This report explores the 2022 Safety Management Plan for Management of the Environment of Care (EOC) in Duke University Hospital (DUH), North Carolina. In particular, the report examines DUH Plan’s compliance with the directives stated by the American Society for Healthcare Risk Management (ASHRM). In addition, the areas of potential risk management and safety improvement are assessed, and the role and scope of responsibilities of the DUH Safety Officer are examined.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in various settings and domains. The critical component’s content is summarized in this section; the summaries are supplemented with a brief description of stakeholders responsible for implementing a particular component. According to Guler (2017), patient experience is the critical indicator of a hospital’s performance, which demands diligent leadership and strong standard practices. In this regard, one can claim that DUH strives to create a highly-standardized EOC, where patient safety and positive experience are ensured through multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s grounds and equipment via TRIMMS — a special computerized management system. The responsibility for properly implementing this component falls on the Duke University Facilities Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions are responsible for this component’s implementation (DUH, 2022). Their role lies in managing the programs for reporting, investigating, and following up on incidents of occupational illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive smoking. According to DUH (2022), all managers are responsible for monitoring compliance with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings and recommendations are headed to the Duke University Safety Committee (DUSC), presided by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published reporting schedule. The DUSC approval is necessary for planning each function’s objectives (DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews. According to DUH (2022), the policy reviews are conducted by the DUSC at least once every three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within their function. The indicators are based on priorities identified by the function and the DUSC (DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections. According to DUH (2022), all hospital areas where patients a served musted be monitored for compliance with safety requirements on a bi-annual basis. Unlike the activities within the Performance Improvement component, Effectiveness Monitoring is performed by external agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are integrated through interactions between responsible functions’ personnel and specific oversight committees. For instance, the DUH Safety Officer participates in the Performance Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC successfully coordinates its activities with oversight committees, creating an integrated patient safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees. Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational directive covers risks created by flawed documentation, an unclear chain of command, and deviations from standard practice. The patient safety directive includes medication errors, serious safety events, and hospital-acquired conditions. The strategic directive relates to care partnerships, marketing, and various business arrangements. The financial directive deals with the risks stemming from costs and billing issues. The human capital directive relates to workforce conditions, such as injuries and fatigue. The legal directive covers risks associated with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates. Next, the technology directive addresses potential risks and safety issues related to hardware, tools, or specific techniques. Finally, the hazard directive covers risks from improper facility management or environmental conditions (ASHRM, n.d.). These directives are followed in the DUH Safety Management Plan since functions are specifically assigned to match a particular directive.
For instance, operational and patient safety directives are covered by the Patient Safety function. Compliance with the human capital and legal directives is ensured by the Employee Health and Corporate Risk Management functions. In addition, the Corporate Risk Management function covers potential strategic and legal risks. Furthermore, potential technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain improvements could be added to the Plan’s policies to enhance patient safety. In particular, the DUH safety plan is seemingly lacking in terms of the communication culture component. Meanwhile, multiple sources pointed to the importance of effective teamwork and communication between the medical team members. For instance, Santa et al. (2018) found that error feedback and communication quality substantially impact the quality and safety culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient safety culture. As such, DUH could have improved its Safety Management Plan by adding a dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates individual functions’ plans with the general patient safety program, and examines recommendations submitted by the functions’ leaders as a part of risk assessment activity (DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the whole system, making a crucial impact on the creation of the integrated Environment of Care. Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk management and patient safety program.
References
American Society for Health Care Risk Management. (n.d.). Healthcare risk management: The path forward.
American Society for Health Care Risk Management. (2004). The growing role of the patient safety officer: Implications for risk managers.
Duke University Hospital. (2022). The 2022 safety management plan for management of the Environment of Care (EOC).
Guler, P. H. (2017). Patient experience: A critical indicator of healthcare performance. Frontiers of Health Services Management, 33(3), 17-29.
Gunawan, D., & Hariyati, R. T. S. (2019). The implementation of patient safety culture in nursing practice. Enfermeria Clinica, 29, 139-145.
Santa, R., Borrero, S., Ferrer, M., & Gherissi, D. (2018). Fostering a healthcare sector quality and safety culture. International Journal of Health Care Quality Assurance, 31(7), 796-809.