Clare Mock, MD, CPPS, assistant professor in the division of hospital medicine has been named Director of Patient Safety for the Department of Medicine. For the past three years and while serving as medical director at the UNC Hillsborough Hospital, Mock has been actively involved with the UNC Medical Center Improvement Council (MCIC), and through that, she’s been part of a group that redesigned the SAFE reporting system (formerly known as PORS – Patient Occurrence Reporting System). Now, Mock is working with the UNCMC Patient Safety Subcommittee to redesign and standardize the root cause analysis (RCA) process, a tool used to study and address the root causes of undesired outcomes to prevent them from reoccurring.
How did you become interested in patient safety?
“I started my journey towards patient safety about 10 years ago thorough engaging and training in Quality Improvement techniques – Lean and Sig Sigma. I was fortunate enough to be selected as an Assistant Program Director for a yearlong fellowship in Patient Safety and Quality Improvement at Johns Hopkins, and through my work with that program was exposed to some of the pioneering leaders in the world of Quality Improvement and Patient Safety – Dr. Peter Pronovost (who developed the central line checklist which is now standard of care), Dr. Albert Wu (who coined the term “second victims” which acknowledges the emotional harm to healthcare workers involved in errors), and Dr. Bryan Sexton (who developed the Patient Safety Culture Survey – now used nationwide).
“I think the biggest reason that the science of Patient Safety appeals to me is that it helps me reconcile two very disparate truths — that on the one hand I took an oath, that I am committed to uphold, to “First do no harm” and yet on the other hand, I am a human who is fallible and at times, despite my best efforts, I make mistakes.”
“I have a particular interest in human factors engineering and how that integrates into the health care system. The basic tenant of human factors engineering is that we should make systems and products that work effectively for the people who use them, rather than requesting that people work around faulty systems and products. I recently became CPPS credentialed (Certified Professional in Patient Safety), and if you’ve never heard of that you’re probably not alone. It’s typically held by patient safety officers and people in higher-level risk management positions and recognizes a competency in patient safety science and human factors engineering that can be effectively applied to plan and implement patient safety initiatives.
How do you envision working across the department?
“Our biggest task will be to create an accountable, responsive event reporting structure for our entire department. I want to acknowledge two things, and the first is the current state. I know there is great work already being done in this area and I want to learn from and expand on that. Second, I want to acknowledge there are probably some negative thoughts surrounding the event reporting system (SAFE-formerly called PORS), and I would imagine some people have had experiences where perhaps concerns haven’t been addressed in a positive light or manner. This is common and something we can improve over time. I also want to note that in my mind, a robust event reporting system can be a very effective vehicle for creating an overall culture of safety – which is the ultimate goal. By the way we respond to events, we can model a “Just Culture” and the stress the importance of creating safe systems.”
Tell us about your work in Hillsborough.
“We formed our patient safety team about three years ago. The former state was one that didn’t have any formal expectations or process for review. There wasn’t a lot of positive emotions associated with the reporting system and it was known as the black box, something no one wanted anything to do with. We started by tackling the smaller issues first and celebrating wins, with a key group who shared a safety mindset, and we grew that group to represent all areas of the hospital. We developed standard work, which we know is very important for the quality improvement process. Having clear expectations and standard processes, we strived to create a culture of continuous quality improvement, moving toward high reliability–consistent excellence in quality and safety across all services maintained over long periods of time–then worked on closing the loop.
“We made roles and assignments clear. As event reporting improved and more people became engaged, we needed to create a process for determining what could be safely handled at the unit level and what we would need to escalate. For that, we used the safety assessment code, to provide a standardized process, for determining how and where to review an event. Closing the loop is important once you have a standardized process, so we employed thanking the individuals for taking the time to be committed to safety. Once we had created this system, developed a safety newsletter, so we were not only highlighting units in areas that were doing very well and engaging in patient safety, but individuals as well, who were contributing to our culture. As we identified reporting trends, we tried to distribute this information around the hospital so that we could have shared learning about what was going on with our committee. This resulted in clear and sustained improvement and engagement in event reporting, not only from a data perspective.
Can you share some of the improvement practices now in place?
“Our safety group at Hillsborough included inpatient, surgical and ED colleagues, and they came up with great work, such as the ‘Red Hat Initiative’ for pre-operative patients. This is where we were using human factors engineering with a clear visual cue. A red hat means ‘stop’, and a green hat means ‘go’, signaling whether or not a patient is safe to go back to the OR in terms of completion of their pre-operatively safety checklist. From the inpatient side, we did a lot of our work around the delivery of critical care at night, as this is a key time where staffing gaps can lead to unsafe situations. To lessen this gap, we provided mega code training, redesigned our emergent transport algorithm through a root cause analysis. We also developed a nighttime huddle where we were able to escalate a patient concern preemptively rather than retro-actively, especially in terms of airway support.”
How will you approach improvements in Chapel Hill?
“Over the coming weeks and months, I want to find out what is already working really well within our Department and build on the great work in progress. For example, I know Oncology is already engaged in a robust event reporting process, and I hope we can learn from their successes and expand ‘best practices’ from oncology, and other divisions, across the department. My goals are to support current work, help grow safety leaders in places where assistance is desired, and develop a culture of safety which is just, accountable and action-oriented.
“A “Just Culture” recognizes that human error is just inevitable. It’s part of who we are. We don’t punish people for making mistakes. We strive to fix the systems and make processes better so errors are less likely to result in patient harm. Accountability to me means that we listen, and when possible, address the concerns of our teams, acknowledging that we can’t fix everything right away. Last, we want a system that is action-oriented, which means we think about it from a science of safety perspective. When we’re thinking about interventions that will result in lasting, meaningful change – by applying tools such as the VA National Center for Patient Safety “Action Hierarchy.”