Multi-Method Proactive Risk Assessment

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DESCRIPTION (provided by the applicant): Despite increased attention to the safety of the medical system over the past 5 to 10 years, clear evidence of improvements in safety has been sporadic. Selected institutions appear to have made great gains in specific areas. While technology offers much to improve safety, human factors failures in well intended systems have been repeatedly noted. The national movement towards a safer health care system continues to have strong support from the Federal government and the Agency for Healthcare Research and Quality (AHRQ), but it has become apparent that much still needs to be done at the local level. Organizations cannot expect that the work of others will automatically translate to safer care across the entire healthcare system. The inpatient component of the health care system has received the most attention in understanding the source of errors and interventions to improve care. Nonetheless, in any given month approximately one quarter of the American public are seen in an ambulatory care facility while approximately 1% will be cared for in the inpatient setting. Furthermore, errors in ambulatory care have been well documented. Thus, the need for a safer ambulatory system is clear. Developing interventions to reduce errors and harm requires local information concerning not only system failures but also local care processes, practice level readiness to change, and a commitment to the provision of safe care at all levels of an institution. The specific aims of the project are to: 1) Collect practice level data using the instruments listed below from 12 University of Colorado Hospital (UCH) ambulatory clinics to help inform a proactive risk analysis: a) AHRQ Medical Office Survey on Healthcare Quality and Patient Safety; b) AHRQ-supported Office Vital Signs instrument; c) Medical Group Management Association's office risk assessment instrument; and d) Proactive risk assessment through a visual process map and group reflection; 2) Analyze data from UCH-specific two ambulatory error database to corroborate specific ambulatory high risk areas identified in Aim 1; and 3) Develop a data driven risk reduction plan for one of three areas (laboratory management, imaging management, medication management) using participatory methods within the UCH ambulatory system using a Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis.