A critical nursing responsibility, patient education may seem like a simple and expected function. But certain factors can impede our ability to perform this essential function. Whether you’re a staff nurse or a nursing administrator, you are responsible for planning and supporting patient-education activities. So how can we guarantee that the educational material and delivery methods we use will meet our patients’ needs?

The Joint Commission requires healthcare organizations to “proactively seek to… reduce risks to the safety of patients” by selecting a high-risk process and “identify the ways in which the process could break down or fail to perform its desired function.” Because a patient’s lack of understanding in certain areas can be considered a safety issue, a proactive process should be used to review the organization’s patient-education delivery methods.

One tool available for reviewing high-risk processes is Health Failure Mode Effects and Analysis™ (HFMEA), developed by the National Center for Patient Safety (NCPS) of the Department of Veterans Affairs (VA). This article describes how the intensive care unit (ICU) staff at Elmendorf Air Force Base Medical Center in Anchorage, Alaska used HFMEA to analyze its patient-education process.

Initiating HFMEA

At Elmendorf, patient education was identified as a high-risk process after a patient found printed material from the Internet that had been left in his room anonymously. The material contained questionable information about food restrictions and supplements to be taken before medications, and the article appeared to have no scientific basis. The patient became angry because many of the article’s recommendations went against his personal beliefs; also, they could have caused serious allergic reactions. When he asked who’d left the material at the bedside, no one in the unit claimed awareness of the activity. Subsequent chart review showed a lack of customized education specific to the patient, other than orientation to the ICU and discussion of his plan of care. Nurses hadn’t documented ongoing assessments for his educational needs.

Nursing leaders held a staff meeting to address the incident. Later, it was decided that a group of staff nurses, as subject matter experts, would meet to examine the processes and expectations for patient education in the ICU. Two had experience using HFMEA in other areas where they’d worked; they were recruited to promote team discussions. The HFMEA model was chosen because it’s a systematic approach for identifying ways a process can fail, why it might fail, and how it can be made safer.

Steps of the HFMEA process

Step 1 of the HFMEA process is defining the HFMEA topic; step 2, assembling the team. Step 3 is graphically describing the process related to the chosen topic. During this step, the ICU group began to develop a flow-diagram of how patient education ideally should happen, from ICU admission through discharge.

Each major step in the patient-education process was numbered, so team members later could communicate clearly when discussing subprocesses. Sometimes team members’ opinions differed as to the expected sequence to follow in managing patient-education needs.

Step 3 in the process can be confusing, time consuming, and possibly frustrating as team members work together to define the sequential steps. Team leaders should try to help members find consensus on specific steps, as by drawing the flow-diagram on a large sheet of paper or whiteboard so everyone can see the flow. Another way is to write each step on a separate piece of paper, put each piece of paper on a board placed in front of the group, and move the pages individually as team members agree on the sequence.

Conducting a hazard analysis

Step 4 in the HFMEA process is to list all possible ways each sequential step could go wrong. These are called failure points—points related to the potential for major or minor healthcare errors affecting patient safety. One point in the patient-education process is to create a nursing diagnosis or patient problem list, which should include which educational topics to address with the patient. For instance, a nurse might write: knowledge deficit related to diabetic insulin administration. The ICU team identified the following potential failure modes for this step:

• admitting nurse fails to fill out the patient problem-list document
• nurse doesn’t include the problem list in the admission note
• nurse includes only a few problems while neglecting to document others.

According to the VA’s “The Basics of Health Care Failure Mode & Effect Analysis,” step 4 is the one in which team members’ expertise and experience really pay off. Various methods may be used, including the triage/triggering questions created by NCPS, brainstorming, and cause-and-effect diagramming to identify potential failure modes.

After Elmendorf CU team members listed the various ways in which the steps might not go as planned, they listed the problems and failure modes on the HFMEA worksheet.

Next, the team determined the severity of the potential failure modes and the probability of each one occurring, and recorded this information on the worksheet (See the link below.) Severity rating can more clearly be understood and discussed in a group setting by asking the following question: If this failure mode were to occur, how serious would it be? The ICU team deemed that failure to teach the patient, or the patient failing to fully understand instructions, would be major on the severity scale. To rate probability, they asked: What’s the likelihood that this failure mode will occur? The team then entered the severity and probability designations on the HFMEA worksheet.

The next component of the hazard analysis is to follow the HFMEA decision tree to determine if the failure mode warrants further action ( http://patientsafety.org/). Using this tree allows team members to agree whether to proceed on developing actions to prevent the failure mode—or to stop and move on to another step. If the group decides to proceed, they list all potential causes for the breakdown in process.

Actions and outcome measures

In step 5 of the HFMEA process, the ICU team discussed whether certain causes for perceived failures in patient education could be eliminated, controlled, or accepted. They also began to discuss which actions could be taken to address the causes that could be eliminated or controlled. These actions included:

• recommendation to request formation of other workgroups to review and create priority lists of common ICU conditions and procedures
• recommendation to create a list of standardized educational materials to offer patients as appropriate
• opportunities for staff training on electronic resources, such as the hospital’s intranet library for patient-teaching materials.

These decisions were recorded on the HFMEA worksheet. Finally, the group attempted to recommend outcome goals for achieving control over most of the identified causes. Examples of initial outcome goals included “Standardized patient-education material will be available within 12 months” and “Regular chart reviews will demonstrate greater than 90% completion of the nursing history within 24 hours of admission.”

At this point, the ICU team believed it should submit these recommendations and the HFMEA worksheet to ICU leaders for top-management concurrence and assistance in assigning point people to carry out agreed-on recommendations. In essence, the ICU team had completed its task—to review patient education in the ICU using the HFMEA process.

Lessons learned

HFMEA provides a systematic approach to address high-risk areas in health care. The ICU team met four times over 6 weeks to complete the process. At step 5 (actions and outcome measures) the team felt uncomfortable recommending actions because many members didn’t think they were qualified to make such decisions. However, after they consulted nursing leaders, they felt empowered to make recommendations. Nursing leaders accepted seven of the team’s 11 recommendations for implementation.

Patient education shouldn’t be overlooked when considering quality improvement. At Elmendorf’s ICU, nurses were expected to provide education to patients, but current practices hadn’t been reviewed recently. Using HFMEA allowed staff nurses to act as change agents to improve patient safety and advocate for patients. The ICU team and nursing leaders agreed HFMEA was a good tool for addressing the patient-education process because of its forward and proactive approach.

Gregory S. Kopp is an ICU staff nurse at Joint Base Elmendorf/Richardson Hospital in Anchorage, Alaska.

Selected references

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Joint Commission. 2012 Hospital Accreditation Standards. Author: Oak Brook, Ill; 2011.

Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010 Jun;145(6):582-8

Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009 Jun;5(2):86-94.

U.S. Department of Veterans Affairs. The Basics of Health Care Failure Mode and Effects Analysis. Video Conference course presented by VA National Center for Patient Safety. www.patientsafety.gov/SafetyTopics/HFMEA/HFMEAIntro.pdf. Accessed May 9, 2012.

U.S. Department of Veterans Affairs. Health Care Failure Mode and Effects Analysis. www.patientsafety.gov/SafetyTopics.html#HFMEA. Accessed May 9, 2012.

Vlayen A. Evaluation of time- and cost-saving modifications of HFMEA: an experimental approach in radiotherapy. J Patient Saf. 2011 Sep;7(3):165-8.