A safety culture can have more than one life
Reinvigorating your safety initiative
They made every list, accolades coming left and right. A safety culture had been born and bred and things were looking good for Memorial University Medical Center in Savannah, GA. No sentinel events for 17 months. Reporting data at a high. It was like they were on autopilot. And then things changed.
Financial problems led to high turnover among staff and senior leadership, says Sherry Sweek, RHIA, CPHQ, CPMSM, quality management director.
The safety culture that had been cultivated by the quality department looked as though it had fallen hard. The wake up call didn't go unheard. When three sentinel events occurred consecutively in just one month, quality knew it had to do something, Sweek says.
And they learned in that time that building a safety culture is a journey and like the popular saying the important thing is not the destination itself but the journey.
The beginning of the story
Memorial Health began building its safety culture in 2002 and "was one of the first in the country to go down this road of patient safety," says Sweek. The hospital, working with a consultant group, revamped its medical staff committee structures and formed an oversight committee comprising half physicians, half administrators that addressed medical staff peer review, quality-of-care issues, and patient safety issues.
Error prevention training was made mandatory for all staff and physicians. The root cause analysis process was revamped, and staff had on-site training with experts. A big push to increase reporting was made, and incentives were based on achieving increased reporting.
One of the problems the quality team saw, says Martha White, RN, MBA, patient safety officer, was that people feared punitive action for reporting and they never saw any changes result from their reporting. What changed the culture on reporting, White says, was making the process transparent, sharing data with staff, and sharing changes made and results seen.
"We had done all of those things, had really good results from it. We didn't have a sentinel event for several months. Everything was good, and because we early adopters into it, there was never any planning for what happens next. A lot of things went on autopilot," Sweek says.
The thinking became: "Oh, we did well on that. OK, what are we onto next?" The hospital expanded into pay for performance measures, began using the American College of Surgeon's database, and added staff positions for Six Sigma and Lean initiatives.
The fall
And then the hospital began dealing with hard financial problems. "And basically everything stopped. The only thing that anybody talked about for a good year and a half was finance. Everything. Whether it was a team leader meeting, e-mails, newsletters, a board meeting — everything was finance. There was never any time for quality or safety," Sweek says.
Staff were jumping ship, senior leaders that knew the history and the culture the hospital were leaving.
"The wake-up call was when we had three sentinel events in one month and we had a couple other ones within a month of that. So in a five-month time frame, we had five sentinel events and we knew we had to refocus on safety and do something. That's where this revamp and our recommitment to safety really started," she says.
The Phoenix rises
Last year, the quality department refocused. They built a comprehensive plan and presented the plan to the board. "We were very specific on addressing lots of things and putting lots of actions into play and getting the accountability at all levels," Sweek says.
One thing they implemented was safety huddles for individual units. Since most units at the hospital are staffed on 12-hour shifts, huddles are usually done at 9 am and 9 pm. Staff are called including the patient care techs, secretaries, and all nursing staff. The huddle lasts only a couple of minutes. The conversation, White says, might be "OK, I've got a fall risk. Mr. Jones in Room 453 is a fall risk." That, she says, removed the notion of Mr. Jones is nurse Jane's patient and not nurse Joe's responsibility. "It made it 'our' patient," she says.
With the huddles, and tracking falls with injuries over the year, she says the hospital had a 51% reduction in falls with injuries.
In the safety huddles, they also discuss name alerts — that there are two Jacksons on the floor, for example. The team is alerted if there is a pool nurse or floating nurse or an orientee on the floor, who may not be as familiar with the patients. "We're a teaching hospital, so when we have the new residents coming in July, that's a safety huddle concern because we want to make sure we're checking their orders and that treatments and order sets and the medications are appropriate for the patient," White says.
Huddles address low-volume, high-risk things. White says questions might include: "Who do we have who's a fall risk? Are we doing a procedure that is not familiar to us? Do you have multiple names? Do you have someone who might elope in the behavioral unit? Do you have someone who has some kind of family issues or maybe they're not supposed to have a visitor? Maybe we have a gunshot victim who's under an alias."
Memorial also instituted safety rounding. "The first time we went through this safety journey, we really didn't have the senior leadership involved in doing safety rounds. And support and endorsement, we found, are really two different things," White says.
Everyone in the quality department is assigned certain areas to oversee "so they're consistent when they do rounds. When we have a standdown, they go to those areas and facilitate things," White says.
Safety rounding includes clinical and nonclinical senior leaders. So the chief medical officer, for example, and the CFO would go onto the floor with a quality representative and round and visit designated areas to talk about patient safety issues.
Sometimes the quality department assigns senior leaders, who are always paired with clinical leaders, in areas outside of their comfort zones "so they have a fresh set of eyes in other places," she says. Most senior leaders are required to do, on average, about two rounds a month.
Data from the rounds were collected. Then the quality team assessed the risk, asking: "Is this a department issue? Is this systemic?" Issues were sorted by quantity and the team used "a scoring methodology to determine if it was systemwide, if there was a risk of a bad outcome, if it was within our scope to correct," Sweek says.
From that, senior leadership created a top 10 list of high-priority safety concerns. Those are put on the intranet and senior leaders are designated as responsible for specific ones. If an item appeared such as IT systems didn't communicate and weren't working together, the vice president of IS would be tasked with improving that.
White emphasizes the list is not static. When issues are resolved, other issues are put on the list. And the issues, Sweek points out, aren't issues that can be fixed immediately.
Communication about the data tracked, the results, and the solutions back to staff is something the quality department emphasizes now in getting everyone on board. They also use results from the Agency for Healthcare Research and Quality culture index to identify problems that need to be addressed.
Lessons learned
Hospital Peer Review asked White and Sweek what they learned from their quality and safety journey. "I would say that I think the most important thing, especially when you're trying to reengage people who have been there and done that and now we're on round two, is to actually listen to what they're saying and give them the right feedback," White says.
"Part of the issue is, people feel like they want to be heard and they feel sometimes like they're not being heard because they don't see any action steps. So I think our biggest thing was closing the feedback loop to make sure the information got out again to the people. When people see that you're trying to do something about what they're reporting to you, they're much more likely to share their concerns with you. Then you start getting deeper and deeper — under the wallpaper on the wall to see untold issues because you were trustworthy in the little things."
Sweek echoes White's sentiments. "I would say the most important thing that I would tell people about patient safety is it's never off the list. You always have to be working it. It can never go on autopilot. What you do three months from now can't be the same thing that you're doing this month. What you did last year is not going to work for next year. You have to constantly be working it.
"And I think that's a struggle in health care, because we have so many different priorities and staying focused on patient safety is really difficult if it's not a problem. If it's a huge problem, then everything stops to address it but when things are going good it's hard to get people engaged in taking action. You've got to constantly be doing different things."
They made every list, accolades coming left and right. A safety culture had been born and bred and things were looking good for Memorial University Medical Center in Savannah, GA.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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