October 21, 2014

Stories

Out With Errors, In With Team Spirit

Greater understanding of roles improves workflow--and quality of work

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Kerry Dease, Kerry.Dease@kp.org

Camelia Christian, Ohio medical assistant and OPEIU Local 17 member, prepares a specimen.

Last spring, when the Ohio Parma Medical Center Internal Medicine unit-based team set out to improve its lab specimen labeling, team members got an unexpected benefit—a greater sense of employee empowerment.

After several instances of specimens going to or from the lab mislabeled, unlabeled or incorrectly reported, the team decided to figure out what was going wrong so it could get back on track.

Kerry Dease, Ohio's regional patient safety lead, was invited to evaluate the team's process and help it determine how to eliminate errors.

Diagnosing the issue

Dease's first step in determining where the missteps were occurring was to make sure everyone understood—and agreed on— the goal: to label each specimen correctly at the patient's bedside and properly log it before sending it to the lab.

It turned out that not everyone was following the procedure properly.

"What we realized," says physician co-lead, Kathleen Greiser, MD, "was that some system changes were necessary."

Keeping the protocol in mind, Dease next had each team member list factors he or she thought were getting in the way of completing the steps successfully.

A number of barriers were identified, including the need to retrieve specimen labels from a printer some thought was too far away and the fact doctors didn't always enter results into the system.

Dease and the team determined that staff members did in fact have easy access to the printer, and they went through the list looking for other solutions.

The team agreed to consistently label each specimen at the bedside, verifying the patients' name and medical record number;  to log the specimens at day's end before sending them to the lab; and to be sure there was a physician's order logged in the system for each specimen.

Team members also agreed to speak up when they saw a problem or breakdown in the process, Dease says, including times the doctors didn't log orders.

"Everyone knows what their accountability, responsibility and workflow is," says Sandra Clifton, interim lead RN. "We're all on the same page, everyone knows what the process is, and it's going to work out better."

Putting themselves in colleagues’ shoes

Throughout the process, Dease asked team members to explain their jobs to one another. Some team members acknowledged they had been unaware of how much work their colleagues do.

For example, Dease says, "Doctors didn't realize all the work [the nurses] do. Making them aware of the entire process, and for them to see it end to end, was helpful."

"What [nurses] realized was that not only are the providers part of the process, they are complementary [to it]," says union co-lead Cecelia Golden, RN care manager and an ONA member.

Getting results

Since the new procedures were implemented, there haven't been any reports of mislabeled specimens.

And a sense of teamwork has grown.

"We're making sure there are no errors together," says union co-lead Doris Frisco, medical assistant and OPEIU Local 17 member. "It has improved our communication [between] providers and support staff," and that leads to better quality.

Dease thinks the team-building lessons will carry over into other problem-solving opportunities.

"They saw how they could use the tools for teamwork," she says. In the future, she added, "When they identify a need for improvement, they can do it themselves."

What worked:

These three principles helped the Parma Medical Center Internal Medicine UBT get results:

  • Systems thinking: Understanding what other people's jobs are and how the pieces of the process fit together.
  • Empowerment and accountability: Creating a work environment in which people feel safe to speak up if they see something not happening the way it should.
  • Open communication: Agreeing to provide clear information, expectations and feedback to all team members, regardless of job title.