Evaluating Inpatient Crisis Response

As the Medical Director of patient safety for a large healthcare system I can say that conducting unannounced “mock codes” (Inpatient Crisis Response Evaluation System is the title of our program) is a critical pillar of safety quality improvement efforts. WISER oversees our program and provides the evaluation and consultation service to many of our 20 hospitals in conjunction with and close collaboration with the local hospital physician and nursing leadership.

The unannounced part allows true system evaluation of such a response. The events are closely choreographed with our simulation team (led by a physician medical director), as well as the local hospital leadership. Our evaluation system has afforded us as a system, the opportunity to unveil many latent system threats as well as identify opportunities for targeted training efforts. With regard to simulation and training it is a TRUE needs analysis in this way.

With regard to acceptance, I believe that it is related to the maturity of the overall organization and the simulation personnel conducting the events. In the words of James Reason on high reliability organizations “They anticipate the worst and equip themselves to deal with it at all levels of the organization. It is hard, even unnatural, for individuals to remain chronically uneasy, so their organizational culture takes on a profound significance. Individuals may forget to be afraid, but the culture of a high reliability organization provides them with both the reminders and the tools to help them remember.” Thus I believe in highly mature safety culture organizations it is incumbent upon both the leadership and the healthcare clinicians to be accepting of “external” evaluations for such critical moments as inpatient crisis events.

I also believe that the naming of the program has significant implications. The title “Mock Code” in my opinion sounds somewhat trivial, extra, perhaps of marginal utility, or at the very least “fake.” If that is the intent, then I believe that is easier to argue that the events should be pre-planned and/or avoid being completely “unexpected”. However if the intent is to seriously evaluate a high reliability organization’s response to an unexpected patient situation, and identify needs, process improvement opportunities and uncover latent threats, I would argue for the unannounced methodology.

Our health system shares a deep commitment to continue on the journey to high reliability and believe our Inpatient Crisis Response Evaluation System is an important component of our success. As WISER is accredited by the SSH in Systems Integration (among other categories) we believe a fully integrated approach is necessary, very safe, feasible and our responsibility to execute and provide feedback to our health system.

As anyone who provides actual care for patients there are risks and benefits to ALL decision that are made from therapeutics, to staffing, to salting the parking lot. There are certainly safety items that must be attended to in any of our simulation efforts, particularly those which occur in proximity to actual care. However carefully crafted programs, process and execution will ultimately ensure the benefits outweigh the risks.

I truly believe the undiscovered system latent threats to inpatients are a greater risk than the conducting of the mock code itself.