At this week's MHRI Town Hall at MedStar Union Memorial Hospital, one of our associates spoke about what led her to MHRI and shared her research projects. Here she is— making her blogging debut, sharing her story with all of you!
Guest Blogger, Crystal Morales, RN
|Crystal Morales, RN (second from left) participating in|
the "Color Me Rad" race with her daughters.
As the Patient Safety Officer my focus was on preventing patient harm events. Focused on systems approaches to change and a just culture, I leveraged already existing administrative systems always looking to mitigate risk to the patient.
As the Patient Safety Officer I am well versed in performing and leading adverse event and patient harm investigations, conducting interviews, facilitating Root Cause Analysis, Failure Mode Effects Analysis, implementing action plans, and lastly evaluating effectiveness.
I recently joined MedStar Health Research Institute as the Program Director and am currently working on two projects, “We Want to Know” and CandOR. “We Want to Know” is an AHRQ funded project which is aimed at detecting, addressing, and responding to patient perceived breakdowns in care in real time, and engaging patients in the reporting of care breakdowns. This project grows out of prior research that has shown that 1 in 4 patients have concerns related to their care but fail to speak up fearing that voicing concerns will negatively impact their care. Our overall goal is to enhance patient centered reporting of breakdowns in care and to integrate those identified breakdowns into the system-wide response to patient harm in real-time.
CandOR (Communication and Optimal Resolution) is built out of a 2010 AHRQ patient safety and medical liability programs grant. The goal is to develop a communication and resolution program toolkit. The toolkit will include the following components: gap analysis, incident reporting, event review, process improvement, communicating consultation services, care for the caregiver, and measurement and evaluation techniques. This project will last 2 years, will include 8 MedStar Hospitals, 4 Dignity Health Hospitals, and 2 Christiana Care Hospitals. At the end of project MedStar health will have 30 Master Trainer in the CandOR process that will have expertise in the following areas: Leading Gap Analysis, training and simulated experiences in patient communications consultation, expertise in how to conduct event reviews and action planning, specifically, to integrate a systems-based approach to event review, identifying the human factors elements as causal factors, and expertise in measurement and resolution techniques.