State-wide Leadership Creates a Culture of Patient Safety in Rhode Island
September/October 2011
State-wide Leadership Creates a Culture of Patient Safety in Rhode Island
To provide a safer environment for patients in Rhode Island, 13 hospitals in the state have initiated a program to improve the way data on adverse medical events is reported, analyzed, shared, and utilized.
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This is the second in a series of articles about Rhode Island’s implementation of a state-wide patient safety organization (PSO) to facilitate the reduction of medical errors. The first article, “How Rhode Island Is Leading a Revolution in Patient Safety,” appeared in the January/February 2011 issue and is available at www.psqh.com/ |
Led by the Hospital Association of Rhode Island (HARI), a steering committee that consists of chief nursing officers from each of the hospitals has been collaborating since March 2010 with the GE Healthcare Patient Safety Organization (GE PSO). The purpose of this collaboration is to implement identical medical event-reporting technology across the state and to standardize reporting criteria for all the hospitals so that funneling of event reports merges into a common statewide database. The hospitals hope to gain insight into the causes of adverse medical events and to develop information that will lead to improved processes for patient care.
The first article in this series looked at the reasons for the initiative, how the event-reporting technology was selected, the structure of statewide and hospital project committees, and early benefits of the collaboration. This article will explore how leadership engagements during implementation of event reporting at the facility level facilitate the cultural transformation necessary to improve patient safety across the entire state.
From Risk System to Operations System
Senior leaders have to make it clear that they are comfortable with and support changes required for safer patient care. Furthermore they must also realize that placing blame is not healthy nor the point.
— Robert T. Francis II, former vice-chairman of the National Transportation Safety Board and member of the GE PSO Advisory Board
In most hospitals, error reporting systems (electronic or manual) are under the purview of either risk or quality management departments. When staff report on adverse and near-miss (close call) events, it is assumed that the risk/quality departments will not only investigate the events, but also initiate steps to resolve the organizational or operational factors allowing the same problems to continue occurring. This can be a critical disconnect in the problem-resolution chain, since risk and quality managers typically do not have the operational responsibilities and mandated authority to make such changes. The Rhode Island PSO implementation set out to change this historical construct.
The Rhode Island state-wide patient safety initiative has helped to address this “ownership” issue in a number of ways. First, the state-wide steering committee consisted primarily of chief nursing officers, which put the responsibility for implementation directly with those having authority to make operational improvements across the greatest number of patient care areas in the hospitals. Second, the core team at each hospital included leadership representatives from multiple disciplines including nursing, pharmacy, IT, medical staff, and administration, as well as quality and risk management.
At the individual hospitals, this approach has helped to create a shared sense of ownership about patient safety that permeates all levels of the organization, from CEOs and senior administration to managers and front-line staff. In the process, patient safety has been transformed from a mandate imposed by a single department to a multi-disciplinary operational objective that unites employees within and across departments.
Providing Tools, Establishing Expectations
Reporting tools need to be intuitive and quick to use, and guidelines available for staff to set expectations about what to report. We know that without great tools, underreporting of patient safety events is significant.
— Kathy Martin, GE Healthcare PSO managing director
The roll-out of the event-reporting platform was a critical element in this transformation. The 13 hospitals in the initiative used Medical Event Reporting System (MERS) technology incorporated into the GE PSO, to standardize event captures.
Management follow-through had been identified as an area for improvement at many of the RI hospitals in their previous attempts at event reporting. One reason was that expectations for managers in this regard had not been adequately established and communicated. Introduction of MERS was accompanied by comprehensive manager trainings and at some of the hospitals, a written policy was also developed that clearly laid out expectations for the management in patient safety events. This move toward increased accountability for the managers in patient safety events marked a significant cultural shift. Instead of the customary practice of sending out materials and hoping that employees would adopt them, policy guidelines were now being established, communicated, and explained with a compliance metric added to employee performance appraisals.
Several of the RI hospitals combined the MERS roll out with development of a non-punitive, but accountable culture for reporting, modeled after the Just Culture program. As an example of this, Lifespan hospitals held a series of off-site training events in which close to 900 people participated—including managers, supervisors, physicians, nurses, and other staff—to emphasize the need for culture change and increased accountability. At these meetings, senior administration described their expectations for developing a culture of safety. Expectations included holding all staff and physicians accountable for patient safety as well as implementing an algorithm based on Just Culture principles in order to deal with all individuals involved in a patient safety event.
Throughout the meetings, educational staff conducted role-playing exercises based on true event management scenarios while attendees participated in question-and-answer sessions. Current event-reporting analysis results were shared by the quality and risk management executives, and resulted in a significant emphasis on the need for managers to ask why an event happened rather than only, “What happened?” The underlying theme that came from these meetings was that patient safety was not the “flavor-of-the-month”; rather, it was the most important part of each employee’s job.
The CEO as Champion
Patient safety requires a top-down transformation. You need to bring in board members and the executive leadership of the hospital. They have to know what’s happening and understand some basic concepts about how to design safe systems. You can ask a lot of staff, but ultimately it’s going to be the leaders who model the behaviors.
— David Marx, author of Patient Safety and Just Culture and Whack-A-Mole: The Price We Pay for Expecting Perfection
The influence of senior leadership has been the driving factor in setting expectations and getting employees engaged in this state-wide program. The high-profile nature of the initiative captured everyone’s attention, but the fact that CNOs were leading the effort and the CEOs of all 13 hospitals were personally involved and committed to its success created genuine interest and excitement. Even before the program was implemented at the individual hospitals, there was much discussion at board, management, and employee meetings within the various institutions.
For example, the CEOs and senior leadership at the Lifespan hospitals have been involved in every step of the process. As part of the MERS roll-out, a training video was created in which hospital CEOs were featured, introducing the program and explaining its importance. Rather than having to recruit individual champions for the cause, some of the CEOs became the champions, and their influence pervaded the entire organization. Human resources played a key role in training and education, as did the major patient care departments. The communications department created multiple tools, including tent cards, posters, and a web page to get the word out.
At Kent Hospital, Sandra Coletta (president & CEO) communicated to her entire staff in a memo that “I’m addicted…not to a substance but a website. I log on the minute I get to work and check on it several times a day.” She was referencing MERS and then followed-up with “I’ve learned so much about the challenges you (the staff) face in delivering safe care to our patients and where you need support to correct the problem rather than just work around it.”
Making Time for Safety
People involved in patient safety need time to use information in new ways, Leadership needs to provide for the time to pilot and thoughtfully implement solutions.
— Harold S. Kaplan, MD, professor at Mount Sinai School of Medicine and member of the GE PSO Advisory Board
Even though a CEO may say that patient safety is the most important focus for the organization, there is still the practical challenge of freeing up employees’ time in order to take part in patient safety initiatives. This is especially true when the managers are responsible for inquiry, follow-up, and analysis of reported events. These activities can be time-consuming, and yet the expectation remains for most that they will continue with their other routine duties such as staffing or running a unit or a department. Providing them with available time to manage both responsibilities is an ongoing challenge.
One way to address this problem is to create a manager role of quality and patient safety—within the operations table of the organization and reporting to an operational leader. These employees, who have no patient or unit management responsibilities, are charged with helping a unit, or group of units, to improve performance around quality and safety metrics while also enhancing training opportunities. With event reporting, these managers can be instrumental in conducting well-performed root-cause analyses (RCA) of events reported at all the hospitals. Some hospitals have developed special training programs for performing root-cause analysis and have trained employees from various departments to be RCA facilitators.
Creating a Learning Culture
A culture of safety is an informed culture.
— Dr. James Reason, professor emeritus at the University of Manchester and author of Human Error
One of the most important messages delivered by senior leadership about the event reporting system has been, “We want to learn from it.” This has helped to establish a non-punitive culture of safety in which employees feel comfortable about reporting. With the MERS automatic routing of event data, information is shared widely. Leadership from these hospitals, and others, have clearly stated that the only way to prevent problems from occurring is to understand what is happening and why.
One way this learning mindset has been operationalized at some of the hospitals is through the creation of root-cause analysis meetings. In these regular sessions, managers present their root-cause analyses of events to the hospital’s senior leadership. The analyses are discussed by the group, as are the proposed action plans to remedy problems. The issues are scrutinized to see if they affect multiple areas and therefore need to be managed from a broader organizational perspective. This systematic approach is a way for hospitals to use the data that they are getting from MERS to improve the quality and safety of patient care on the broadest possible scale. The MERS system’s HAWK analysis, an inferencing part of the software that allows staff to search for similar events, contributes to that process.
Conclusion
The early results of this state-wide Rhode Island patient safety initiative have been encouraging, and already organizational cultures have started to change in a positive fashion. There is a greater sense at all RI hospitals that safety issues need to be recognized, talked about, and approached from a systems-based point of view. By establishing a safety culture that starts with hospital leadership, and continues to demonstrate leadership commitment at the very top, each hospital is making that goal a reality. The Rhode Island state-wide approach is already demonstrating large-scale change and this is due in large part to the commitment demonstrated by senior leadership across all RI hospitals.
Mary Cooper is the senior vice president and chief quality officer at Lifespan Corporation in Rhode Island.
Joan Flynn is vice president for risk management at Lifespan Corporation in Rhode Island.
Patricia Daughenbaugh is senior manager for patient safety at GE Healthcare Performance Solutions.
Kathy Martin is director of the GE Healthcare Patient Safety Organization. She may be contacted at Kathleen.Martin@med.ge.com.
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Leadership and Culture in Patient Safety Improving the safety of healthcare saves lives, helps avoid unnecessary complications, decreases secondary expenses related to complications, and ultimately enhances consumer confidence that receiving medical care makes patients better, not worse. Every individual seeking care should be able to expect (and receive) safe, reliable care—every time, under all conditions, and in all environments. Changes in contemporary healthcare are occurring gradually, and numerous successes have been recognized, yet there is a clear consensus that much still needs to be accomplished before safety in healthcare reaches a stage where improvement is consistently recognized across all sectors. Leadership and culture—we now hear these terms routinely in the context of patient safety, and how critically important they are for successes to occur when creating and driving changes. Leadership from government is one approach. Passage of recent federal healthcare reform legislation has improved access to healthcare for many citizens, but it has only created a small new beginning for improving the overall safety and quality of healthcare in America. There are numerous segments in the new legislation that set the stage for safety improvement, as well as important medical finance and malpractice reform language that may lead to significant new initiatives. Appreciation for how these changes create improvements at the clinical bedside, however, remains to be seen as the legislation becomes enacted. Creation of potential changes in healthcare culture is even less clear. A large gap exists between what is enacted from legislative reform at federal or state levels and what is actually occurring within frontline facilities of all types and sizes. Every day, patients are still harmed, or nearly harmed, in healthcare organizations. These incidents are rarely intentional and usually can be avoided. It is now better appreciated that the errors that can create harm often stem back to organizational system failures, leadership shortfalls, and predictable human behavioral factors. Within this improved understanding of medical errors, however, the often touted call for development and instillation of a “culture of safety” is proving difficult to initiate and sustain at all levels of healthcare. Further learning and ongoing improvements are needed on how to sustain changes in workforce values, beliefs, and behaviors that will ultimately contribute to the desired changes in culture. And this is where organizational leadership setting these expectations is crucially important. Harmonization is a pivotal strategy for creating simplification and uniformity of approaches when improving patient safety. In essence, every healthcare stakeholder group should insist that provider organizations demonstrate their commitment to reducing healthcare errors and improving safety. This includes promoting an environment of effective reporting and learning from errors or mistakes within a blame-free culture. Collective reporting and learning from the mistakes of others are also essential components to improve healthcare safety. And more importantly, healthcare organization leaders and governance boards must be explicitly called upon to proactively review the safety of their organizations and to take actions to continually improve the safety and thus the quality of care they provide. The Rhode Island initiative for simultaneously improving patient safety across all 13 hospitals has the distinct possibility for providing numerous lessons on how to implement large-scale change across an entire state so that a culture of healthcare is transformed. Leadership has been pivotal in this initiative, and will remain critically important so that long-term change is sustained and this new culture towards patient safety becomes the new norm for expected behaviors of all healthcare providers. The entire country should be watching closely for the valuable lessons being learned. Peter Angood is the medical director of the GE Patient Safety Organization (GE PSO) and chair of the GE PSO Advisory Board. His previous roles include chief patient safety officer and vice president of the Joint Commission; senior advisor for patient safety at the National Quality Forum; and president for the Society of Critical Care Medicine, among others. Along with his professional contributions to the GE PSO, Dr. Angood continues to collaborate on World Health Organization (WHO) Patient Safety initiatives after having helped lead early development of the WHO Collaborating Center for Patient Safety Solutions. |