Sanford Health (SH) System has long been committed to quality care, patient safety, and risk reduction. Therefore, we employ multiple quality/safety initiatives, including the AHRQ Safety Culture Survey (SCC). Now we wish to focus on SH patients'experiences and provide feedback to SH- associated physicians and Hospital Units too often associated with patient complaints. The Vanderbilt Center for Patient and Professional Advocacy's work on """"""""service recovery"""""""" and use of patient complaints to identify and intervene on high-complaint physicians and service units is congruent with SH values and priorities. Because the CPPA's programs and processes have not been linked directly to patient safety metrics such as the SCC, the proposed project will help answer the extent to which medical liability risk, risk management outcomes and staff evaluations of safety culture are correlated. Substantial assessment, planning, and inpatient/outpatient complaint capture integration at SH will be required before effective implementation can begin. But if our planning proves successful, SH will be positioned to disseminate the process to other health systems. The proposed collaborative planning process is designed to: (1) analyze the congruence of SH's baseline unsolicited patient complaint data and safety survey outcomes for identifying (and implications for improving) hospital units at high risk;(2) assess SH's overall infrastructure-related readiness to adopt the Vanderbilt Patient Advocacy Reporting System (PARS(R)) program for both physicians and hospital units;(3) identify and rectify gaps, if any, in (3a) SH systems for capturing patient complaints and staff perceptions of unsafe systems, (3b) SH's systems for responding when high risk physicians and safety- threatened service units are identified, and (3c) utility of SH safety/quality data and claims files for setting priorities;(4) revise/adapt CPPA's service recovery training program and extend PARS(R) intervention training for non-physician care givers within hospital units;and (5) translate PARS(R) processes and programs from their existing single-hospital orientation to the requirements and circumstances associated with a multifaceted system such as SH. SH will employ Just Culture principles to address deviations from professionalism that threaten quality and safety and increase risk: (1) a Learning Culture that sees, reports and mitigates risk;(2) a Design Culture that integrates human factors, communication theory and reliable design;(3) a Respect Culture that distinguishes human error and unintentional risk taking from intentional risk taking;and (4) an Accountability Culture which seeks to balance """"""""blameless"""""""" with """"""""punitive"""""""" and the individual with the system. This planning project will expand Sanford's enviable record in these areas and assess the CPPA's programs'utility for other multi-site, multi-state systems.

Public Health Relevance

Sanford Health wishes to promote professional self-governance, foster a system-wide just culture of safety and kindness, and reduce avoidable lawsuit risk. Our plan is to develop the infrastructure for eventually implementing Vanderbilt's Patient Advocacy Reporting System (PARS(R)) throughout our multi-state, multi-facility system, aiming to improve capture of patient/family concerns about their care, enhance our service recovery programs, and identify both inpatient units and physicians at disproportionate risk for unsafe care and unnecessary lawsuits. The results will offer Sanford Health and other systems a roadmap leading to fair, constructive, peer-delivered, evidence-based, norm-referenced interventions that address care practices and patient-provider communications.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZHS1-HSR-O (02))
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Battles, James
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Sanford Research/Usd
Sioux Falls
United States
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