PSQH0505_SeptOct08      8/26/08      11:45 AM      Page 12                                                                ...
PSQH0505_SeptOct08     8/26/08     11:45 AM      Page 13        Figure 1: Safety Climate Survey Results        Culture of ...
PSQH0505_SeptOct08    8/27/08     4:18 PM     Page 14                                                                     ...
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Creating a Cuture of Safety in PSHQ Magazine


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Creating a Cuture of Safety in PSHQ Magazine

  1. 1. PSQH0505_SeptOct08 8/26/08 11:45 AM Page 12 By Stephen W. Harden TEAMS & C O M M U N I C AT I O N C r e at i n g a n d S u s t a i n i n g a C ul t u r e of S af et y Healthcare consumers are increasingly Step 1. Develop change-initiative tion of culture changing behaviors and aware of medical error and publicly skills for key leadership positions and tools is primarily a function of effective reported quality measures. Additionally, an organizational structure that will leadership action. the Centers for Medicare and Medicaid support the new culture. Realizing no Step 2. Provide training in team- Services’ (CMS) pending refusal to pay change would occur without partner- work and communication to support for certain “never events,” the advent of ship with the institution’s physicians, desired culture-changing behaviors. the Hospital Consumer Assessment of TNMC recruited physician champions, Following a site visit, a thorough patient Healthcare Providers Survey (HCAHPS), briefed all physicians in perioperative care processes review, and preparation and the work of the Institute for Health- services through monthly meetings of a teamwork scorecard as part of their care Improvement (IHI), the National and surgery Grand Rounds, and made needs analysis, LifeWings prepared cus- Patient Safety Foundation (NPSF), and sure each physician understood the tomized courseware targeting the needs Joint Commission have combined to methodology, potential results, and of TNMC and presented it to physi- produce conditions where creating and “what’s in it for you” for supporting the cians and staff. The training was inter- sustaining a culture of safety is a priority initiative. This was an important step, disciplinary, experiential, and based on for many healthcare organizations. That as TNMC already had very high levels healthcare case studies. It provided evi- was the case for The Nebraska Medical of patient safety in other areas. Next, dence-based teamwork skill sets based Center (TNMC) in Omaha. The aca- key leaders at both the institutional and on team training from the aviation demic medical center realized in 2004 departmental level were trained on industry—called Crew Resource Man- that their patient safety efforts needed a leading change initiatives. Skills learned agement (CRM)—and adapted for the boost to move from very good to great.A included: needs of the OR team. CRM is based on focus on quality and safety was one of • responding to difficult questions the best science and research on high four CEO leadership priorities, and the about the initiative, performing teams. focus on quality and safety was incorpo- • recruiting champions and Step 3. Create and implement site- rated into the hospital’s strategic plan coaching low performers, and specific safety tools to hardwire the with full approval of the Board. • conducting rounding for patient teamwork behaviors into daily work Chief Medical Officer Steve Smith, safety. life. Using a process based on Lean, a MD, spearheaded the effort to change small work group of physicians and staff TNMC’s culture:“We want a safer place Organizational development to support met to 1) identify points in their work- to practice medicine with the confi- the initiative included: flow where improvements in patient dence that all steps necessary to ensure • a project oversight and steering safety were most needed and 2) create our patients’ safety to the highest degree committee, safety tools such as checklists, structured are taken into account for all cases.” • revisions to policy and procedure handoffs, protocols, and communica- Based on a recommendation from the manuals, tion scripts to facilitate the needed chief of surgery, Smith elected to join • alignment of leadership assess- improvements. An education and forces with LifeWings, a consultancy ment systems to support the implementation plan was created for group that works with clients to create culture, each tool. Tools were implemented over a culture of safety by adapting the best • a data collection and analysis plan a period of weeks. The first tool com- practices of aviation and other high for project measurement, and pleted and implemented was a Pre-Pro- reliability organizations. • making the training and new cedure Briefing (Figure 1) for surgical TNMC chose to follow a five-point safety tools mandatory for cases that incorporated the elements of plan for creating and sustaining an all physicians and staff— the Universal Protocol (which is avail- improved culture of safety. In a 6-month including consequences for able online at It period of 2005 and 2006, the first four non-compliance. also included checklist items to ensure steps of the plan were conducted in peri- all staff and needed equipment were operative services as proof of concept Step 1 was perhaps the most impor- available and operational, and that the with follow-on implementation planned tant part of the methodology as patient was completely ready for the for other areas after success in the OR. research shows that “end user” adop- procedure to begin. 12 Patient Safety & Quality Healthcare I September/October 2008 w w w. p s q h . c o m
  2. 2. PSQH0505_SeptOct08 8/26/08 11:45 AM Page 13 Figure 1: Safety Climate Survey Results Culture of Patient Safety Survey Results Cath/EP was hired externally. Once qualified by Pre-CRM: August 2006 (n=24), Post CRM: July 2007 (n=16) LifeWings, these trainers assumed ■ Pre-CRM ■ Post-CRM responsibility in 2007 and 2008 for the 93% roll out of Steps 1 through 4 in the 100% 86% emergency department, the cardiac 73% 83% 80% catheterization and electrophysiology 63% 60% labs, and the obstetrics and gynecologi- 29% cal services department. TNMC contin- 40% ues to roll out the system in its critical 20% care areas with plans to implement the 0% culture change in its entire hospital. We are actively doing Staff will freely speak up Staff feel free to question things to improve patient if they see anything that the decisions or actions of Results safety. may negatively affect those with more authority. The culture of safety has improved at patient care. TNMC. Results of the safety-climate sur- vey administered after the implementa- Step 4. Collect and analyze data to the culture-changing initiative in-house tion in the areas listed above show dra- document results. TNMC created a as quickly as possible and avoid an matic improvement in the perception of measurement plan to analyze results by extended engagement with an outside staff, physicians, and residents on those examining safety measures including consultant. To develop their internal indicators related to patient safety in their safety climate surveys, teamwork and capacity, three trainers were chosen in area (Figure 1). Additionally, the culture communication issues, and process reli- 2006 to learn to provide the teamwork has produced multiple examples of ability and efficiency. skills training and to create and imple- “good catches” by the staff as they have Step 5. Conduct training for “mas- ment the safety tools. Two trainers were intercepted potential errors that might ter trainers.” TNMC wanted to bring from the Six Sigma department and one have affected patient safety. In addition to September/October 2008 I Patient Safety & Quality Healthcare 13
  3. 3. PSQH0505_SeptOct08 8/27/08 4:18 PM Page 14 improved patient safety, TNMC has seen an improvement in cases without signifi- Figure 2: Percentage of Procedures without Delays cant events, reducing unexpected delays ■ Cath Lab 2007 (Figure 2). As a result of their culture- changing efforts, TNMC recently won 100% the “Quest for Excellence” award given each year by the Nebraska Hospital Asso- 90% ciation. The award represents “the high- 80% est level of professional acknowledge- ment in Nebraska’s hospital quality 70% improvement arena.” TNMC has proved 63% that though disciplined leadership 60% action, effective interdisciplinary skills training, use of site-specific safety tools 50% that hardwire behaviors, and program- 40% guiding measurement, the safety culture can be changed and improved. SPSQH 30% 21% Stephen Harden is the co-founder and president of LifeWings Partners LLC. He is 20% co-author of CRM: The Flight Plan for Lasting Change in Patient Safety 10% (published by HC Pro) and is a nationally known speaker on creating a culture of 0% July (N=36) Sept (N=92) patient safety. He can reached at 14 Patient Safety & Quality Healthcare I September/October 2008 w w w. p s q h . c o m