Patient Safety
From Board to Bedside: Experiencing Patient Safety Culture Firsthand
UP Health System – Portage leaders discuss how board rounding drives accountability
By Amy Disharoon
Interview
Orienting the board of trustees on quality and patient safety is an essential aspect of the Culture of Safety: From Board to Bedside foundational area of the American Hospital Association’s Patient Safety Initiative (PSI). In an interview with Amy Disharoon, performance improvement coach with the AHA, UP Health System - Portage leaders share their process for implementing board rounding as a board orientation tool, providing trustees with an up close and personal opportunity to engage with the frontline and better understand the organizational patient safety culture.
UP Health System – Portage has been serving Michigan’s Western Upper Peninsula since 1896. It supports a multi-specialty medical community with over 40 physicians and more than a dozen allied health professionals. The main campus features a 36-bed hospital, accredited as a chest pain center by the Society of Cardiovascular Patient Care (SCPC). UP Health System – Portage was the first in the state to achieve Level III ACC (American College of Cardiology) verification as a trauma center.
Ryan Heinonen, MBA, MSN, RN, CPPS, is the chief executive officer at UP Health System – Portage and has been with the organization for 15 years. A nurse by training, he has worked in a variety of leadership roles and has served as the CEO for the last three years.
Casey Baird, MBA, BSN, RN, CPPS, is the chief nursing officer at UP Health System - Portage and has been at the organization for 9 years. Prior to this role, she served as the director of quality and infection prevention.
John Lehman, Ph.D., is a trustee and has been on the board at UP Health System – Portage for six years. He serves as a vice president at a local research university.
Amy Disharoon: There has been a lot of interest from the AHA membership to learn more about board rounding, including how to implement board rounding as a strategy to better understand patient safety culture and quality improvement initiatives at the frontline. How did this practice begin at UP Health System - Portage, and what makes this activity so important for the organization?
Ryan Heinonen: I think you really have to go back many years. Portage Hospital has always been known for being a very high-quality organization. Patients come first, and we really focus on continuous improvement. We are always asking, “how do we provide the best care at the bedside?” We’ve had a strong culture of safety and great retention of employees, and we have maintained this culture for many years.
Through culture of safety surveys, we consistently heard that communication could be better. About 10 years ago, we were able to put a few different processes in place that continue today and have really helped to drive the organization forward from a culture of safety standpoint. We implemented the daily shift brief and debrief — staff are coming together at the beginning of the shift and talking about what the plan is for the day and then at the end of the day they’re debriefing about what went well, what were opportunities to do things differently, and how can we do better? That’s really been hardwired across the organization, especially in our clinical departments, and has driven consistent communication. We also implemented huddles, so if staffing or patient challenges come up, we get a group together and have a conversation to make sure everybody’s on the same page moving forward. We also wanted to make it visual, so we implemented learning boards in our departments. If there is an issue that surfaces during a brief, huddle or debrief, staff can put up an opportunity for improvement on the learning board for other staff to see.
We’ve seen a lot of success with all of these strategies, but I think the piece that was missing was, how do we get the frontline staff further exposure to our executive team? We implemented structured rounding called executive patient safety rounds. This is where members of the executive team including myself, the chief nursing officer, the chief financial officer, and some of our higher level directors go around and meet with all of our departments to talk through what opportunities exist to do things better. As an organization, are there safety concerns, equipment opportunities, or process improvements we can be making? We did those for a few years and as that process matured, we thought about bringing in physicians and our board members. The board was really the best opportunity to include in that process because we had community board members and we had physicians from our medical staff on the board. The board really embraced it, because they’re all about quality, and want to make sure we’re doing the best thing for our employees, which in turn will have great impact for our patients.
The opportunity to include board members in rounding has really given high visibility to our frontline staff as well as our board members, both in the community capacity and in the physician capacity. This has been really valuable because the board member can bring back concerns from rounding to the board meeting.
It’s an education piece, not only for our board members so that they have a further understanding of what’s happening at the frontline — they are also involved in that change by communicating to the board and providing that feedback to the community and to the staff members. Executive patient safety rounds is a regular board meeting agenda item, and we have a feedback loop at the next board meeting to discuss, “what was the action that took place?” so that we’re closing that loop. The staff is also getting to see that.
Disharoon: I’d love to hear more about what this process looks like in your organization. Who is involved, how often does this take place, where do board members visit, and how do they report back what they’ve learned to the larger board?
Heinonen: To start the year, we compile a list of places that we want our board members to visit. We then ask the board members to sign up for one or two times. They average about two visits per year on two separate occasions.
The board member rounds with a member of the executive team and we provide them with a template which lists questions they can utilize or they can develop their own questions. The rounding is usually anywhere from 15 minutes up to an hour if the staff have a lot of items for discussion. The staff know that they are coming, and it’s a really nice conversation that provides a lot of great feedback.
Disharoon: Board rounding is an opportunity to better understand the patient safety culture and quality improvement initiatives at the frontline. Casey, can you share more about how board members prepare for this experience, including what they should be looking for and what questions they should be asking?
Casey Baird: We’ve started a newer process of orientation for new board members where they meet with the quality director and talk through executive patient safety rounds and what those look like. As Ryan mentioned, there’s always a member of the executive team that accompanies them on the rounds to provide assistance with any issues that arise.
We support the board by providing a script with certain questions that they can use as a guide, but we do really leave it open to the board member to let them run the conversation and ask the questions that they want to ask.
The script includes a high focus on patient harm and where the next harm might come from, if the staff have everything they need to keep patients safe, and the culture of safety.
We also share the results from the annual safety culture survey with the board, so the board members are aware of all of that when they round. The action plans are also posted on the learning boards that Ryan discussed. As part of our tools for best practice, the board member reviews the learning board as well, because that’s a really good visual of process improvement — what’s going well in the department, and what’s not going well. I love all of our board members because they keep us very accountable and have a very high focus on quality.
Disharoon: How have you seen frontline staff prepare for a board visit, and what do they take away from this experience?
Baird: Since we do the executive patient safety rounds on a routine basis, the staff are very familiar with us coming around and asking these questions. The staff do know when these executive patient safety rounds are going to happen, including when they’re occurring with a board member, so they are prepared sometimes, depending on which department they choose to go to. It can be a little bit difficult depending on how many staff are available to have the discussion, but we don’t really see anybody ever hiding away from these rounds. Everybody is very willing to come forward and discuss things with the board member. We have a very high level of psychological safety within our facility, so everybody feels very comfortable speaking up and sharing their thoughts.
The board members always come up with some type of twist, especially those board members who have been here for a while. They’ll come up with questions that I wouldn’t have even thought of, so it’s always a really good conversation.
One recent example is that we had a board member round in our medical surgical department, and there was some angst regarding a recent change to the vendors for our toothbrushes and tissue boxes. Frontline staff expressed that this change is less than ideal for our patients, so the board member took this information back to the board meeting and expressed the concern that was brought forward. We were able to bring that concern to our value analysis team, move forward with an evaluation of the quality of these products, and consider options for purchasing something different.
Disharoon: John, as a current board member at UP Health System, you have a unique perspective on the process of board rounding. I’d love to hear — what has your experience been like? What did you take back to the boardroom, and how has this impacted your leadership as a board member?
John Lehman: It’s been a learning process for me, and I suppose for most of the board members as well. The first couple of times I did this I was still trying to understand the mechanics and the culture of the organization.
Casey, in her previous role as director of quality, is well known for giving very thorough board reports about quality and that really helped us as a board understand the dynamics and the topics that we might be hearing as we engage.
The first couple of times I rounded it was more of a learning process for me. I quite honestly don’t know how much value I provided the organization at that point. As I became more familiar and comfortable with the jargon and the goals of the organization, I found that the rounding provided an opportunity to really triangulate the culture and the problems that were talked about in the boardroom with the experiences of the staff. Solving issues that leadership have at the organization with solutions presented within the various units helps the organization perform at a higher level.
I’m really good at asking really dumb questions. I think that as board members, it’s really important for us to have the temerity to be willing to ask dumb questions and doing that in those environments uncovers hidden assumptions. I think that it also helps clarify complex topics, models curiosity, learning, accountability, and maybe prevents groupthink. By talking with the staff and directly observing care dynamics, it helps us as board members gain firsthand experience about what we’re talking about in the boardroom and it becomes less abstract and more real.
And hearing staff perspectives — more often than not, I’m hearing the same issues from staff that we hear in the boardroom, but now it’s in that first person with tangible stories. It also helps to identify gaps between policy and practice. Occasionally those gaps come up and it reinforces how well leadership has built a trusting relationship with their staff, which gives a board member higher confidence in the suggestions and solutions leadership brings to us.
One example I can share is that I had the opportunity to round at one of our offsite physical therapy facilities. I blew an ACL the year prior to that so it actually gave me a holistic view. I was both a patient in their care and then got to see the back end of that, which was a very meaningful opportunity for me as a board member. To see the complete picture and experience both sides of that life cycle was well worth my time.
The critical piece about this that shouldn’t be undersold is how leadership mandates accountability into this process by including rounding follow-up as an agenda item for each meeting. As a board member, it feels good that our thoughts aren’t just being written down and shelved, but they’re acted on and there’s follow-up. This instills a great deal of confidence from the board in leadership and into the value of time spent rounding with the frontline.
Amy Disharoon, MPH (adisharoon@aha.org) is performance improvement coach at the American Hospital Association.
Please note that the views of interviewees do not always reflect the views of the AHA. This interview has been edited and condensed for clarity.