Eliminating Patient Harm
SNAPSHOT
Hospitals that strive for high reliability aim to drive out the possibility of error and reject incremental improvements.
In 2006, Cincinnati Children’s Hospital Medical Center became the first pediatric hospital to receive the American Hospital Association–McKesson Quest for Quality Prize. Its board of trustees took the honor to be a challenge.
“We could have patted ourselves on the back and said, ‘Aren’t we wonderful?’ ” says Lee Carter, who served as board chairman at the time. “Instead, we realized that we were being recognized as a high-quality hospital but, at the same time, we were harming 18 children a year through events that we should not have done, such as operating on the wrong side or leaving a sponge in a patient.”
The board set the objective of zero serious safety events — and Cincinnati Children’s started on a journey toward high reliability.
Moments like these that serve as a wake-up call to the board can’t come soon enough. The board is accountable for the quality and safety of the care delivered in its hospital and a look at the stats each month is not enough to drive meaningful improvement from the C-suite to the front lines. In addition to Cincinnati Children’s, Trustee spoke with board members and senior executives from the University of Vermont Medical Center and MedStar Health to learn more about high reliability and how the board’s commitment to it creates a culture of safety.
High Reliability Defined
The term high reliability has entered the provider vocabulary as health systems seek to address this paradox: Even though most health systems have been trying to improve patient safety since the Institute of Medicine’s 1999 “To Err Is Human” report revealed the high incidence of preventable health care errors, they haven’t been able to completely eradicate patient harm.
Joint Commission President and CEO Mark Chassin, M.D., and Executive Vice President of Healthcare Quality and Evalution Jerod M. Loeb analyzed the situation in a 2011 Health Affairs article: “What has eluded us thus far ... is maintaining consistently high levels of safety and quality over time and across all health care services and settings. The pockets of excellence … coexist with enormously variable performance across the delivery system.”
Looking outside the field for solutions, health care leaders found inspiration and guidance from other high-risk industries such as aviation and nuclear power, where safety rec-ords are much more laudable. Pioneering health systems are adopting the principles of high-reliability science, which seek to eliminate errors by standardizing processes to remove the variability in outcomes.
Making progress toward this goal requires that health care organizations make three major changes, according to “High-Reliability Health Care: Getting There from Here,” Chassin and Loeb’s 2013 Milbank Quarterly article: the commitment of leadership (defined as the board, senior management and physician and nurse leaders) to the goal of zero patient harm; the incorporation of all principles and practices of a safety culture throughout the organization; and the widespread adoption and deployment of the most effective process improvement tools and methods.
While “high-reliability organization” has a comforting sound, health care leaders at the forefront of the high-reliability movement avoid using the term. At the University of Vermont Medical Center, moving to high reliability is one of the organization’s top strategic aims. The big-picture goal is to look at every process — clinical, business and operational — to drive out the possibility of failure or error, but it will never claim to be a high-reliability organization.
“It really is a proactive approach to go from high quality to high reliability, knowing that in health care, it’s very unlikely that you would ever fully achieve the status of high reliability,” says John Brumsted, M.D., president and CEO of the University of Vermont Health Network and CEO of the University of Vermont Medical Center, Burlington. “We don’t think there is a definition for a high-reliability organization in health care, but we think that there is a definition of a highly reliable process, where you have proven that you can drive errors to an absolute minimum, but not zero.”
Similarly, David Mayer, M.D., corporate vice president of quality and safety at MedStar Health, a 10-hospital system serving Maryland and the Washington, D.C., area, makes no claim of becoming a high-reliability organization.
“Because you never achieve high reliability, a lot of people in the error science world like to say we are seeking high reliability,” Mayer says. “We are on this high-reliability-seeking journey.”
True Top-to-Bottom Training
Mark T. Jensen was serving on the board of one of MedStar’s hospitals when he attended the Institute for Healthcare Improvement conference at which the 100,000 Lives Campaign was announced. Listening to a presentation about the high rate of mortality linked to ventilator-associated pneumonia — and the feasibility of reducing that rate to zero — he turned to the hospital’s vice president of medical affairs.
“I said, ‘Hey, do you think we could do that?’ ” says Jensen, founder of the Baltimore law firm Bowie & Jensen LLC. “He said, ‘Sure. We don’t have to hire anybody. We don’t have to buy any equipment. We just have to do things that we’re already doing — but we have to do them consistently every time.’ ”
Today, Jensen serves on the MedStar Health board of directors at the system level and chairs its quality, safety and professional affairs committee. MedStar began its high-reliability journey nearly three years ago and has seen a nearly 50 percent reduction in its serious safety event rate during that time, Mayer says.
The journey began with training 2,400 MedStar leaders, including board members, about the “leadership absolutes” of high reliability [see High Reliability in Practice, Page 10].
“We sat at tables with nurses, with people from accounting, and with doctors,” Jensen says. “The feedback we’ve gotten from Dave Mayer and other senior management is that it sends a message from top to bottom that people at MedStar are serious about this.”
In addition, another 24,000 MedStar employees have been trained in high-reliability protocols, such as reporting any irregularity that could lead to a safety lapse.
“In the last 18 months, we have more than 55,000 occurrence reports across our system about workarounds or a piece of equipment not in the right place when it was needed,” Mayer says. “Those are all workflow inefficiencies that can truly lead to a safety issue.”
He knows the staff will continue to drive down the rate of patient harm, but he also knows that the organization’s progress eventually will plateau. That is why MedStar has created the National Center for Human Factors in Healthcare.
Mayer’s own medical specialty — anesthesiology — has many examples in which machines have been redesigned so that humans could not accidentally make anesthesia administration mistakes.
“We need more of that,” he says. “That’s why MedStar has a team of 16 human factors engineers who look at things from a process and engineering standpoint. We say, ‘If somebody made that mistake today, some other nurse, physician or pharmacist will make that same mistake eight months from now unless we redesign our systems to prevent that mistake from happening again.’ ”
No More Incremental Gains
During his years as an obstetrician at the University of Vermont Medical Center and eight years of service on its board of trustees, Philip B. Mead, M.D., has watched the organization work through quality-assurance, quality-improvement and total quality-management initiatives. He considers UVMC’s high-reliability journey to be the logical next step.
“That basically says you’re not going to be satisfied with incremental improvement in your patient safety scores, but you are really working toward zero preventable harm,” says Mead, who now serves on the board of UVMC’s parent, University of Vermont Health Network.
Anna Noonan, R.N., vice president of UVMC’s Jeffords Institute for Quality & Operational Effectiveness, says zero harm is not realistic, but pursuing the goal of zero is essential. She has been a leader in UVMC’s efforts, which were honored with the 2014 Partnership in Prevention Award for achieving sustainable improvements toward eliminating health care-associated infections. The award is given by Health & Human Services, the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America.
Since 2008, Noonan and her staff have recruited multidisciplinary teams to focus on infection prevention and control initiatives with great success. By 2013, the medical center had achieved a 77 percent reduction in central line-associated bloodstream infections in its medical intensive care unit. For the year ending July 2014, the unit experienced 0.33 infections per 1,000 central line days, down from a baseline rate of 2.72 infections per 1,000 central line days in 2009 and 2010.
Meanwhile, UVMC has not had a surgical-site infection among its nearly 2,000 patients who had total knee replacement surgery since November 2010. The surgical-site infection rate for patients with total knee and hip replacements fell by more than 80 percent between 2009 and 2014, while the rate for orthopedic spinal fusion patients dropped by more than 60 percent.
In the neonatal ICU, a 36-month period without a central line-associated bloodstream infection was broken when two patients were infected in 2014. The unit’s infection-prevention team was mobilized to analyze what went wrong and how future infections could be prevented.
UVMC’s perspective is that safety lapses reflect system failure. Even if an individual makes a mistake, the system should have processes in place to prevent a single mistake from causing patient harm. That perspective creates a blame-free environment that treats each failure as a learning opportunity for the entire system.
“We believe in treating a defect as a treasure,” Noonan says. “When something fails or doesn’t go optimally, we bring expertise to analyze the event and look at how we can adjust the system so that we correct this potential for failure from happening again.”
The Trustees’ Role
“Let’s start with the fact that the board ultimately owns quality and safety,” says Cincinnati Children’s Carter, who has served on the board since 1980. “If you start with that fact, then we have to do whatever is required to get there.”
In his view, trustees must first take responsibility for transparency within the organization.
“I think many boards of trustees may not have asked the question: ‘What is our safety rate?’ ” he says. “And once you find out, as we found out at Children’s that we weren’t doing as well as we thought we were, we then said, ‘How do we improve?’ ”
He adds, “We need to be constantly saying, ‘How do we improve? How do we get where we want to go?’ ”
Lola Butcher is a contributing writer to Trustee.
High Reliability in Practice
When it started its high-reliability journey, MedStar Health established a few “leadership absolutes,” or behaviors that spread a culture of safety throughout the organization. For example, leaders throughout MedStar start every staff meeting or management meeting with a safety moment, which is a brief story that reflects MedStar’s mission around safety. Leaders are trained to share positive examples in which a staff member prevented a potential safety problem, interspersed with reports on safety lapses that did or could have caused patient harm.
“That grounds us because we remember we’re not selling shoes, we are taking care of patients,” says David Mayer, M.D., corporate vice president of quality and safety for the system. “And whether you’re in marketing, finance, environmental services or a nurse at the bedside, our goal is to provide the safest, highest-quality care possible.”
Leaders are also trained to use safety huddles as a learning and prevention opportunity. At 9 a.m. each day, directors from each unit of each hospital gather for a 15-minute huddle, in which each person reports any safety issues that emerged in the past 12 hours and any safety-related concerns for the 12 hours ahead. Then the directors go back to their individual units for safety huddles, sharing information from the organizational meeting and heading off potential problems.
High-reliability practices used by MedStar staff include:
• Validate and verify. Staff members are trained to not ignore the nagging sense that something just isn’t right. For example, rather than proceed with a medication order that doesn’t quite make sense, staff are encouraged to double-check with a leader without worry of being a nuisance.
• “I have a concern.” Staff are trained to speak up rather than be deferential to higher-ranking colleagues, even a surgeon who is performing a procedure. “If another associate or leader hears that phrase, we are to stop and have a conversation and make sure we’re dealing with that concern,” Mayer says.
• Celebrate the people who speak up. MedStar’s “Good Catch” awards program recognizes staff members who identify a problem before a patient is harmed. — L.B.
Where Safety, Transparency Intersect
The National Patient Safety Foundation’s Lucian Leape Institute recently issued wide-ranging recommendations to bring greater transparency to health care, making the case that transparency will lead to improved outcomes, fewer medical errors, more satisfied patients and lower costs of care. The following recommendations highlight opportunities for trustees.
Actions for all stakeholders:
• Ensure disclosure of all financial and nonfinancial conflicts of interest.
• Provide patients with reliable information in a form that is useful to them.
• Present data from the perspective and needs of patients and families.
• Create organizational cultures that support transparency at all levels.
• Share lessons learned and adopt best practices from peer organizations.
• Expect all parties to have core competencies regarding accurate communication with patients, families, other clinicians and organizations, and the public.
Actions for leaders and boards of health organizations:
• Prioritize transparency, safety, and continuous learning and improvement.
• Frequently and actively review comprehensive safety performance data.
• Be transparent about the membership of the board.
• Link hiring, firing, promotion and compensation of leaders to results in cultural transformation and transparency.
Actions for CEOs and other leaders to improve transparency among clinicians:
• Create a safe, supportive culture for caregivers to be transparent and accountable to each other.
• Create multidisciplinary processes and forums for reporting, analyzing, sharing and using safety data for improvement.
• Create processes to address threats to accountability: disruptive behavior, substandard performance, violation of safe practices and inadequate oversight of a colleague’s performance.
Actions for CEOs, other leaders and boards to improve transparency among organizations:
• Establish mechanisms to adopt best safety practices from other organizations.
• Participate in collaboratives with other organizations to accelerate improvement.
Actions for health system leaders and clinicians to improve transparency to the public:
• Make it a high priority to voluntarily report performance to reliable, transparent entities that make the data usable by their patients (e.g., state and regional collaboratives, national initiatives and websites).
Making the Safety Culture Stick
“A culture of safety that fully supports high reliability has three central attributes: trust, report and improve,” wrote Joint Commission President and CEO Mark Chassin, M.D., and Executive Vice President of Healthcare Quality and Evaluation Jerod M. Loeb in “High-Reliability Health Care: Getting There from Here,” a 2013 article in the Milbank Quarterly. In this context, trust is foundational. An organization establishes trust by eliminating the intimidation that keeps staff from reporting errors or concerns, fixing problems quickly and communicating improvements to the individuals who reported the issue. But to maintain trust, high-reliability organizations “establish clear, equitable and transparent processes for recognizing and separating the small, blameless errors … from unsafe or reckless actions that are blameworthy,” and hold all staff — regardless of seniority or role — accountable for adhering to safe practices, and take disciplinary action when necessary.
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Boards can learn from hospitals that are closer to eliminating harm in "Lessons from the High-Reliabity Journey".