"Situation Room" for Patient Safety
The University of Virginia Medical Center admits more than 28,000 patients a year and does nearly 54,000 outpatient surgeries.
When you’re dealing with so many sick people, things are bound to occasionally go wrong, but the federal government ranks UVA below the national average in five of thirteen categories linked to patient safety. That one man is leading the charge to eliminate medical mistakes at UVA, and he’s set up a war room to do the job.
“Yesterday we had no employees that were injured, we had no falls. We had three pressure sore alerts, no urinary tract infections and no blood system infections.”
Each weekday morning at 7 a.m. Dr. Richard Shannon, UVA’s Vice President for Health Affairs, assembles 15 top administrators.
“Pretty soon we’re going to have to give out tickets, because it gets pretty crowded in here in the morning.”
Operations and Nursing, Human Resources and Facilities, Pharmacy, Orthopeadics - everyone is in to talk about what went wrong in the past 24 hours.
“The Situation Room is a live place where we actually see the harm that occurred yesterday, and we can evaluate it.”
Surrounded by white boards and monitors, they examine every new infection, every unexpected death. After the discussion, Shannon and other members of the executive team head for places where problems have occurred. Some yield easily to common sense solutions.
“We discovered, at one of our outpatient facilities that patients were tripping over the mat at the entrance into the building.”
This information came from the receptionist, who was promptly empowered to remove the mat on dry days when it wasn’t needed to keep people from slipping.
Then there are more complicated problems - like the way the hospital is organized.
“The nurses change shift every twelve hours, the doctors change shift every 16 hours, some every 24 hours.”
To improve communications, he thinks it’d be better if everyone was on the same schedule. He also takes issue with a medical care pyramid that puts doctors at the top.
“The physician may spend 20 minutes at the bedside a day. The nurse is there 24/7 and has about 13 times more direct contact with the patient than does the physician. You can’t have someone at the head of the pyramid who is absent a lot of the time.”
That’s music to the ears of Dorie Fontaine, Dean of the School of Nursing. Many hospitals struggle to keep good nurses, in part because they don’t get the respect they deserve. Shannon and Fontaine agree -- nurses need to be on the team - making rounds with the doctors and sharing essential information.
“While they love being a nurse, they often do not like the work climate. When people say ‘Thank you for making time to be on rounds with me today,’ I say if a physician says that to a nurse, she’s never going to miss rounds, especially when she contributes a data point that might change the whole plan of care.”
Patients and their families must also be part of this team effort, so Shannon wants healthcare professionals to make rounds in the afternoon, when visitors are more likely to be on hand.
Finally, from the Situation Room, he’s keeping an eye on costs - convinced that doing the right thing will also, in the long run, prove to be the least expensive approach to care.