Complying with NPSG #16A requires culture change
Implementing a rapid response team (RRT) requires an understanding among staff members that putting an RRT into action is best for patient safety. However, introducing family-activated rapid response to a hospital requires a greater social change.
“Healthcare professionals are not very good at giving up control; it’s very scary for some people. They have a lot of issues to deal with,” says Sharon Garretson, RN, MSN, manager of orthopedic and surgical services at University Hospitals Richmond Medical Center (UHRMC) in Richmond Heights, OH. “We automatically assume when patients enter the hospital that we know more than they do.”
The 2008 Joint Commission (formerly JCAHO) National Patient Safety Goals (NPSG) include NPSG #16A, which says that as of January 1, 2009, staff members should be able to call for extra assistance when a patient’s condition rapidly deteriorates. One of the implementation expectations says that facilities also need to provide a way for patients and their families to call for assistance if they think it is needed.
UHRMC staff members plan to roll out family-initiated RRT during the first few months of 2008. General rapid response has been in place at the facility since April 27, 2005, following four months of staff education about RRTs and why they were necessary.
“We were gung ho about education,” Garretson says, who estimates that 35 education sessions were held during that time.
“We went forward with a tough stance because we believed it was right for the patients. There was a lot of resistance though.”
Dealing with resistance
Garretson says there was tension among staff members: ICU nurses thought RRTs would add to their workload, and floor nurses were insulted by the inference that they could not handle patients who needed immediate care.
University of Pittsburgh Medical Center (UPMC) dealt with some of the same strong feelings when it instituted a family-activated RRT at its Shadyside location in early 2005. Called “Condition H,” with the “H” signifying “Help,” the program was launched with the help of Sorrel King, a known activist on behalf of patients’ families. King lost her 18-month-old daughter due to medical complications in 2001.
“We initially had a couple of challenging conversations,” says Beth Kuzminsky, RN, MSN, staff associate of the Center for Quality Improvement and Innovation at UPMC. “Some nurses were concerned that if their patients called a Condition H it would be punitive toward them. Others had concerns such as ‘What if patients call inappropriately?’ ”
However, UPMC Shadyside forged ahead telling concerned staff members that the hospital had to start somewhere. Kuzminsky says her best advice is, “Don’t let the ‘what ifs’ get in the way.” As of presstime, UPMC was in the process of implementing Condition H in all of its system hospitals by January.
To begin its Condition H program, UPMC Shadyside piloted it on a 24-bed unit and eventually expanded it to two sister units. By July 2005, Condition H had spread throughout the entire UPMC Shadyside facility.
UHRMC and UPMC take similar steps when a family-initiated response is called. They are:
1. A patient, family member, or staff member calls a trained hospital operator, telling him or her of the emergency and its location.
2. The rapid response need is announced via pagers and overhead alert.
3. A team of healthcare providers responds to the patient’s bedside within five minutes. The team can be made up of various people. UHRMC uses an ICU nurse, a hospitalist, a house intern, and a respiratory therapist. UPMC Shadyside uses an internal medicine house physician, an administrative nurse coordinator, a patient relations coordinator, and a floor nursing staff member.
4. Regardless of the patient’s primary physician, members of the RRT are allowed to make medical decisions; patients are sent where they need to go for care if necessary.
5. Follow-up meetings are scheduled to discuss the event.
One difference between UHRMC and UPMC is that UHRMC’s family-activated response team will arrive when an RRT has been called, quickly assess the patient’s condition, and if the problem is determined to be a communication issue, a nurse manager will assist. If the problem is judged to be clinical, a more formal RRT is called.
Convincing staff members of the need
Garretson knows from implementing UHRMC’s initial RRT that staff members need to see that a new idea works before they get on board. Within the first three weeks, after the first RRT call had come through and the system worked well, staff members started to realize the benefits of the system, she says. Family-activated RRTs should be similar.
“In January 2007, we did research into the opinions of nurses concerning RRTs, and the results were overwhelmingly positive,” Garretson says. “They saw it was about the patient and not an insult to them.”
Kuzminsky says it takes ongoing leadership support, open communication, and education to ensure that staff members accept Condition H as a means to address patient safety. “We’re working to make it part of the everlasting fabric of our hospital, but anything that requires a culture change takes time.”
Showing staff members that family-activated RRTs make sense can be beneficial as well. “People call an RRT when they’re at home and they call 911—no one says to them, ‘How do you know your mom’s having a stroke?’ ” Garretson says. “The whole concept of [family-activated] rapid response teams is common sense.”
One of the biggest factors in getting staff members to embrace the idea of family-initiated RRTs, especially in the beginning stages, is getting hospital leadership to vocalize their thoughts about its importance. Kuzminsky says leadership led the charge at UPMC Shadyside, and that really struck a chord with staff members.
“Leadership is the single most important ingredient in the program,” Kuzminsky says. “Without leadership support, buy in, and their spreading of information, it fails. The president of UPMC is behind it, and when it’s that high on the food chain, people pay attention.” She adds that it’s equally as important to have the supporting data and information from patients in terms of their opinions about family-initiated RRTs.
Garretson says that it’s not only administration that’s needed to lead the charge, but also physician leaders.
Getting the word out
For those facilities in the later stages of starting RRTs, Kuzminsky recommends not jumping headfirst into implementing a family-activated RRT. “I always tell people it’s the right thing to do to have your culture very strong with rapid response first, and then Condition Help is the natural next step,” she says.
Educating staff members about NPSG #16A and the way in which the family-activated RRTs are started is up to each facility, and each facility will find its own way of doing things, says Garretson.
“My philosophy is we were successful [with our initial RRT implementation] because we spent so much time on education,” Garretson says. “I think those hospitals that want accreditation, they’re just going to have to do it. They’re either going to have to have a concise plan and stick to it, or they’re just going to have to wake up one morning and say, ‘We just have to do this.’ It can be any structure they want; it just has to work.”