ORGANIZATION:	SWEDISH MEDICAL CENTER, Department of Surgical Services, Englewood, CO
PROJECT:	THE O.R. BOARDING PASS

In healthcare today, we take for granted the daily miracles that happen and the intricacies of the processes and procedures performed. The Swedish Medical Center completed the Joint Commission survey in October of 2002.  During that survey it was suggested that the Department of Surgical Services adopt the Boarding Pass as a means of assuring safe passage of all surgical patients into the operating room.  The Department of Surgical Services recognized the Boarding Pass as a high priority department-wide patient safety initiative and began educating the staff in December of 2002.The Boarding Pass became effective January 6, 2003 and included the following checkpoints:

• Correct surgical site
• Valid History and Physical
• Valid operative consent
• Valid anesthesia consent
• Identification band in place
• Time Out recorded on the patient’s operative chart

The Department of Surgical Services has improved the Boarding Pass process since it’s beginning January 6, 2003.  The proactive initiative to this patient safety issue has led to better communication amongst the perioperative team members, and the protection of patients and surgical team members.

This award goes to not only an outstanding hospital Swedish Medical Center but also an outstanding and exceptional team of innovative nurses, who were willing to think outside of the box.  They looked for the answers and changed the practice of how patients are received in the operating room.  What they did was look to an industry that deals at the same level of need for impeccable safety as healthcare.  They examined how the airlines board passengers and reviewed their safety checks that are performed to board the plane.  They took this process, applied it to patients that were going to the operating room and this is how the O.R. Boarding Pass was developed.  We would like to congratulate this team of nurses on their wonderful contribution to Patient Safety and for winning the 2003 Colorado Patient Safety Coalition Award.
 

ORGANIZATION:	COMMUNITY HOSPITAL, GRAND JUNCTION, CO
PROJECT:	A CULTURE OF PATIENT/GUEST SAFETY:  COMMUNICATING THE SAFETY MESSAGE

Quality healthcare requires excellence in many areas, medical practice, guest relations, and most importantly, patient-guest (guest) safety. In healthcare quality really is safety and this can only be achieved through an integrated culture that focuses on safety.

Community Hospital has made an organizational devotion to safety and error prevention the basis of their culture of safety. Their belief is that only when your culture advocates safety can you make the pervasive, systematic changes needed to improve guest safety and quality. They have changed the fundamentals of how they do business and how they communicate their safety values to their employee Partners and guests to improve the safety and quality of guest care.

Communicating the importance of guest safety is key to their culture. They have made the commitment to a well-conceived, consistent safety message that is on going across the entire organization. Community Hospital understands that communication among their caregivers, and perhaps most importantly with their patient-guests, is essential for a “culture of safety” to be effectual.

Communicating their safety philosophy and practices starts with the initial orientation to their organization. Extensive efforts are made to keep the safety culture “alive’ within the organization by making safety a key “standing” agenda item at every inter-departmental monthly meeting and by supporting the safety message with posters that have been developed to relate specific safety information to the employee Partners and guests. Safety posters serve as on-going reminders to the physician and employee Partners that safety is a top priority. The posters also educate their guests about safety practices and “empower” them to question, inquire and become comfortable with safety practices.
 

ORGANIZATION:	THE COLORADO STATE BOARD OF NURSING, Denver, CO
PROJECT:	CHANGING THE FACE OF REGULATION:  THE ALTERNATIVE COMPLAINT RESOLUTION PROGRAM

Regulatory agencies, whose mandate is public protection, play a vital role promoting cultural change that facilitates the ability of the individual health care professional to recognize, report and remedy the root causes of adverse events in patient care thus resulting in the continuous improvement in patient safety. The Alternative Complaint Resolution Program (ACR) at the Colorado Board of Nursing (Board) is helping professional and practical nurses to return to active and safe practice after receiving a complaint of substandard care against his/her license.  The program was created in 1999 by legislative approval of a decision item and is designed to identify the root causes of the practice problem, promote timely resolution of complaints, and to reduce the cost of regulation.  While these outcomes are significant, perhaps most significant is the return to safe practice of professional and practical nurses in an era of significant nursing shortage.  Prior to the establishment of ACR, regulators assumed that nurses made practice errors because of individual knowledge deficits, judgment errors, or oversight.  Consequently, investigations and discipline focused primarily on these issues.  The discipline was expected to be the same---usually a two-year probation for all nurses whose practice was found to be substandard.  ACR seeks to establish an approach to the regulation and reporting of errors that will increase knowledge and incentives for error detection, reporting, and prevention while fulfilling the duty to protect the public from unsafe practice.

The Board of Nursing was also invited to participate in the Practitioner Remediation and Enhancement Partnership (PREP) program, sponsored by the Citizens’ Advocacy Center.  The PREP program advocates for the use of remediation in resolving complaints against health care providers and the establishment of collaborative relationships with health care agencies in preventing practitioner errors.  The Board also elected to participate in a national project to develop a research instrument for the identification of root causes of errors, the “Taxonomy of Error, Root Cause Analysis, and Practice Responsibility” (TERCAP).  The IOM report, PREP program, and TERCAP have contributed to the acceptance of ACR as a new, evidence-based approach for regulation and prevention of nurses’ errors.
 

FOUNDER’S AWARD

PRESENTED TO: MARK LEVINE, MD Colorado Patient Safety Coalition President:  2000-2003 In recognition of his tireless devotion to the principles of quality improvement in health care through fostering a culture of patient safety.  The Founder’s Award is a special presentation to an individual that has distinguished himself here in Colorado as the driving force behind the patient safety movement.  As Lucian Leape has become known as the “godfather” of the patient safety movement across the country – Dr. Levine has become the symbol of our efforts here in Colorado.  Starting with the convening of the first patient safety meetings three years ago – and culminating this year with the establishment of the Coalition as a formal Colorado not-for-profit Corporation – he not only guided the ship – but he built the darned thing!

One of Dr. Levine’s most important contribution to the Colorado patient safety movement was to assure that in providing structure for our efforts – that no group was excluded.  His efforts have encouraged the inclusion of consumers and patients, as well as providers of care, regulators and policymakers, researchers and others.  His efforts are reflective of the balance that he brings to all of his endeavors!

Best of all, Dr. Levine remains a vital participant in the Coalition and beyond.  In his new role with the Centers for Medicare and Medicaid Services, Dr. Levine will continue to provide the vision and wisdom needed to improve health care for the citizens of our state and beyond.