Communications Blackout Poses Patient Safety Challenge

CHICAGO — In the fall of 2006, a vendor accidentally cut the wrong cable in the computer room at Children's Specialized Hospital, New Brunswick, N.J., leaving the large pediatric rehabilitation provider's eight facilities without computers or phones for 3 days.

Staff continued to care for patients with semimanual systems, and no adverse events occurred as a result of the power loss. But the sobering experience sparked a comprehensive overhaul of the organization's communications downtime procedures, using a Six Sigma risk reduction method known as FMEA (failure modes and effects analysis). Widely used in manufacturing, the Six Sigma system was first created by Motorola as a method for improving quality and efficiency. The FMEA component involves rating on a numerical scale the risks associated with components in a process, then prioritizing corrective actions based on risk levels.

A root cause analysis and a review of policies and procedures revealed serious shortcomings, including gaps between the administrative policy and the emergency operations plan, inconsistencies across some departments, no policies and procedures at all in other departments, and critical steps that were missing, including a formal process for communicating to staff that systems were down, said Lorraine Quatrone, medical administrator at Children's Specialized Hospital.

“The staff was completely out of the loop,” she said at the Joint Commission national conference on quality and patient safety. “We thought we had a plan in place,” but “we were operating in silos.”

The hospital tightened computer room security, revised the administrative policy, and developed a flowchart showing who should notify whom after a communications failure. For example, the chief information officer was instructed to notify the chief executive officer and the chief safety officer.

Following these quick fixes, “we could have sat back and said we're prepared,” Ms. Quatrone said. Instead, the hospital decided to “drill down and look behind doors” using FMEA methodology.

The hospital identified potential areas of vulnerability and prioritized areas for improvement. “Our analysis told us we were weak in communication of unplanned downtime and the implementation of procedures,” Ms. Quatrone said. In other words, staff needed to be alerted about a communications failure, and they needed to know what to do to ensure patient safety after they were informed about the situation.

The hospital developed a template for downtime policies and procedures for every department. In addition to asking directors and managers what their departments needed in order to continue to function without computers and telephones, the hospital asked them to look at their departments as suppliers of information to the organization and to indicate how they could help other departments.

“We wanted to make this an organizationwide commitment to helping each other,” Ms. Quatrone said. Facilities management, for example, is now responsible for immediately distributing two-way radios to patient areas, making hourly rounds to check for emergency issues, and monitoring the hospital's energy management system. All nursing units are required to immediately begin recording the administration of all medications on a written worksheet.

The hospital also addressed procedures that would govern how each department would continue to function after systems were working again, including how information from the interim paper process would get entered into the electronic system. Once the system has returned to operational status, for example, pharmacy staff are required to enter all new medication orders electronically.

Following the revision of policies and procedures, department directors and managers were asked to educate their staff and to decide with them which electronic forms would be needed in paper form and where information should be kept. Information about the emergency plan became an integral part of new employee orientations as well, she said.

To measure the initiative's success, the hospital conducted a series of simulated downtime drills and asked a sample of employees six questions about the emergency plan, including “How would you complete an event report if the system went down?” and “Can you show me your department's downtime policy?”

Awareness “seemed pretty low at the beginning, but as time went on and we did drills to reinforce our commitment to the process, we started to see the results edge up,” Ms. Quatrone said.

The need for emergency plans will become even more crucial as more providers move toward electronic medical records and continue to automate other systems. “You can't fall short of recognizing the value and importance of having a backup within your organization,” she said.

CHICAGO — In the fall of 2006, a vendor accidentally cut the wrong cable in the computer room at Children's Specialized Hospital, New Brunswick, N.J., leaving the large pediatric rehabilitation provider's eight facilities without computers or phones for 3 days.

Staff continued to care for patients with semimanual systems, and no adverse events occurred as a result of the power loss. But the sobering experience sparked a comprehensive overhaul of the organization's communications downtime procedures, using a Six Sigma risk reduction method known as FMEA (failure modes and effects analysis). Widely used in manufacturing, the Six Sigma system was first created by Motorola as a method for improving quality and efficiency. The FMEA component involves rating on a numerical scale the risks associated with components in a process, then prioritizing corrective actions based on risk levels.

A root cause analysis and a review of policies and procedures revealed serious shortcomings, including gaps between the administrative policy and the emergency operations plan, inconsistencies across some departments, no policies and procedures at all in other departments, and critical steps that were missing, including a formal process for communicating to staff that systems were down, said Lorraine Quatrone, medical administrator at Children's Specialized Hospital.

“The staff was completely out of the loop,” she said at the Joint Commission national conference on quality and patient safety. “We thought we had a plan in place,” but “we were operating in silos.”

The hospital tightened computer room security, revised the administrative policy, and developed a flowchart showing who should notify whom after a communications failure. For example, the chief information officer was instructed to notify the chief executive officer and the chief safety officer.

Following these quick fixes, “we could have sat back and said we're prepared,” Ms. Quatrone said. Instead, the hospital decided to “drill down and look behind doors” using FMEA methodology.

The hospital identified potential areas of vulnerability and prioritized areas for improvement. “Our analysis told us we were weak in communication of unplanned downtime and the implementation of procedures,” Ms. Quatrone said. In other words, staff needed to be alerted about a communications failure, and they needed to know what to do to ensure patient safety after they were informed about the situation.

The hospital developed a template for downtime policies and procedures for every department. In addition to asking directors and managers what their departments needed in order to continue to function without computers and telephones, the hospital asked them to look at their departments as suppliers of information to the organization and to indicate how they could help other departments.

“We wanted to make this an organizationwide commitment to helping each other,” Ms. Quatrone said. Facilities management, for example, is now responsible for immediately distributing two-way radios to patient areas, making hourly rounds to check for emergency issues, and monitoring the hospital's energy management system. All nursing units are required to immediately begin recording the administration of all medications on a written worksheet.

The hospital also addressed procedures that would govern how each department would continue to function after systems were working again, including how information from the interim paper process would get entered into the electronic system. Once the system has returned to operational status, for example, pharmacy staff are required to enter all new medication orders electronically.

Following the revision of policies and procedures, department directors and managers were asked to educate their staff and to decide with them which electronic forms would be needed in paper form and where information should be kept. Information about the emergency plan became an integral part of new employee orientations as well, she said.

To measure the initiative's success, the hospital conducted a series of simulated downtime drills and asked a sample of employees six questions about the emergency plan, including “How would you complete an event report if the system went down?” and “Can you show me your department's downtime policy?”

Awareness “seemed pretty low at the beginning, but as time went on and we did drills to reinforce our commitment to the process, we started to see the results edge up,” Ms. Quatrone said.

The need for emergency plans will become even more crucial as more providers move toward electronic medical records and continue to automate other systems. “You can't fall short of recognizing the value and importance of having a backup within your organization,” she said.

CHICAGO — In the fall of 2006, a vendor accidentally cut the wrong cable in the computer room at Children's Specialized Hospital, New Brunswick, N.J., leaving the large pediatric rehabilitation provider's eight facilities without computers or phones for 3 days.

Staff continued to care for patients with semimanual systems, and no adverse events occurred as a result of the power loss. But the sobering experience sparked a comprehensive overhaul of the organization's communications downtime procedures, using a Six Sigma risk reduction method known as FMEA (failure modes and effects analysis). Widely used in manufacturing, the Six Sigma system was first created by Motorola as a method for improving quality and efficiency. The FMEA component involves rating on a numerical scale the risks associated with components in a process, then prioritizing corrective actions based on risk levels.

A root cause analysis and a review of policies and procedures revealed serious shortcomings, including gaps between the administrative policy and the emergency operations plan, inconsistencies across some departments, no policies and procedures at all in other departments, and critical steps that were missing, including a formal process for communicating to staff that systems were down, said Lorraine Quatrone, medical administrator at Children's Specialized Hospital.

“The staff was completely out of the loop,” she said at the Joint Commission national conference on quality and patient safety. “We thought we had a plan in place,” but “we were operating in silos.”

The hospital tightened computer room security, revised the administrative policy, and developed a flowchart showing who should notify whom after a communications failure. For example, the chief information officer was instructed to notify the chief executive officer and the chief safety officer.

Following these quick fixes, “we could have sat back and said we're prepared,” Ms. Quatrone said. Instead, the hospital decided to “drill down and look behind doors” using FMEA methodology.

The hospital identified potential areas of vulnerability and prioritized areas for improvement. “Our analysis told us we were weak in communication of unplanned downtime and the implementation of procedures,” Ms. Quatrone said. In other words, staff needed to be alerted about a communications failure, and they needed to know what to do to ensure patient safety after they were informed about the situation.

The hospital developed a template for downtime policies and procedures for every department. In addition to asking directors and managers what their departments needed in order to continue to function without computers and telephones, the hospital asked them to look at their departments as suppliers of information to the organization and to indicate how they could help other departments.

“We wanted to make this an organizationwide commitment to helping each other,” Ms. Quatrone said. Facilities management, for example, is now responsible for immediately distributing two-way radios to patient areas, making hourly rounds to check for emergency issues, and monitoring the hospital's energy management system. All nursing units are required to immediately begin recording the administration of all medications on a written worksheet.

The hospital also addressed procedures that would govern how each department would continue to function after systems were working again, including how information from the interim paper process would get entered into the electronic system. Once the system has returned to operational status, for example, pharmacy staff are required to enter all new medication orders electronically.

Following the revision of policies and procedures, department directors and managers were asked to educate their staff and to decide with them which electronic forms would be needed in paper form and where information should be kept. Information about the emergency plan became an integral part of new employee orientations as well, she said.

To measure the initiative's success, the hospital conducted a series of simulated downtime drills and asked a sample of employees six questions about the emergency plan, including “How would you complete an event report if the system went down?” and “Can you show me your department's downtime policy?”

Awareness “seemed pretty low at the beginning, but as time went on and we did drills to reinforce our commitment to the process, we started to see the results edge up,” Ms. Quatrone said.

The need for emergency plans will become even more crucial as more providers move toward electronic medical records and continue to automate other systems. “You can't fall short of recognizing the value and importance of having a backup within your organization,” she said.