Strategies to put safety first
Adverse events, staff and patient engagement must be priorities, panelists say
Editor’s note: The following is an edited excerpt of a full transcript of a Dec. 21, 2011 editorial webcast, “Safety First,” conducted by Modern Healthcare. The panelists were Dr. William Conway, senior vice president and chief quality officer at the Henry Ford Health System in Detroit; Dr. Mary Reich Cooper, senior vice president and chief quality officer at Lifespan in Providence, R.I.; and Dr. Stanley Hochberg, chief quality officer and vice president of quality and patient safety at Boston Medical Center. In an exchange moderated by reporter Maureen McKinney, the panelists discussed the latest tools, techniques and strategies to make care as safe as it can be. The webcast was sponsored by Elsevier Gold Standard. Per editorial policy, sponsors are not involved in the development or publication of editorial content.
Maureen Mckinney: How were you able to overcome existing hierarchies among the staff in order to ensure that all clinicians felt comfortable speaking if there was a problem, and did you have any problems with that that you struggled with?
Mary Reich Cooper: So this is a journey that we’ve been on for almost five years. And it didn’t come easily as we tried to roll this out. First of all, we engaged the services of the folks who coined the term ‘just culture’ to come in and assess the organization and see where we were, and as many of you know who use the AHRQ survey, there are questions in both of those that show where front-line staff feel that potentially are punitive versus where the administrators may feel we are right on the money in terms of that behavior. So we used our AHRQ survey to guide us in terms of success. We used the number of events reported and where they’re coming from as a second measure of whether or not we are achieving buy-in from the front-line staff. So in the beginning, when people were a little bit more afraid to report, when we started reporting back to them some of the outcomes of change that had been created by event reporting, that was a successful model of allowing them to see that by coming forward, change could occur and that by coming forward using the just-culture model, there wasn’t necessarily retribution for coming forward.
Mckinney: You mentioned your hospital’s adverse-event reporting system. What strategies do you use to boost reporting among staff, and are there obstacles that you’ve run into?
Stanley Hochberg: We have—part of this is to have everybody understand the system. We make the interfaces absolutely easy as possible. It comes up quickly on the server. If you don’t want to identify yourself, you can instantly enter, click on a couple categories and put as little or as much information as you wanted. So that’s been enabling that to be simple. It’s been important. We empowered and tried to use peer pressure to enable people that have someone just mention something to them, one of the questions that everyone else should ask in the institution is, ‘Have you entered into Stars?’ which is our reporting system, so that that becomes a peer expectation. And if we hear of anything that wasn’t attributed to Stars, we always have questions back, ‘Why was this not entered?’ So this just becomes business as usual.
Mckinney: You mentioned the importance of delegating to other departments in the hospital— pharmacy, infection control, in order to run the campaign. Explain in a little more detail if you would to me how you hold those different departments accountable and ensure that they’re adhering to the overall standards of the no-harm campaign.
William Conway: Well, as I said, the transparent—the measurement of the harm index is available throughout the organization, and it’s monitored by this system of quality forum, which is chaired by the CEOS, so there aren’t too many pharmacy leaders in the system that aren’t anxious to show how effective and good they are at this.
Mckinney: What’s the best role for a CEO to play in making care safer?
Cooper: I think that the CEO has to have tremendous visibility out on the floors. I think there is nothing that is better achieved or faster achieved than having a CEO who goes out onto the floors and talks to the staff. I think it shows interest. I think it allows for feedback to occur through the systems that are set up. People don’t frequently talk to that person and necessarily tell him or her bad news when that individual’s out on the floors, but it gives them the impression that he or she is listening, and I think most importantly allows the CEO to see for him or herself what really is happening out on the floors—what the needs are, what the patterns of behavior are—so that would be my one thing that I would tell CEOS to do. Get out there on your floors.
Hochberg: I agree with that. We just implemented—i would encourage people who are interested to look at patient-safety walk-arounds, which comes from the Institute for Healthcare Improvement. We actually broaden that to the entire executive team needs to be behind this. One of my staff rounds on a weekly basis with a member of our executive team, including the CEO, takes them through the clinical areas and specifically that we work off scripts where we have the CEO, CFO asking questions in informal settings what staff do to make your unit safer? How many misses did you have today? What feels unsafe to you? We’ve been doing that for about two months. I think we’ve been getting very strong feedback around how that drives people’s perception of the institutional priorities and also getting a lot of information or things we need to address.
Conway: I would agree. Leadership is absolutely critical. I’ve been fortunate to be backed up by two things: One, the CEO has been personally involved and leads the effort. This is our No. 1 priority as an organization, and the board looks at the harm index report at every single meeting.
Mckinney: How do you see the role of patient advocates who are born of a fatal medical error, either a family member or the patient themselves, is that an asset to the hospital?
Conway: Well, absolutely. As part of this campaign, we’ve tried to engage our patient and family population. We’ve got literature on them on what they’re role is on ensuring safety. We’ve encouraged them to speak up, and it can only help. We’ve got a sign for hand-washing first. We’ve got signs in the entry level of every hospital saying, ‘It’s OK to remind us to wash our hands if we forget.’
Cooper: I would say that patient and family advocates not only have a place at the table, but we are all helped by their presence. And I say that because we have found that even with those patients and families who have been harmed by us, that there’s some reluctance to be public about what has happened—that their grief—a lot of times people don’t feel like grieving in public. And I think that we as hospitals and healthcare systems probably are not making it easy for them to come forward and talk about what has happened. And I think we need to be
better we are. about It’s part that—show of the overall how push accepting that I think of transparency, all of embraced about towards talking the notion about mistakes, about talking about when things go wrong, about making sure that people understand that our mission is to keep people safe. But when we don’t keep them safe, that we want to fix what the results are and make it safe for the next person as well.
Hochberg: I think I agree with everything. The only thing I would encourage is for people to get families and patients involved. Even in committee work, we just started doing that. And there was a very rewarding experience of one of our quality-improvement projects. We actually brought several patients in to be part of the team. That was relatively new for us; I think something we will continue to build upon.
Mckinney: How transparent is Henry Ford Health System in sharing safety events among staff. You mentioned daily huddles. What’s covered in these?
Conway: Over the course of the year, we embed different safety messages in the huddles. There’s a whole program. Some of that is fed by incident sentinel events that happened throughout the system as reminders that some of it— In fact this past year, we got very explicit about using particular case stories that have causal messages and then that affect multiple departments.
Mckinney: In the event of an adverse event, does your organization have a team to provide disclosure or apology for the injured patient, and how is that procedure handled?
Cooper: So we have a team, but we also have a process, because as you know sometimes team members are not available. So there’s a process, and in fact for reference for people, it’s actually on the IHI website for how to respond to an adverse event, and our process is very close to that process. We have a requirement that for any significant adverse event, that it be communicated immediately up to senior leadership. We have a very collaborative relationship with our state Department of Health, and we notify them immediately of significant adverse events—verbally, so a phone call in. In Rhode Island we’re a million people, so it’s a little easier for us to have personal relationships with all of our governmental leaders, but we call to the Department of Health and give them a verbal notification even before we file. We immediately have the CMO and the CNO for any egregious adverse event go to the site of the adverse event so that they can start finding out what happened. We have staff support groups that we started a few years ago called Here for Us. And those are made available to the staff if they’ve been involved in an event so that if they are having a difficult time understanding what went wrong and what their role in it was, that we could make available support services to them. And we try and do our RCAS really promptly. We gather some information, but then we delve into the RCAS pretty rapidly, so a quick pathway up to senior leadership so that I at the system level and my boss, the CEO of the system, know about adverse events that are significant right away. A notification among all members of the team to any kind of regulatory responders, and a reach out to the patient and the family right away with an apology. And if there needs to be any kind of mitigation at all, that we initiate that process right away. And that’s been very, very effective for us.
Mckinney: You mentioned in the process of monitoring that there is an initial burst of enthusiasm that then can sometimes fall a bit. Explain a little bit about some strategies that you’ve employed to keep that enthusiasm up.
Hochberg: I think for any improvement project even as part of our initial planning, that we also plan on post-monitoring and maintenance of performance so that it’s really explicit portion of any project we kick off. And as much as we can, it usually involves monitoring. One of our beliefs here is that as much as we’d like to believe everything would occur the way we want it to, if we’re not actively monitoring compliance with something, the compliance is always at risk. So that just becomes part of the way we think about things, we look at things and do things. The other is intermittent re-education campaigns. So sometimes things that were very visible in the institution ... as we move on to something else that also creates compliance risk. So we need to have a regular long-term campaign around maintaining visibility.