Quality and Patient Safety
Quality and Patient Safety at Winchester Hospital
UP Health System – Portage leaders discuss how board rounding drives accountability
By Sue Ellen Wagner
Leading Board Practices
Every board has a vital role in providing oversight of quality and patient safety for their hospital or health system. Preparing boards for this role is critical, and it is important that all board members are educated about quality and safety. This interview with Al Campbell, CEO and president; Karen McAlmon, M.D., medical director of the Special Care Nursery; and Karen Keaney, chief nursing officer and vice president of Patient Care Services, highlights leading practices from Winchester Hospital in Winchester, Mass.
Sue Ellen Wagner: Can you underscore the importance of the board’s role in oversight of quality and patient safety? Please also share the work Winchester Hospital is doing on quality and patient safety.
Al Campbell: This is a topic that we hold near and dear at Winchester. There are five key areas relating to the board of trustees and their role in quality and patient safety: The first is governance responsibility. Our board is accountable for the quality and safety of care and how that is delivered. Ensuring safe care is not just an operational goal for us — it is central to the board’s fiduciary and ethical responsibilities in carrying out the organization’s mission.
The second is setting the tone. This is something that must come from the top down. Our board’s engagement is a signal to all that quality and patient safety is a priority for us. Our trustees were proud to play a critical role in helping to shape the culture of safety. They [continue to] do this by asking the right questions, expecting transparency, and supporting our quality improvement efforts and initiatives. It is also important that we help them understand the trends, variations and benchmarks so they can make informed decisions.
The third area is alignment with our strategic goals. It is embedded in the organization’s strategic plan and is also a part of our quality plan. That is reviewed on an annual basis, and that alignment is then tied back to our financial, operational and workforce priorities equally. The board ensures that resources and leadership are in place to support the improvement work that we’re doing.
The fourth component is education and continuous learning for our board. They are educated on safety and quality metrics, regulatory requirements and key metrics that our organization monitors. We make sure the board receives the information and that they feel empowered to ask questions.
The fifth piece is collaboration with our clinical leadership teams. Our board has a strong relationship with those team members, ensuring we remain connected to our frontline workers. Five of our 15 board members sit on the Quality and Patient Safety Committee. That committee has folks from different backgrounds, including operational leadership, finance and clinical backgrounds. Having that kind of multidisciplinary support helps us provide safe, effective patient care.
Wagner: The five areas are a wonderful way to frame this. Dr. McAlmon, patient safety rounding is a way to educate board members about what is happening in the hospital. The process can also provide a way for trustees to ask questions and to highlight areas of concern. Can you describe your board rounding process and provide some examples of how it works? How is the feedback from board rounding shared with the full board?
Karen McAlmon: Our manager for Risk and Patient Safety schedules monthly safety rounds. Trustees are invited to join this manager, our president, the chief medical officer and the chief nursing officer to round on different units within the hospital. This includes patient areas, but also includes other sites such as food service, environmental services, radiology and security. Trustees can sign up in advance or even on the morning of the rounds. We gather with whomever is working that day, introduce ourselves and make it clear that this is a safe space, open to anything that the employees or physicians have on their mind. We ask, “What keeps you up at night when you think about work?” That is what we want to know, and those are the areas that we want to be able to address. During these rounds, each person’s care and deep commitment to quality in whatever their job might entail is really evident. These staff have deep pride in their work and they always seek ways to improve.
Even as a physician who is based at the hospital, I have learned so many new things about the hospital and how it functions [during board rounding]. One of the highlights from a round I attended was when I learned just how high-functioning the pharmacy really is. They have protocols for communication between pharmacists and ordering providers to ensure the appropriate medication is given to each patient. Very importantly, per the pharmacists, providers receive these discussions because they ensure safe care for the patient.
In addition, I learned about the automation in the pharmacy that allows for efficiency and accuracy in delivery of medications.
Other rounding feedback included ensuring appropriate access to patient units, confirming doors are properly secured and installing safety buttons. The safety of employees, patients and physicians is truly important.
In another round, we learned that OR staff were concerned about scrubs. We heard that scrubs were oftentimes too long, leading to a trip or fall hazard, or that they sometimes were very rough, leading to skin irritation. This report by staff led to a change in the vendor, helping address these issues and preventing some of the potential risks.
At each board meeting, there is an agenda item for our CNO to report about safety rounds. This allows the trustees to hear the feedback, to be provided updates, and to let us know where the hotspots are — both in areas for improvement and in areas where we can show pride in what we get right.
Wagner: These are great examples. Karen, can you describe in detail the dashboards that you use to inform board members about quality and patient safety metrics? Please also discuss the importance of having a clinician on the board.
Karen Keaney: The two primary dashboards presented to the board are the patient harm dashboard and the employee harm dashboard. As Dr. McAlmon indicated, the board is interested in all aspects of quality and patient safety. The patient harm dashboard presents metrics such as patient falls with serious injury, pressure injuries and hospital-associated infections. These are measures we monitor closely on a routine basis at Winchester Hospital. We review these measures and conduct root cause analyses to determine if there are any themes or trends and to identify opportunities for improvement. The board is very interested in patient harm prevention. These three measures are “nurse-sensitive” indicators, meaning that there is typically a direct correlation between nursing standards, care and outcomes. On the employee harm dashboard, we focus on serious harm, such as sharps injuries, bloodborne pathogen exposures, material handling injuries and employees who are injured by patients. This last component has become of greater interest to the board over the years due to concerns over workplace violence in health care organizations. The board places great importance on ensuring that we have interventions to mitigate risk to all. One of our improvement initiatives that came from safety rounds attended by board members was mentioned by Dr. McAlmon: We added doors to create a locked overnight unit, providing our employees with the ability to control who enters the unit.
The board is also interested in our throughput measures. Concerns for Emergency Department (ED) boarding has grown in the past years, not just here in Massachusetts, but throughout the country. At Winchester, with our board and CEO’s support, we have many helpful initiatives, safely trimming the time it takes for us to move patients from one area to another. Even when we are surging during busy months, we have been able to effectively manage our patients and minimize the amount of ED boarding. Our board also regularly hears about patient experience and satisfaction scores.
We are a five-time Magnet-designated organization. As a result, we have formed what we call a professional governance model. We used to call it shared decision-making, but we refer to it now as a professional governance model. We look to elevate the voice of nursing throughout the organization. Receiving their feedback informs [hospital leaders’] decision-making. Part of that is due to the nursing presence on the board. It gives us an opportunity to carry the voice of our nurses to the highest decision-making group within the organization. Our overall approach at Winchester is evidence-based practice, which is another reason it’s important to have clinicians on the board.
Wagner: Workplace violence prevention is something the AHA is deeply invested in. We support the Save Healthcare Workers Act that is currently before Congress. Al, would you like to add anything else?
Campbell: Our board and leadership share a mutual understanding that patient safety is foundational to the hospital’s mission. It comes all the way back to the mission and how we provide care to our patients. Our board’s commitment to patient safety extends beyond just the metrics. They are truly champions of our patient experience, advocates for our frontline caregivers and stewards of the community. They hear from our community members, allowing Winchester to become champions for them. We see that by way of our patient Family Advisory Council, which is led by Karen. We have a number of members on that council and our advisory board that have a deep interest in quality and patient safety and how that ties back to our reputation and standing in the community. The trust of the community along with the trust that the board has in us as leaders and clinicians helps enhance the work we do here at Winchester Hospital.
Sue Ellen Wagner (swagner@aha.org) is vice president, trustee engagement and strategy, 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.