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Quality, Reliability & Leadership

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Knowledge and support for health care leaders working for high reliability, quality and patient safety in all areas of health care.

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In a Safety Culture, Appropriate Behaviors Start at the Top


May 24, 2017 | Comments (0) | 1257 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.”

Safety Culture: Shattering the Myths of Perfection and Punishment


Apr 27, 2017 | Comments (0) | 4606 Views

By Gerard Castro, Ph.D., M.P.H.
Project Director
Patient Safety Initiatives
The Joint Commission

This is the second 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 second tenet: Use clear, just and transparent risk-based processes for separating human error from error arising from poorly designed systems, or unsafe or reckless actions.

In testimony before Congress in 2000 on the topic of patient safety, Dr. Lucian Leape, a professor at the Harvard School of Public Health, said, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes”.

Dr. Leape later explained that to create an open and fair environment to improve patient safety and prevent future mistakes, we need to dispel two key myths:

  • The perfection myth: If people try hard enough, they will not make any errors.
  • The punishment myth: If we punish people when they make errors, they will make fewer of them.

An internationally recognized leader in the patient safety movement, Dr. Leape was among the pioneers who understood that encouraging the reporting and investigating of errors and resulting adverse events or close calls was an essential way of learning from them and preventing future mistakes.

Framing Opportunities for Improvements
In a safety culture, organizations consider errors, hazards, close calls (“near misses”), and adverse events as opportunities to make improvements, rather than seeing them primarily as occasions calling for the blaming, punishment or termination of team members. Health care team members understand that systemic vulnerabilities exist and that each step in the care process has the potential for a negative outcome.

By cultivating an open and trusting safety culture, health care leaders can encourage team members to identify these weaknesses and find solutions to them before they reach the patient and cause harm. Leaders can also encourage team members to be proactive, continuously trying to anticipate developments and seeking to understand and learn why things go right.

By seeking these types of learning opportunities, an organization begins to exhibit and foster an important trait of a safe culture and learning organization – one in which team members feel able to report patient safety incidents without undue fear of the consequences. Indeed, rather than fearing consequences, team members are encouraged and even rewarded for reporting adverse events and close calls. Leaders, in turn, apply the lessons learned from these mistakes throughout their organizations.

Montefiore Medical Center’s Approach to Adverse Events
One example of this paradigm shift can be found at Montefiore Medical Center, which has developed an easy-to-use just culture tool that unifies and transforms the way this large health system approaches errors., The Montefiore team reviewed the existing tools used in the fields of industrial engineering and healthcare and did not find any that were completely suited for Montefiore’s purposes. Inspired by the work of James Reason and David Marx, they decided to develop Montefiore’s own Just Culture tool, which is simple to learn and use, and supports a fair and balanced approach to analyzing errors. This tool makes the Just Culture concepts tangible to Montefiore’s clinical teams and helps them to analyze errors in the context of a Just Culture framework. The tool helps users that review adverse events to discern the human failures that led to the event from the underlying system failures.

The tool walks the user through two simple questions pertaining to each individual involved in an adverse event to help determine individual accountability. The practitioner’s performance is then put into one of four categories, each of which leads to an intervention- from consoling to coaching to discipline (for the rarely found reckless behaviors). After the individual attributions are assigned, the tool instructs the team to explore the system issues contributing to the event and this becomes the primary focus and lens through which the case is reviewed. The tool is used by front – line nurse managers, Departmental and Institutional safety leaders, HR professionals and Board Members throughout the health system.  

Montefiore’s approach recognizes that individual practitioners should not be held accountable for system failings. In this way, Montefiore creates an environment in which team members are comfortable reporting adverse events, close calls and unsafe conditions. They are confident that these reports will be used to build stronger processes and systems to improve safety.

Resultingly, Montefiore experienced a dramatic rise in adverse event and close call reporting by all types of clinical staff, including physicians. “To sustain this, we need to continue to support a just culture and demonstrate that we are listening and responding to the voice of our front-line clinicians,” said Jeffrey Weiss, M.D., Montefiore’s vice president for medical affairs and senior medical director.

Montefiore’s patient safety model shifts from the traditional culture of individual blame described by Dr. Leape many years ago to one that investigates errors in the context of complex systems.

Montefiore advances patient safety through improved identification of errors, creates an infrastructure for learning about these errors, and translates this learning into meaningful change and system improvement.

By not expecting perfection and by focusing on creating safer systems, Montefiore is preventing errors and making health care safer.

How Engaged is Your Board?


Mar 03, 2017 | Comments (0) | 2652 Views

By Ann Scott Blouin, RN, PhD, FACHE
Executive Vice President
Customer Relations
The Joint Commission

Gone are the days when membership on a board of directors meant just casting a few votes at a quarterly meeting. Modern boards of directors are truly partners with the leadership team at hospitals.

Despite general consensus that board members retain responsibility for quality, safety and the financial security of organizations, it can be difficult for board members—especially those newly appointed—to understand how they can best contribute.

To that end, The Joint Commission has released the 3rd edition of Getting the Board on Board: What Your Board Needs to Know About Quality and Patient Safety. This publication is written for both board members and executive audiences, offering the patient safety and quality focus that’s often lacking at new board member orientation.

Challenges to Board Engagement
No executive ever sets out to isolate the board of directors; people volunteer their time on a board to make a difference in a cause that’s important to them. Still, a disconnect somewhere along the line is common.

On the part of the health care organization, senior leadership often hesitates to share their problems with the board. Meeting agenda items rarely outline quality and safety problems, with senior leaders often uncomfortable to share patient stories and challenges.

Lacking this guidance, board members don’t always understand that their fiduciary responsibility includes more than just financial guidance. They may not know that their role is broader and, perhaps  are unaware of what reports on quality and safety are reasonable to expect from senior leaders.

Board Structure
Emphasizing quality and safety is often a simple matter of constructing (or re-constructing) the board agenda and supporting materials. It’s far less complicated than it sounds.

The board should always receive a quality and safety report at the meeting. It’s best if this is presented before the very end of the meeting when time’s running out. 

Some organizations allow patients and their families to share their hospital experience—both good and bad—at board meetings.

It’s a real asset to have a dedicated board committee focusing on quality and safety matters, including:

  • Serious safety events review
  • Risk management trends and patterns
  • Impact upon quality and safety issues due to staffing and other challenges

The Right Questions
Opening a dialogue with senior leaders will go a long way toward closing the communication gap. In the book, an entire section is dedicated to questions board leaders can pose to senior leaders and staff.

Recommended conversation starters include:

  • What is the most important indicator of quality we are tracking?
  • Have there been any serious safety events this month? What type? Where did they occur? What did the root causes show? How do we prevent that from happening again? How does this benchmark with other organizations like us?
  • I’ve heard about high reliability; what are we doing to get to move the needle toward zero harm?

Measuring Goals
Another excellent, ongoing discussion topic is how hospitals are measuring improvements on safety risks; the approaches are guaranteed to be varied.

Most organizations use a dashboard with Hospital Acquired Conditions, Core Measures and Serious Safety Event Rate included. Those that create visual bar graphs, line graphs, and other graphics can help make it easier for the board to understand and ask questions.

There are plenty more nuggets of information in “Getting the Board on Board: What Your Board Needs to Know about Quality and Patient Safety”. Order your copy today and start maximizing your board/leader efficiency.

What We Have Here… Is a Failure to Communicate


Jan 26, 2017 | Comments (0) | 4425 Views

By Emily Aaronson, MD
Fellow
Harvard Medical School
Fellowship in Patient Safety and Quality Improvement
Massachusetts General Hospital

Despite the growing emphasis on “patient-centered care,” patient safety lapses attributed to poor communication are still commonplace. Noting this, during my fellowship at The Joint Commission, we developed a Quick Safety framework on this important issue. It’s important to reflect on some of the contributing factors and key drivers to change.

Over the last decade, major communications improvements have been achieved during transitions of care and for patient populations with unique communication needs. Despite that, there is more to be done. Specifically, a focus on all provider-patient encounters.

There are some key components of effective patient-provider communication that should be a part of every encounter:

  • Clear expectation setting
  • A patient-centered approach to communication that ensures patients play an active role in the dialogue and that their values are incorporated into decision making
  • Expressions of empathy
  • A focus on clear information exchange and patient education that promotes the understanding and retention of key information

Issue Rooted in Medical Education
Certainly, no doctor sets out with intentions of leaving patients confused or unengaged in their care.  However, in speaking to patients, that is often what happens.

While we once considered communication a “soft skill” that was innate for clinicians, the literature is now suggesting otherwise. Instead, it is now understood that this is a highly trainable, essential “non technical” skill—a skill in which all providers should be trained in and have to demonstrate competency. Given the demonstrated link between poor communication and poor patient outcomes, communication should be considered a core competency.

Modern medical education incorporates some training on empathy and communications skills, but older doctors weren’t required to take these courses. Even for those who have been exposed to these communication curriculums, there’s still an opportunity for more learning surrounding communication. Although there are increasingly “alternative” modules in medical and nursing schools that often bundle ethics, empathy, communication and emotional skills in medical practice, there is rarely a comprehensive, systematic training in communication. As a result, providers may start their careers both without strong skills in this domain, and without understanding its importance.

High-Level Leadership Support
Like anything else, effective patient-provider communication within an organization needs management’s endorsement to get off the ground.

In addition to embracing an attitudinal shift that communication is not second-tier training nor inherent in an individual’s disposition, there are some concrete steps leadership can take to improve communication, including:

  • Conducting an internal assessment of your organization’s current communication training programs and explicit institutional focus on the value of patient-provider communication
  • Measuring clinicians’ communication-focused skills using, for example, patient experience and scores related to communication competency. This information can also be used as a basis for determining goals to improve performance.
  • Carving out protected, compensated time for training
  • Incentivizing staff on metrics related to provider-patient communication
  • Providing coaching for caregivers who are struggling to achieve competency
  • Perhaps most important: Speaking openly at the highest levels of leadership about the importance of communication

Patient Activation Strategies
No discussion of patient-provider communication can be complete without mentioning patient activation, which has been proven to enhance communication. More activated patients are more likely to:

  • Follow their provider’s recommendations
  • Experience better outcomes
  • Avoid unnecessary readmission

While the health and communication status of the patient usually drives the outcome improvement, it’s important to note that misdiagnoses and medications errors do occur as a result of communication breakdowns, even when the patient doesn’t have a verbal limitation.

Logically, strategies to improve engagement is a three-step process:

1. Understand the type of support your patient population needs
2. Provide it
3. Measure the results.

It’s critical that staff members fully commit to patient activation and are trained in communication skills that allow active patients to maximally participate. What we don’t want is a dichotomy between the organization’s strategy to activate patients and the front-line providers’ skills in cultivating a truly shared-care model. 

Lastly, don’t lose sight of equity in this work. This links to the measurement piece. Being sure that you understand which patient populations are using the resources provided (and which aren’t), and measuring these different populations’ overall degree of activation, ensures that we are not inadvertently creating larger disparities in care. For those groups we are not reaching, we need to think more creatively about their individual needs.

Let’s share successes. What’s worked for you in activating patients in their care?

Innovative Ways to Eliminate Health Disparities


Jan 06, 2017 | Comments (0) | 5218 Views

By Ana McKee
Executive Vice President and Chief Medical Officer

Though The Joint Commission has been leading health equity initiatives since 2002, we recognize that the real work is done by the healthcare organizations we accredit.

Health Equity ForumLast fall, we co-hosted an inaugural Health Equity Forum along with the American Hospital Association, to spark discussion about efforts several health care systems and health care professional organizations to reduce health disparities. The Joint Commission also partnered with the American Hospital Association as a supporter in the 1-2-3 for Health Equity campaign. In hosting the forum, we aimed to encourage hospitals to continue in this important endeavor. A number of health systems and organizations are making great strides in addressing equity:

  • View and purchase the moduleAmerica’s Essential Hospitals cultivated the nation’s first online module to collect race data that aligns with Joint Commission, Office of Management and Budget and meaningful use requirements. The REAL (Race, Ethnicity and Language) training module is an online course for registration staff to identify and resolve disparities.

  • Kaiser Permanente developed a holistic care coordination program that encompasses phone assessments, references to relevant community agencies and home visits. It was also lauded for eliminating disparities in cardiac risk and diabetes mellitus among black and white seniors.

  • Henry Ford Health System created a three-year campaign to address sources of inequity, which includes raising awareness and implementing tools to facilitate cross-cultural communication. Its blueprint for the Center for Health Equity includes:

    • Culturally competent care

    • language access

    • health literacy.

Henry Ford’s Kimberlydawn Wisdom, chief wellness and diversity officer, said monitoring national trends and best practices played a huge role in the creation of its Center for Health Equity. Data is a significant component as well and Henry Ford conducts needs assessments and fills its own gaps.

Sometimes, though, it’s the simple courtesies that go a long way toward eliminating disparities.
Henry Ford Health System also recognizes the importance of asking patients:

  • What is your race?

  • What is your ethnicity?

  • What is your preferred language?

Just the few extra minutes to ask and document the answers to those questions help the facility use appropriate interpretation services and patient education information, and better track data. The facility created a patient information document on the importance of these simple questions and Wisdom justified the rationale: We ask because we care.

  • The Detroit Regional Infant Mortality Reduction Program, composed of Detroit Medical Center, Henry Ford Health System, St. John Providence Health System, and Oakwood Healthcare System, formed Women-Inspired Neighborhood Network. The idea was to provide the social support to help support infant survival.

  • The Institute for Healthcare Improvement (IHI) implemented a strategic plan to incorporate quality improvement into all of its activities.

The Joint Commission’s Equity Endeavors

We at The Joint Commission are so proud of the hospitals that contributed to our Health Equity Forum and others working towards eliminating health disparities every day. Beyond supporting their mission, we are working toward the same goal.

As I mentioned, The Joint Commission began addressing disparities nearly 15 years ago. Like you, our projects have been too numerous to list but highlights include advancing patient- and family-centered care for the LGBT patient, improving linguistic services and so much more. David Baker, MD, executive vice president of healthcare quality evaluation at The Joint Commission, noted 30 years of Joint Commission research on pain control disparities.

Our full record of health equity resources are available anytime.

Staff Diversity

Bruce Siegel, MD, MPH, president and CEO of America’s Essential Hospitals organization, also observed the importance of staff—and board members—being as diverse as the communities we represent. Navicent Health promotes this philosophy by including a bonus for search firms who recruit minority candidates. Navicent also re-purposed its human resources department into a coaching department to promote integration.

Nationally, we expect discussion surrounding health equity to intensify and that’s natural. As the U.S. transitions to a new administration, the debate over reimbursement will likely gain steam and it’s important not to ignore any implications that could adversely affect health equity. One pertinent example is the Medicaid debate. At the Health Equity Forum, Sarita Mohanty, MD, executive director community-clinical care integration of Kaiser Permanente, said it’s important to support Medicaid for continuity of coverage.

With the coming of a new year, a new president and expectations of an unprecedented amount  of change,  it is important to continue to reduce disparities in health care. Disparities lead to unsafe care and unfavorable outcomes. There is no one solution for this complex problem and that is why it is critical for healthcare organizations to continue implementing strategies to reduce disparities and share their learnings with others. What is your organization doing to promote health equity?

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