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May 2017 Archive for High Reliability Healthcare

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Systemic solutions to analyze underlying causes of specific care breakdowns and improve overall quality.

What’s Your Board’s Competency in Quality and Safety?


May 30, 2017 | Comments (0) | 3517 Views

By Steven Berman
Executive Editor
The Joint Commission Journal on Quality and Patient Safety

Board members play a vital role in ensuring high-quality care and patient safety in health care organizations. However, a new study suggests problematic gaps between what board members think they know and what they do in regards to quality and safety, as well as board members’ capability in quality and safety, as assessed by safety and quality leaders (SQLs) at their own health care organizations.

In “Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety,” from the June 2017 issue of The Joint Commission Journal on Quality and Patient Safety: Patricia A. McGaffigan, RN, MS, CPPS, chief operating officer and senior vice president, Programs, National Patient Safety Foundation, [which has since merged into the Institute for Healthcare Improvement], and co-authors, conducted a 36-question survey with a convenience sample of board members, CEOs and SQLs.

Assessing Board Competency
A large percentage of each group among the 605 respondents—105 board members, 53 CEOs, and 447 SQLs—reported that safety was ranked as number one on their organization’s list of strategic priorities. Analysis of responses concerning their knowledge and understanding of specific concepts, such as leadership, culture, serious events and harm prevention, revealed similar patterns across the three groups. In addition, findings revealed:

  • CEOs rated their own knowledge and understanding as highest.
  • Board members reported lower ratings of their own knowledge and understanding.
  • SQLs were less likely to rate their own board members’ knowledge and understanding as “high.”

The authors conclude that the survey “reveals specific areas of focus for improving governance and leadership practices at board meetings, as well as several areas where knowledge and understanding of safety and quality were variable. Further research and consensus would be beneficial to identify best practices for board education and governance activities to drive quality and safety.”

In an accompanying editorial, “Knowing, and Doing: Closing the Gaps in Board Leadership for Improvement of Quality and Safety,” James L. Reinertsen, MD, president, The Reinertsen Group, Alta, Wyoming, and senior fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts, states that “The study reaffirms it would be a good idea to develop more capable boards, both by recruiting board members with expertise in quality and safety, and by offering all board members the opportunity to ground themselves in serious knowledge of quality and safety concepts and methods. But it is even more important that we establish practices—at the board level, and at the quality/safety committee level—that allow our board members to apply their knowledge effectively.”

June Journal Highlights
In addition to the board competency study and editorial, the June issue covers a variety of other patient safety and quality topics. I encourage you to read the remaining articles on:

For more information, visit The Joint Commission Journal on Quality and Patient Safety website.

In a Safety Culture, Appropriate Behaviors Start at the Top


May 24, 2017 | Comments (0) | 4248 Views

By Coleen Smith, RN, MBA, CPHQ, CPPS
Director, High Reliability Initiatives
The Joint Commission Center for Transforming Healthcare

This is the third in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic: This post examines the third tenet: To advance trust within the organization, CEOs and all leaders must model appropriate behaviors and champion efforts to eradicate intimidating behaviors.

Citrus Valley Health Partners President/CEO Rob Curry said his organization’s safety culture initiatives have led to significant reductions in adverse events year after year since the organization began these initiatives in 2014. “As an example, in our first year we reduced patient harm by more than 25 percent and it has continued to drop,” he stated.

He believes much of this improvement is due to adopting and modeling appropriate behaviors, starting at the top of the organization. Citrus Valley participates in Robust Process Improvement® (RPI®) and highly reliable organization processes in its pursuit of zero harm. “About 150 people in leadership roles [including executives, board members and physicians] have been trained in high reliability, including Six Sigma tools and change management,” he said.

Empowering Providers
This organizational commitment and training has gradually shifted the hierarchal culture common at Citrus Valley and other hospitals into one that considers patient safety first and empowers all team members to speak up when necessary. “We have adopted a policy that no matter what your role is if you say, ‘stop the line,’ literally the line is stopped,” Curry stated.

For example, timeouts before surgery have proved to reduce instances of wrong-site or wrong-patient surgery. “If surgery is starting, and a nurse in the operating room doesn’t feel comfortable that all team members are listening to the timeout, he or she says ‘stop the line. We’re going to start this timeout again and everyone is going to pay attention.’ I have seen that happen, and it’s a powerful cultural phenomenon when everyone feels empowered to speak up and stop the line,” Curry explained.

Hospitals must encourage this kind of assertive behavior on behalf of patients to overcome what Curry described as “normalized deviance,” which describes situations in which adverse events or other substandard results become accepted as normal. Rather than expecting and accepting that patients will fall or that surgical site infections or medication errors will occur, hospitals must take the initiative to stop these adverse events from happening.

Personalizing Responsibilities
Citrus Valley began personalizing error reports to make them more human rather than only numbers on a spreadsheet. “Jane Doe fell last night because we didn’t have the side rails up, and that could have been avoided,” Curry said as an example of a personalized report.

The organization also adopted a no-pass zone, which Curry described: “if there’s a nurse’s call light on, the nearest employee to the patient – could be a nurse, unit secretary, EVS employee, whomever is closest has the permission and responsibility to go in, see what the patient needs, and aid in facilitating a safer, more responsive environment. This sensitivity to the patient’s needs is purposeful because it is everyone’s responsibility to keep all patients safe and reduce harm.”

Encouraging transparency in response to reports of adverse events, close calls and unsafe conditions helps to mitigate intimidating behaviors, according to The Joint Commission’s recent Sentinel Event Alert on safety culture. The Joint Commission’s leadership standards also call for the elimination of intimidating and disruptive behaviors, emphasizing the link of these behaviors to medical errors and patient harm.

For now, however, organizations like Citrus Valley are more the exception than the rule, according to a National Association for Healthcare Quality report, which states that “reports of retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies” have increased concomitantly with safety culture initiatives. Intimidation has included overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities.

For the most part, those days are gone at Citrus Valley, Curry said. “There was some resistance initially because you had to change the mindset,” he explained. Staff no longer fear retaliation from speaking up, rather a team member now knows, ‘if I don't do something, the patient is going to be harmed’. The hierarchy is gone. A team member is not going to be intimidated he knows he’s doing the right thing.’

“But it took some time for the culture to learn how to do that. I think that's only fair,” Curry stated. “One lives in an environment for so long that you get used to a set of rules and expectations. But you have to learn that when it's about the patient, everyone is equal and everyone has a responsibility to prevent a potential harmful occurrence.”

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