What do metrics have to do with patient safety?

TUESDAY, AUGUST 9, 2011

Early in 2008, the 59-bed medical-surgical unit-based team at Fontana Medical Center began a remarkable two-year run in patient safety. It was a sharp contrast to the 2006-2007 period, when 17 patients had developed pressure ulcers, a painful, dangerous and expensive complication of inpatient care.

That record was unacceptable to everyone on the team.

“We all shared a commitment to create a safe healing environment for patients and build a culture of safety,” says Kathy Smith, RN, the assistant department administrator and management co-lead at the time, along with labor co-leads Toni Leonen, RN, and Zeny Bauzon, RN, both UNAC/UHCP members.

The team launched several tests of change to eliminate the problem, involving wound-certified nurses, nutritionists, and new training and care procedures. It also made smart use of metrics, which were collected and shared every day—giving team members a clear picture of whether the changes they were making were having the desired effect.

‘Exciting and motivating’

“Our metrics were easy to follow,” Smith says. “It was exciting and motivating to go each month and see we’d kept our record going.”

With the increased vigilance, the team went nearly two years—from February 2008 to January 2010—without a single hospital-acquired pressure ulcer. The data team members were collecting allowed them to quantify their success and gave them evidence the improvement wasn’t coincidental or merely an anecdotal impression.

“And if we missed a target,” Smith says, “the data let us respond quickly, go back and see what’s not working.”

That occurred in mid-January 2010, when the team tested a soft boot that was supposed to reduce pressure on patients’ feet—but found it made things worse. Three patients using the device that month developed heel blisters.

“If the foot was not kept at a constant 90-degree angle, the boots caused more irritation,” Smith says. “We stopped using them, and the next month were back to zero.” The next incident occurred in September 2010, when the unit had staff turnover. It then went till March 2011 without another incident.

Read more about the Fontana team’s work.