Strate­gies to put safety first

Ad­verse events, staff and pa­tient en­gage­ment must be pri­or­i­ties, pan­elists say

Modern Healthcare - - OPINIONS WEBCASTS -

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.





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