In addition to the environmental scan and the development of the searchable catalog of programs, AIR investigated consumer perspectives on the advantages and disadvantages of different characteristics of patient safety education and training programs. For this effort, AIR leveraged contacts at nine health organizations with whom AIR and/or AHRQ has partnered over the years on various projects. In accordance with the exploratory nature of this investigation, the sample was limited to key organizational contacts. Exhibit 13 provides a list of key contacts by organization.
Exhibit 13. Key Contacts by Partner Health Organization
|Sisters of Saint Mary Health||Andrew Kosseff, MD|
|Duke Health Systems||Laura Maynard, MDiv|
|Mayo Clinic||Lori Scanlan-Hanson, RN, MS|
|University of Central Florida||Bethany Ballinger, MD|
|Shady Grove Hospital||Tony Slonim, MD, DrPH|
|University of Minnesota||Karyn Baum, MD, MSEd|
|Carilion Clinic||Charlotte Hubbard, RN|
|University of North Carolina||Celeste Mayer, RN, PhD|
|Maryland Patient Safety Commission||Inga Adams-Pizarro, MHS and
C. Patrick Chaulk, MD, MPH
AIR initially designed the interviews with contacts at the partner health organizations to help direct the environmental scan and data abstraction process. However, the interviews also afforded the opportunity to gather input on the interviewees' perspectives on patient safety education and training programs as consumers of these programs. Although there was no formal interview protocol, AIR presented a few topics to consider prior to the interview to stimulate thinking about patient safety programs.
- What patient safety education and training programs are in place at your organization?
- Which patient safety education and training programs are you most familiar with?
- Which of the programs have been most successful and why?
Partner health organization contacts were invited to speak freely about patient safety programs at their organization and their views on these programs in general. Each interview lasted approximately 30 minutes.
Themes from the Qualitative Analysis
AIR conducted a qualitative analysis of the interview notes to identify key themes emerging across the interviews. It is important to reiterate that the purpose of these interviews was to help direct the environmental scan and design of the searchable database. The input from these interviews highlighted several interesting issues that AHRQ may want to consider before developing, implementing, or marketing new patient safety programs or products. Further, the interviews were not conducted as part of a rigorous evaluation of consumer perspectives and, therefore, simply reflect input from organizations with which AIR and AHRQ have previously worked. Due to the small sample size and informal nature, the results are not generalizable and may not be representative of all patient safety program consumers.
Six key themes emerged from the nine interviews as follows (in order of issues discussed most frequently): (1) customization, (2) self-build, (3) cost, (4) perceived effectiveness, (5) evaluation and measurement, and (6) "Patient Safety 101." In this section, we present an overview of these themes.
- Customization, Self-Build, and Cost. Interviewees identified a need to adapt patient safety programs to specific organizational needs. This may mean tying new programs into larger organizational structures and curricula or modifying programs to suit trainee level of expertise. Without the ability to customize programs, organizations may feel compelled to create their own patient safety education and training programs. There is a perception among some that this may be more cost effective than buying an off-the-shelf program. In other cases, an organization may find the perfect patient safety program but not be able to use it because of prohibitive cost. Due to misconceptions about the cost and adaptability of programs, there are many well designed, customizable, comprehensive, reasonably priced programs note being used by consumers.
- Perceived Effectiveness and Evaluation and Measurement. An organization's decision to use a specific patient safety program can be very subjective, and programs are often judged by their perceived effectiveness. One reason organizations rely on perceived effectiveness is that no repository currently exists to capture objective information about programs and their impact. Evaluation and measurement of patient safety education and training programs may be weak or hard to find, particularly at the higher levels of evolution (Kirkpatrick levels 3 and 4).
- Patient Safety 101. Interviewees generally agreed that all health care organizations ought to provide some introductory patient safety class or training for their staff. However, the nature and form of such a class is likely to vary significantly by organization, and no standards exist as to what information needs to be taught based on the target audience. Thus, there is no standardized introduction to patient safety.