Executive Summary
A health system in South Carolina is reporting success in creating a culture of safety. The effort has improved patient safety and yielded positive metrics.
- The system’s reported harm rate is very low.
- Safety issues are addressed through a tiered responsibility system.
- The health system has many team members certified in Just Culture.
A focused effort to create a just culture is paying off in big ways for the Medical University of South Carolina in Charleston (MUSC), which is seeing low rates of errors and patient harm while instilling a sense of safety responsibility at all levels.
MUSC Health Chief Quality Officer Danielle Scheurer, MD, says the effort was based on the ideas that reporting issues should be easy, that the hospital should encourage learning and improvement, and that a Just Culture should understand and hold people accountable for their behavioral choices.
Safety metrics have improved steadily for more than 10 years, she says. One of the most significant metrics, the reported harm rate, is currently at 2.5%. That figure indicates that, of all safety event reports received, only 2.5% of them involved actual harm to a patient. The rest are near misses or reports of unsafe conditions, Scheurer explains.
A low reported harm rate is a sign of a high reporting culture, she says, which is a key component in the Just Culture approach. Scheurer notes that MUSC’s 2.5% reported harm rate is much lower than the hospital average.
Tiered Briefing System
MUSC also has encouraged safety reports and error reduction by addressing reported concerns through a tiered system. Units conduct a huddle every day to talk about anything related to safety, and those issues are passed along through a four-level “tiered brief” system, Scheurer says. The issues are addressed at the appropriate level, starting at the front line and moving up as necessary, eventually reaching system senior leadership, she says.
“It starts at the local level. Each unit has a tier one brief every day where the team gets together, typically with either a virtual whiteboard or an actual whiteboard on a unit, and we have a very structured approach to going through operations and safety issues on that team. Anything they can’t resolve goes up to tier two, which is typically at the department level,” Scheurer says. “It goes up to tier two within about an hour, and then it goes up to tier three, which is at the hospital level, again within about an hour. And then, ultimately, all of that information flows up to tier four, which is our system leadership, which convenes every day at 12:45 p.m.”
Each of those tiered briefs is succinct and scripted, she says. The purpose is to escalate unresolved issues all the way up to senior leaders within a couple of hours, should it be necessary.
“That leads to transparency and trust and problem resolution, which makes people more likely to continue to report problems if they know that there is a resolution,” Scheurer says. “If you say the same thing four days in a row, and everyone’s like, ‘Yeah, sounds like a problem,’ but nothing happens, they’re going to stop talking about it.”
Scheurer recalls a recent brief in which clinicians reported repeated problems with glove breakage. The issue quickly went up through the tiers to the supply chain, where it was traced to a recent switch in vendors, which was providing a different glove. MUSC quickly consulted with the vendor about better glove options.
In another example, the briefs revealed that a drug needed by rapid response teams was sometimes not available. The escalating review determined the drug was in short supply nationwide, but MUSC developed a communication plan that would ensure the drug’s replacement in supply cabinets within 24 hours.
“To keep that good reporting culture, a lot of people have to feel reassured that, when they report a problem, someone is going to look at it and do something with it. So, the other key metric that we track is when an event report goes into the system, we actually track it in time to see when the leader addresses the issue with their team,” Scheurer says. “We track all that by leader and by area, by division, by hospital, all of that. That turnaround time on addressing safety reports is important because, obviously, people are not going to keep reporting if they think it goes into a big black hole.”
Hundreds Trained in Just Culture
MUSC also is committed to ongoing education in Just Culture and having as many people certified as possible. The hospital system currently has more than 350 Just Culture-certified team members — including all leaders in risk management, human resources, compliance, legal counsel, and quality — who are thoroughly trained in the concept and serve as ambassadors for the program, Scheurer says. They teach and educate others as part of their daily activities.
“That makes a huge difference. We are very purposeful in ensuring that specific types of leaders are certified in Just Culture because these are what we call the backbone of Just Culture, the leaders that people tend to go to with questions,” she says. “Any time we have a new leader onboard to MUSC that has a leadership role in those areas, we make sure that they are Just Culture-certified.”
MUSC’s Just Culture effort has led to numerous safety improvements, including medication bar coding and redundancy systems, checklists for magnetic resonance imaging safety, and continuing education on the use of new and existing equipment.
Safety rounds also connect senior leaders with support departments and frontline staff.
“We go to their area, ask open-ended questions about what worries you, do you have the resources you need to be successful, all that kind of stuff. And then, whatever we hear, we assign closure of those gaps to other leaders, and we track all of that as well,” Scheurer says. “When we go back to the area, we can close the loop with that team. If they tell us that they have issues with their supply chain and have stock outs, that’s super frustrating and impedes good patient care. Then, we will follow up with supply chain, determine the process for stocking and how to close that gap.”
Leaders Held Accountable
MUSC’s flagship hospital in Charleston has been embracing Just Culture for about eight years, and other hospitals followed suit as they were acquired by the health system. Scheurer says the program does take a while to obtain the necessary buy-in from executives and down the line to frontline workers.
“We watch those processes and evaluate the effectiveness of them and give that feedback to the senior leader team. If there’s a smaller hospital that is routinely canceling safety rounds due to competing priorities, that will quickly get back to not only the local team but also up to the system leadership team to make sure that accountability is reinforced,” she says. “It’s awfully tempting to let these things go by the wayside because there’s always competing priorities and there are always unanticipated interrupted issues in healthcare every day. For a busy nurse manager, this would logically be the first thing to flick off their calendar if there wasn’t that ongoing accountability.”
Scheurer describes the program’s success as using a simple framework for building a culture of safety, a culture of recording, learning, and inculcating those concepts into a structured system.
“It doesn’t have to be just like ours, but something that allows team members on a daily basis to report problems and get resolution, problem solve, and quickly escalate up to leaders that can resolve barriers that can’t be resolved locally,” Scheurer says. “Having something like that in place that’s consistent, of high quality, and supported by senior leaders is critical.”
Source
- Danielle Scheurer, MD, Health Chief Quality Officer, Medical University of South Carolina, Charleston. Telephone: (843) 792-2300
A focused effort to create a just culture is paying off in big ways for the Medical University of South Carolina in Charleston, which is seeing low rates of errors and patient harm while instilling a sense of safety responsibility at all levels.
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