Business case
Radiation oncology department in multi hospital system set goals to (1) eliminate near-miss conditions and (2) confusion on patient order process that led to staff, proceduralist, and patient dissatisfaction
Initial Condition
- Near miss rate approaching 11 per month
- 1 treatment deviation per year
- Compliance rate with patient ID verification 55%
- 85% accuracy and clarity in physician orders
Target Condition
- Near miss rate reduced to zero
- Zero treatment deviations
- 100% patient ID verification
- 100% accuracy and clarity in physician orders
Planned Activities / Intervention
- Step 1. Develop change-initiative skills for key leadership positions and organizational structure that will support the new culture
- Step 2. Providing training in teamwork and communication to support desired culture-changing behaviors such as situational awareness, cross-check and assertion, mutual support, pre-briefing and debriefing protocols
- Step 3. Create and implement site-specific safety tools such as checklists, structured handoffs, new protocols, algorithms, and team huddles to hardwire the teamwork behaviors into daily patient care processes
- Step 4. Collect and analyze data to document results.
Achieved Metrics
- Increase in efficiency and profitability: patient volume increased by 11% with the same level of staffing
- Reduction in treatment deviations to 0 incidents over the last 3 years
- Improvement of clarity of physicians’ orders to 97% at 6-months post implementation and after
- Identified cases where ambiguity or conflicting documentation could have resulted in inappropriate treatment or significant patient harm
- Processes streamlined and standardized across two clinics allowing for flexibility in staff deployment and elimination of overtime costs
