Hitting the high (reliability) notes
April 1, 2013 4 minutes read
Hitting the high (reliability) notes
Eisenberg winner goes for all or nothing
For the last 10 years, Memorial Hermann Hospital in Houston has been on a journey to make the only two scores that matter 100 and zero. They want 100% compliance on positive metrics and zero on things related to patient harm. They have aimed to become a high-reliability organization with the kind of safety profile usually related to nuclear power and airline operation.
The success of that journey won the hospital an Eisenberg Award from the National Quality Forum and The Joint Commission last month.
There was a blip in 2006, when a series of mismatched transfusions plagued the system’s hospitals. Around that time, M. Michael Shabot, MD, was named system chief medical officer. He arrived just in time for a huge culture change signaled by high-reliability safety training for every single one of the systems’ 20,000+ employees.
“The usual quality and safety initiatives weren’t sufficient and weren’t going to be,” he says. “So we had a revolution.”
Training for simple behaviors
The training was done by pilots from commercial and naval aviation, engineers from the nuclear industry, and other experts. It was done off site and no one was excluded. Even physicians are required to undergo a specialized form of the training at three of the campuses if they want membership in the medical staff. Interns, residents, and all medical school students are required to undergo it. Other campuses make it voluntary for their physicians, but the whole system will phase in, making it mandatory over time.
“We train for simple behaviors using the STAR system: stop, think, act, review,” he says. Taking a one-second pause, even in an emergency, can make a huge difference. Indeed, they celebrate the hundreds of instances when that one-second stop has kept harm from a patient. One that they like to cite involves a neonatal nurse. She received an order through the computerized physician order entry system. The pharmacy checked it and dispensed it into the Pyxis unit. It was properly removed by the nurse. The drug has adult and neonatal concentrations, and while the proper prescription was made, and the drug was labeled as a neonatal dose, the nurse still took her one-second stop. She looked at the vial and noted that the neonatal package contained the adult strength drug. Her one-second stop certainly prevented harm to the baby, and possibly averted a tragic death.
“We love, we honor, we cherish near misses and the stories behind them,” says Shabot. “And we teach employees to speak up. We call them the CUSS words.” C stands for “I am concerned.” U is “I am uncomfortable doing this, doctor.” The first S is to stand up and the second is to stand together.
The words they teach employees are used only in those contexts and are so unusual that they make people stand up and take note. In 2007, the system introduced new central line bundles. One physician in a hurry wanted to proceed without using the bundle. But the nurse said those words: “I am concerned” and refused to proceed. The physician was in a huff and demanded they go on. The nurse manager came in and said no. And then, eventually, the chief nursing officer came in and, standing together with the front-line staff, refused to continue unless the bundle was used. “That only happened once. Every single doc heard that story.”
Another instance involved a sponge that a nurse was sure was still in the patient. A huffy surgeon insisted he never left sponges in patients, that the nurse must have miscounted, and he wanted to close the patient. Two nurses, both barely five feet tall, stood up to the surgeon and removed the instruments so that the patient couldn’t be closed. They insisted on an X-ray, which discovered the sponge, still in the patient.
Spreading the word
The grapevine is one way to get the word out, but they also use internal messaging and newsletters to spread the word about events like that. The nurse who saved the baby? She went to Washington, DC, to help accept a safety award the system received. She was brought to a board meeting. She was celebrated.
Since the start of 2007, with more than 763,000 blood transfusions, there hasn’t been a single mismatch. “We don’t intend to ever have one again, either,” says Shabot. There are still close calls, though, and the board has authorized a new barcoding procedure that will require patients to have separate wrist bands for blood products, with all type and cross happening at the bedside rather than the nurse’s station. “It will augment a system that is already working, but where we still catch potential errors.”
Shabot says any organization can change its goals so that they are zero for harm and 100% for the good stuff. “If you have a goal short of that, you are only going to achieve incremental improvement.” To get to zero (or 100), you need to do things very differently, and having a goal of “better than 90%” won’t encourage you to take the leap or consider drastic changes.
Memorial Hermann doesn’t always achieve zero or 100, but it’s always the goal. “Our most commonly reported number for every safety indicator, hospital-acquired infection and hospital-acquired condition is zero.” They give internal recognition to hospitals that go 12 months or longer without a patient safety event, hospital infection or hospital condition. There are about two dozen such conditions — not including air emboli and transfusion reactions because they are viewed as extinct. “So far, we’ve given 91 of those awards.”
For that goal, he admits he’s looking to hit a number well beyond 100.
For more information on this topic, contact M. Michael Shabot, MD, System Chief Medical Officer, Memorial Hermann Hospital, Houston, TX. Telephone: (713) 242-2713.
For the last 10 years, Memorial Hermann Hospital in Houston has been on a journey to make the only two scores that matter 100 and zero.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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