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"One of the great challenges in the whole world of quality and patient safety is learning to take advantage of the richness of clinical cases," says Robert M. Wachter, MD, professor and associate chairman in the department of medicine at the University of California, San Francisco (UCSF) and chief of the medical service at UCSF Medical Center.
"It’s a great challenge whether you are a doctor, nurse, risk manager, quality leader, hospital CEO, or a therapist," he says.
Wachter says he is beginning to believe that AHRQ WebM&M (http://webmm.ahrq.gov), an on-line journal (of which he is the editor) and forum on patient safety and health care quality sponsored by the Agency for Healthcare Research & Quality, is accomplishing just that.
Launched early 2003, WebM&M features:
"It’s grown incrementally over time, exceeding expectations," says Wachter, who notes that there are about 7,500 registered users and 700 unique visitors to the site daily. What’s more, he notes, the average visitor stays on site for 12 minutes, "so it’s likely they’re reading the information," he observes."
This seems to indicate the site has achieved one of its primary goals, which was to make its case commentaries relatively brief and nearly jargon-free. "We did not want it to feel plodding and academic," Wachter explains.
Patrice Spath, of Brown-Spath & Associates in Forest Grove, OR, also is impressed with the site. "What makes it different from many other health care-related web sites is that this one is specific to what the health care professional needs to do to improve patient safety," says Spath, who serves on WebM&M’s advisory board.
"It is constantly updated with new ideas, and has a high caliber of advisors. Also, there’s a very systematic, scientific analysis of the incidents they present — not just random commentary," she continues.
A tremendous epiphany
In numerous discussions with health care professionals, Wachter had noted a common theme.
"What I would hear as we’d go from hospital to hospital is something like this: We had this particularly troubling and interesting case, but we can’t even figure out how to get the information to our other units or departments,’" he recalls.
"AHRQ’s and our epiphany was that there is a tremendous richness in clinical cases, but no one had figured out a way to present them as real, and in a manner that was accessible, lively, and useful. I honestly don’t think anyone else does it," Wachter explains.
By using the web interface, people can send the site cases anonymously from anywhere in the world, he notes.
"Through AHRQ’s resources, we are able to compensate case submitters, which gives them an incentive to submit and enables us to engage the world’s experts," Wachter says.
So, for example, if a case is submitted on a medication error, or on wrong-site surgery, when staff consider who the best person would be to provide expert discussion and commentary, they usually can get them. "Plus, we have a strong editorial team, and all cases read well and in an interesting way," Wachter adds.
"We work hard with the authors to be sure they are as engaging, as practical, and as interesting as possible," he says.
Quality managers taking advantage
While WebM&M originally was oriented toward physicians, a survey this past May indicated the following breakdown: 24% were nurses; 21% were physicians; 4% were pharmacists; 11% were health care administration/managers; and 32% fell into a broad category that included quality managers, risk managers, systems engineers, and ethicists.
"It was equally split between providers and nonproviders," Wachter notes. When asked to rate the educational value of the site, 75% of the respondents rated it as "excellent."
There are many ways quality managers can and should use the site to improve performance, Wachter says.
"For one thing, this field is so broad I don’t think anyone knows all they need to know," he asserts. "The average quality manager or leader or risk manager will learn from the site because the cases we’ve posted range from psychiatry to surgery and safety problems, and from wrong-site surgery to errors related to implementation of IT to cognitive psychology and teamwork."
Just as importantly, Wachter says, it can be used to spread education across hospital silos.
"Many [quality managers] have taken to sending an issue or an individual case and mailing the web link to a doctor or nurse on the patient safety committee, because they believe they can learn from it," he notes. "Then, somebody who might not have gotten the journal might pick it up and then be hooked."
Each month, he explains, there is a "spotlight case" presented with a PowerPoint slide set. "Many people use that as a way of starting each month’s quality or patient safety meeting; if you’re looking for teaching materials, we’ve done some of the work for you."
Could this happen here?’
Spath agrees. "There are two ways quality managers can use this site. First, they can download the PowerPoint from the feature case and use it at patient safety committee meetings, staff meetings, and so forth as a learning tool. But perhaps a more powerful way of using it is something I’ve been teaching people to do, which is a technique called, Could this happen here?’" she points out.
The technique works like this: The case is reviewed and discussed, and group members are asked whether a similar event could occur in their organization. "If the answer is that it could, you then ask what would have to go wrong for it to happen," Spath continues.
The response itself tells her a lot about the culture of an organization, she explains.
"If people look at the case and say it could never happen, that tells me they are not willing to admit that mistakes can happen, which is a significant culture problem," Spath says.
Using a case from another facility has an additional advantage, Spath explains: It takes known faces and names out of the equation, allowing staff to talk about problems they have a little more objectively.
"If you say, Here’s what happened because of an error by Nurse B,’ that puts a face and personalities to the incident, and you can’t get past that to talk about underlying system issues," Spath observes.
"In this method, people do not feel so threatened, and therefore, they don’t feel the need to try and protect themselves," she says.
Once the potential for error is identified (what would have to go wrong), the next step is to show how it can be kept from going wrong, Spath adds.
"That leads to process improvement," she asserts. "Because these incidents are presented in sufficient detail, it makes them even more valuable for a Could this happen here?’ exercise."
"These cases hold lessons for individual institutions," Wachter concludes.
"Every one has an incident report, a root-cause analysis, and we’re all struggling with the same problem — how to take the power that lies in individual cases and get it to the diverse group of people that need to know about it," he adds.
(Editor’s note: In future issues of Healthcare Benchmarks and Quality Improvement, we will be reporting on individual PI projects undertaken by quality managers after reading case reports at WebM&M.)
Need More Information?
For more information, contact:
• Robert M. Wachter, MD, Professor and Associate Chairman, Department of Medicine, University of California, San Francisco; Chief of the Medical Service, UCSF Medical Center, Box 0120 UCSF, San Francisco, CA 94143-0120. Phone: (415) 476-5632. Fax: (415) 502-5869. E-mail: email@example.com. Editor, AHRQ WebM&M. Web site: http://webmm.ahrq.gov.