Hospitals for generations contented themselves with the presumption that patients’ outcomes, good and bad, mostly reflected staff members’ best efforts. Events such as hospital-borne infections and patients’ hallway falls were unfortunate but unavoidable happenstances of medical care.
That mindset has been swept away by a growing sheaf of science-based best practices and trainings intended to manifest patient safety as a north star among all hospital staff – even the weekend custodians. Today at any hospital, to be medical director or quality-control officer is to be the catalyst for sea change in attitudes and expectations necessary to meet the clarion call for accountable care.
At UW Medicine’s hospitals, four standard-bearers of safety recently framed their imperative:
Create a culture in which staff members:
- prioritize patient well-being above all else;
- rely heavily on data to build on successes and learn quickly from failures and near-misses;
- feel obligated to acknowledge mistakes and point out those of others, including co-workers and supervisors;
- strive always to improve.
Communication as the hub
Patient safety is like a wheel, said Elaine Lobdell, Valley Medical Center’s vice president for quality services. “Many initiatives come together like spokes. The wheel is rolling better than it ever has right now. It is not rolling perfectly, but we definitely have a round wheel,” she said.
That wheel’s hub, based on comments by Lobdell and her peers, is communication. It touches patient care in histories, charts, orders, prescriptions, transfers, translations, signage and fleeting conversations during shift changes. On the business side, analyses, rationales, measurements, outcomes all must convey information effectively. Communications can be opaque or crystalline, uncertain or assured; they can encourage, advocate, reprimand, praise and affect behavior in hundreds of ways.
Communication, though, for its many purposes and essential role in clinical care, has only recently been scrutinized objectively, said Dr. Richard Goss, medical director at Harborview Medical Center.
“The entire system is predicated on an intention of clear communication. As medical students, we go to great lengths to learn how to write on a patient’s chart, primarily because someone else will have to read that note. But referring providers do not always get the follow-up that they would like,” he said, illustrating the task of ensuring consistent communication on a massive scale.
“Now we have better science about defining what constitutes good communication, and about the interventions that we think have helped to improve problems.”
Great expectations, systemized
UW Medicine has implemented TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety). It’s a framework for teamwork and unambiguous communication designed by the U.S. Agency for Healthcare Research and Quality, and it derives from other high-reliability industries such as airlines, in which vague information can have fatal consequences.
One of the program’s major tenets holds that “all staff, regardless of seniority, are empowered to ask questions, seek clarification and express concern,” Goss said. “The concept is that everyone on the team brings an important perspective.” (UW Medicine also is one of six U.S. organizations now qualified to train others in the framework.)
It is one thing to invite questions and concerns, and quite another to cultivate that inclination among staff who must overcome natural fears of reprisal and who are loath to jeopardize co-workers. After recognizing an error or near-miss, employees will do the right thing only if an atmosphere of trust exists.
Staff must believe that the greater good is served by calling attention to negatives, even those involving their own team. They must expect the support of managers up the line. They must have confidence that a response will be forthcoming, and be fair, not heavy-handed. Consistent, clear communication and action help to realize all these expectations.
Technology as an enabler
Technology plays a major role: All four safety leads pointed to online reporting mechanisms as pivotal to discovering ad-hoc mistakes and flawed processes that, in turn, spur improvements in care.
UW Medical Center (UWMC) uses a tool designed by the University HealthSystem Consortium, said medical director Dr. Tom Staiger.
“My understanding is that we have one of the highest levels of reports, on a per-bed basis. We see this as a good thing; many are near-misses and minor-harm events that we can learn from to prevent future harm,” Staiger said. “We encourage people to report, and in a way that won’t be punitive.”
When staff become convinced that learning, not punishing, is the intent, desired actions follow. At Valley Medical Center, disclosure of mistakes and concerns increased 187 percent in the first year with online reporting, Lobdell said.
“We felt like we had for the first time a much more reliable representation of events and their relative occurrence. People seemed more inclined to report near-misses electronically than they had with paper forms, and we put more emphasis on that, as well,” she said.
Valley’s online reporting application offers anonymity but, remarkably, very few people exercise that option, she added, reflecting a flourishing culture of trust. Valley also reinforces the value of reporting by celebrating “good catches” by individuals and chains of employees who help avert future errors by taking time to report near-misses.
Buy-in and accountability
A prescribed approach is required to address problems that emerge through reporting and the collection of data.
“If we fail even one measure, a thorough analysis happens to establish, No. 1, is this systemic or is it a fluke?” said Maureen Scherger, performance-improvement manager for Northwest Hospital & Medical Center.
She zeroed in on the meaningful aspects of changing a process or practice:
“Look at the system you want to affect and identify the easiest thing to change. What tactic will you get the most bang for the buck? It could be as simple as rewriting the form that everyone uses. Identify your advocate. Educate the physicians and nurses. Get the data in front of everybody as soon as possible. Don’t just show the data, talk about what action is going to prevent further failures.”
Clinicians’ advocacy is vital to advancing patient-safety initiatives. Campaigns that are actively championed by doctors and nurses tend to gain traction among support staff more readily than programs perceived as administrative decrees driven mainly by cost concerns, she said.
“We have dedicated working groups for each core (safety) measure, and physicians on board every working group. I try to always have a staff nurse involved in improvement plans,” said Scherger, a former ICU nurse and case manager.
Transparency and personal pride are forceful motivators, too, said Goss.
“Showing people their data is a major stimulus for improvement,” he said. “Units and departments’ results are portrayed side-by-side so that we can all see the top-performing practice. Healthcare workers are all very motivated to do the best they can for their patients and do not want to be underperformers.”
Milestones achieved, bars set higher
Performance improvement is the new world order, but safety leaders know they must take the long view. Most formal safety standards and measures have been in place only about 10 years, and meaningful changes in practice and attitude can take longer to become habitual among thousands of staffers. Along the same lines, when staff attain a milestone, recognition – again, communication – is crucial to sustaining energy when the bar is inevitably raised anew.
Each patient-safety chief proudly cited recent gains:
UWMC has lowered its major nosocomial infections rate by more than 50 percent since 2010, Staiger said, keeping patients from harm and saving the organization $2 million in costs associated with these complications.
From 2010 to this year, Northwest Hospital raised its compliance with a new postoperative urinary-catheter protocol from 52 percent – the baseline on a previously unmeasured rate – to 98 percent. “We changed the order sets right away, educated the nurses and ran daily reports that are used in rounds,” Scherger said. “We added an alert to our computer system for nurses. We went to the physicians, especially the group that seemed to have the most difficulty, and did a lot of education.”
Harborview has raised its competence on achieving all core measures – evidence-based clinical processes to improve outcomes – from 55 percent in 2006 to 96 percent in the first six months of 2012.
“Hitting an extremely high number on core measures is not only a major milestone in great care, but it’s also responsive to new federal financial incentives,” Goss said, citing Medicare’s formula to base its payments to hospital partly on their core-measures success.
Since Valley implemented online reporting in December 2009, its patient falls have declined by 49.7 percent, and falls with injury are down by 68 percent.
“Our partners in rehab and pharmacy have been equal champions with nursing. Everyone is bullish on data collection and case review,” Lobdell said. “Falls may happen at the bedside, but rehab looks at safety-mobility issues and pharmacy looks at medication that might have affected the patient’s balance or judgment.”
Much work to be done
These and other advances are compelling, but no stakeholder dared to rest on laurels.
Safety campaigns’ success can breed success but “we also keep raising our goals,” Staiger said, raising the specter of fatigue at the pursuit of perfection. As well, he said, some employees will always be less prone to call attention to mistakes for fear of being held accountable, and continual education is needed to shift those sensibilities.
Nurses’ jobs are so much more oriented to capturing data now than when Scherger was a nurse, she said. “I think there are still times when people feel like writing a report is one more thing that they don’t have time for in a busy shift. But the culture of safety is much bigger than it used to be, and here to stay.”
Progress toward performance goals requires tenacity, Lobdell acknowledged.
“It’s a journey. We have not arrived but managers speak routinely about safety and they have shown increasing accountability for creating that environment on their units – to expect safe performance from staff, and to sort out the difference between system errors and personal behaviors that are unsafe,” she said. “I see more openness to learning filtering down through the ranks.”
Goss summarized: “In the spirit of quality patient care, we’re never done. Harborview has a reputation for excellence, but if we’re not performing at a 95-100 percent success rate on a given protocol, we are not providing the best care to our patients.
“We learn from techniques that have been shown to work and continue to apply them to new problems that come up. I think the next big breakthrough in the healthcare industry will involve communication techniques more than technical aspects of processes and procedures. Communication techniques can be used in every setting.”