The Joint Commission (2013). It is important for specialties to be aware that established patient safety templates may be modified and adapted to integrate within the work flow of the ambulatory practice specialty. Patient safety checklists should be routinely assessed and continuously updated to reflect regulatory, process, or work flow changes.
Have a Questioning and Receptive Attitude
The dimension of having a questioning and receptive attitude is focused on a team's ability to promote open communication of individual members to speak up without an associated fear of reprisal. A work team that promotes members to ask questions or clarify unclear information is less likely to have patient care communication breakdowns and safety errors. Individual team members must also be receptive to questions and concerns regardless of position or role in the healthcare team. Professional nurses are integral in advocating for patients as vigilant guardians during procedure and surgical interventions in healthcare. Dermatology nurses can be proponents of role modeling mutual respect and receptiveness through their daily interactions while clarifying medication/prescription orders, treatment plans, specimen container labeling, or communication of technology concerns of equipment. Organizations that remove barriers to effective team communication, support individuals to speak up, hold individuals accountable for their behavior, and embrace a culture that is receptive to concerns and shared opinion are environment that is mutually respectful and highly satisfying to work in.
Hand Off Effectively
Patient transitions of care are high-risk times for lapses in communication and potential for mistakes that impact patient safety and care quality. Healthcare team members in the practice of dermatology often work collaboratively with many diverse specialty practices such as pediatrics, oncology, rheumatology, immunology, genetics, and multiple surgical services specialties. Transferring pertinent and concise patient information to the next care provider is crucial in maintaining an error-free continuum of care. The transfer of information should be without distractions and interruptions and focused to ensure that nothing slips through the cracks when there is a change in patient care responsibility. A patient safety checklist is a resource tool that can be referenced during patient care hand-offs when transferring the care of a dermatology patient to another care team. A patient having extensive Mohs micrographic surgery with wound closure in an operating room is an example of a time when utilizing a resource tool such as a safety checklist and/or a standardized communication format such as SBAR can prevent errors and lapses in patient care quality during transitions of care. A patient safety checklist is not meant to be a permanent part of the patient medical record but a tool used as a memory aid and additional process safeguard during high-risk moments in patient care.
Support Each Other
The final culture of safety dimension is to support each other and is focused on teamwork. Poor teamwork has been proven to contribute to healthcare error. Manser (2009) concluded, after an extensive research review on healthcare teams, that "observational studies and retrospective analyses of incidents or adverse events indicate that many of the contributing factors originate from flawed teamwork rather than from a lack of clinical skills" (p. 146). Dermatology care is provided in a multidisciplinary team effort. Teamwork is enhanced by all members of the team having a clear shared mission, vision, values, and goals of the practice and care provided. Open and respectful communication among all team members is a key component in promoting team cohesiveness, functionality, and patient safety. Team members need to promote individual success, mentor new colleagues into the team culture, recognize each other for a job well done, and embrace a work environment that is inclusive to team member diversity.
CONCLUSION
Healthcare is a complex and challenging work environment that is constantly changing and evolving at a rapid pace. The ACA has been a catalyst for healthcare organizations to reexamine care practices and delivery models of services to meet the demands of healthcare reform mandates and goals. Organization leaders and healthcare professionals are accountable to patients and families in providing a safe and high-quality care experience. The culture within the healthcare setting is critical and directly related to patient outcomes, satisfaction, safety, and quality of care provided. Continuous risk management strategies, education, and behavioral training can assist organizations and specialty practices, such as dermatology, to safeguard and minimize patient care errors in daily practice.
There have been numerous research studies, evidence-based best practice explorations, and tools developed to assist healthcare practices to create a Just Culture and show to consumers a commitment to safety at all organizational practice levels. The dermatology care team can create a safe and mutually respectful work environment by embracing commitment to safety behaviors and principles such as pay attention to detail, communicating clearly, having a questioning and receptive attitude, handing off effectively, and supporting each other. There are many evidence-based resource tools, communication techniques, and educational programs available that can easily be implemented in all dermatology practice settings to enhance communication. TeamSTEPPS training, Crucial Conversations training, SBAR communication format, and safety checklists are a few resources available to assist organizations, clinics, and staff for improving team communication in the work environment. Dermatology leaders, staff nurses, and allied team members all share in the accountability and responsibility in promoting a commitment to practice safety and quality for dermatology patients and families seeking care in our diverse specialty practice settings.
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