Safety Culture Oregon Hospitals Use Survey Results to Drive Change
January/February 2011
Safety Culture
Oregon Hospitals Use Survey Results to Drive Change
Medical error rates at hospitals are under scrutiny as never before, both from within and outside the healthcare profession. In response, many hospitals have begun transforming their internal cultures to align medical practice more closely with safety goals.
Conventional wisdom once held that errors result from being careless or taking shortcuts. Delving deeper, we have learned that the most important causes of errors are totally different: communication problems, poorly designed work processes and work areas, and sometimes fear of punishment for reporting errors. Common sense, backed up by evidence, suggests that the more secure a hospital’s staff feels about reporting errors, near misses, safety concerns, and barriers to job performance, the safer that environment will be for patients.
Institutional safety culture surveys are a proven tool for improving safety. In a Johns Hopkins University study, hospitals that used an internal survey to assess their safety culture and then took action to shore up weak areas reported reductions in medication errors, the number of days patients were treated in intensive care units, nursing staff turnover, and bloodstream infections in patients with intravenous catheters (Pronovost et al., 2003).
In Oregon, 59 of 61 hospitals completed a safety culture survey in 2010, (Oregon Patient Safety Commission [OPSC], 2010a, p. 5). Fourteen hospitals taking part in the Surgical Care Improvement Project (SCIP) or in the Pressure Ulcer Prevention Project, both sponsored by Medicare, have conducted safety culture surveys since January 2009 in a collaborative effort to improve the reliability, quality, and safety of inpatient care. As expected, the most frequently identified problem areas have been communication and comfort with reporting errors.
New Ways to Talk
Some of the Oregon hospitals have addressed their survey findings in creative ways involving senior executives and frontline staff.
- Samaritan North Lincoln Hospital (Lincoln City), Mercy Medical Center (Roseburg), Kaiser Sunnyside Medical Center (Portland), and Ashland Hospital instituted rounding by senior executives to increase their communication and rapport with frontline staff. Mercy’s senior executives also implemented a “town hall meeting” for staff and patient rounding.
- Senior leaders at Samaritan North Lincoln and Good Shepherd Medical Center (Hermiston) also have committed to providing TeamSTEPPS training for staff. The U.S. Department of Defense and the Agency for Healthcare Research and Quality developed TeamSTEPPS as a tool for improving communication and teamwork skills among healthcare professionals.
- All 14 hospitals in the Medicare projects have implemented or expanded use of the SBAR-R (Situation, Background, Assessment, Recommendation, Readback) communication system to improve the flow of patient handoff information between and among provider teams. Initially, SBAR-R was promoted to improve communication between nurses and physicians. Adventist Medical Center (Portland) and Mercy Medical Center have expanded SBAR-R (known at Mercy as “the passport”) to include staff who transport patients to X-ray and other hospital departments, so they are fully informed of patients’ special needs. Operating room nurses at Mercy also provide handoff reports before and after one nurse takes over for another during breaks.
- Good Shepherd Medical Center identified problems with patient handoffs and began an aggressive campaign to make SBAR-R the only way to communicate critical information from nurse to nurse, nurse to doctor, and nurse to transportation staff. Patient safety coordinator Sally Peatow, RN, says, “It’s always important to provide complete, well-organized information to physicians so that they can make the right decisions, but it’s often critically important when the calls are at night—and that’s usually the shift covered by newer nurses. We make a special effort to educate our new nurses and instill good habits from the beginning.”
- Adventist Medical Center staff identified and addressed a similar issue. Quality Resource Director Carolyn Kozik says, “Typically, hospitals assign the newer nurses, including new graduates, to the night shift. In the spirit of patient safety, some of our senior nurses have volunteered for night shifts so that new nurses would have real-time support from experienced mentors.” The hospital also implemented hourly nurse rounding to ensure early recognition of changes.
- Good Shepherd implemented a confidential electronic reporting system for errors, near misses and concerns. Reporting has increased, with most staff members providing contact data. Today, serious errors are rare. The system allows staff to identify and address safety concerns before they result in bad outcomes for patients.
- Sky Lakes Medical Center (Klamath Falls) approaches safety from the frontline staff up. They formed a multidisciplinary, voluntary safety committee with members responsible for identifying safety issues, prioritizing them in collaboration with a manager, taking action directly on some solutions and recommending interventions that require more resources. As an example, the committee devised a simple method of identifying patients at high risk of falls—requiring these patients to wear red socks—and educated other staff members about this warning signal. The “red socks” project has been popular and successful.
- At Tillamook County General Hospital (Tillamook), a self-directed nursing team has streamlined surgical processes and made it easier for everyone to do the right thing. Estrella Pillar, surgery director, recognized that the nurses had the creativity and commitment to bring the hospital to exemplary performance on the SCIP measures and surgical safety by working with the surgeons and anesthesia in providing safe patient care. The operating room technician, pre-op RN, circulating nurse, anesthesia provider, and surgeon all individually confirm with the patient the positive identification of the patient, the surgery to be performed, and the operative site. While the patient is still in the pre-op area, the surgeon also conducts a “surgical briefing” with the patient, reviewing the procedure to be performed.
- Nurses at Tillamook County General Hospital also took the lead in educating surgical patients. They recommended beginning education at the pre-operative screening clinic, well before surgery, to give patients time to listen, read the materials, and ask questions. Post-operative care nurses provide education in the pre-operative clinic so that the patient may learn from the same nurse who provides care after surgery. Nurses and patients are enthusiastic about this initiative.
- The General Medicine department at Rogue Valley Medical Center (RVMC, Medford) participated in the AHRQ Hospital Survey on Patient Safety Culture in 2009. Using survey results and additional sources, RVMC has implemented “Safety Culture in a Box”—four self-learning modules to be completed by all relevant employees within a defined time frame. The modules cover “red rules” (unbendable policies such as no tests, blood draws, meds, or procedures on a patient without an ID bracelet), clear and complete communication, critical thinking, and checking and coaching. “Our nursing staff has actively embraced this content and put it into practice,” says Joan Voskes, performance improvement director for RVMC.
- Large hospitals often face greater communication challenges than do smaller ones. Kaiser Sunnyside Medical Center devotes resources to creating an environment in which people feel empowered to report errors and near misses. The hospital is also conducting research, along with another hospital system, to understand how surgeons can communicate in the operating room in a way that enables or encourages the staff to speak up. This work will include training surgeons on key messages that create a culture of safety and transparency. “We plan to launch the program with a small group of surgeons, then train additional surgeons and staff throughout 2011,” says Janet O’Hollaren, chief quality and safety officer.
- Mercy Medical Center began work last year on improving physician-to-physician communication. Many surgeons use the electronic health record to provide critical information about surgery patients to referring physicians and physicians who are co-managing care in the hospital, and a few have begun to use secure text messaging.
These and other “soft” initiatives—promoting open communication, teamwork and nonpunitive responses to errors—can strengthen a hospital’s capacity to avoid medical errors and to respond to errors when necessary, even as the hospital conducts “hard” initiatives aimed at improving specific measures of care.
Results Matter
From a patient’s perspective, quality care means getting everything right. Hospitals have been reporting their performance to Medicare on eight SCIP measures for more than three years. The SCIP Appropriate Care Measure (ACM) represents the proportion of patients whose care meets all eight measures. Since 2007, the 11 Oregon hospitals with which Oregon-based quality improvement organization Acumentra Health has worked on SCIP measures have improved their performance on the ACM from 64% to 89%. Five hospitals—Ashland Community Hospital, Kaiser Sunnyside Medical Center, Rogue Valley Medical Center (Medford), Tillamook County General Hospital, and Tuality Community Hospital (Hillsboro)—scored 95% or higher on the ACM for at least one of the last two quarters evaluated. These hospitals would not have been able to improve so markedly without a cultural shift toward problem solving, empowering frontline staff, and standardizing procedures based on team consensus.
In addition, members of the Oregon Institute for Healthcare Improvement Network—Acumentra Health, OPSC, Oregon Association of Hospitals and Healthcare Systems, Oregon Medical Association, and Oregon Office of Rural Health—work closely with all hospitals to achieve full implementation of the WHO Surgical Safety Checklist, with Oregon adaptations. OPSC reports that 54 of the 56 Oregon hospitals that perform surgery now use a safe surgery checklist to reduce surgical complications (OPSC, 2010b). All are striving to move beyond simple implementation to use of the checklist to identify and resolve safety issues that involve equipment, patient transitions to other caregivers after surgery, and processes that could be safer. Communication is the key.
Ruth Medak is associate medical director for Portland-based Acumentra Health, the Medicare Quality Improvement Organization for Oregon. She has more than 20 years of experience as a practicing physician and 10 years in healthcare quality improvement. Among her other roles with the organization, she develops collaborative relationships with a wide variety of stakeholders to promote initiatives and programs designed to enhance the quality and safety of healthcare in Oregon. Medak earned her medical degree from the University of Illinois and completed her internal medical residency at Oregon Health & Science University. She is a past president of the Oregon Society of Internal Medicine and a Fellow of the American College of Physicians since 2005. She may be contacted at rmedak@acumentra.org.
References
Oregon Patient Safety Commission (OPSC). (2010a). Hospital Report. Portland, OR: author. Retrieved from http://www.oregon.gov/OPSC/docs/Reports/Hospital-Report-081910.pdf; updated by personal email, 12/21/10
OPSC. (2010b). Patient Safety Commission web page. http://www.oregon.gov/OPSC/index.shtml
Pronovost, P. J., Weast, B., Holzmueller, C. G., Rosenstein, B. J., Kidwell, R. P., Haller, K. B., Rubin, H. R. (2003). Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care, 12, 405-410. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758025/pdf/v012p00405.pdf