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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.

NOTE: Industry leaders are encouraged to submit guest blogs for the Leadership blog. Those interested should contact Communications Specialist Robin Hocevar.

Using Unit-Level Safety Culture Survey Results to Make Quality Improvements

Oct 20, 2017 | Comments (0) | 33 Views

Smith_C_09-13By Coleen Smith
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the seventh 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 seventh and eighth tenets:
7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement. 
8. Use information from safety assessments and/or surveys to develop and implement unit- based quality and safety improvement initiatives designed to improve the culture of safety. 

A previous blog post centered on tools that hospitals can use to determine an organizational safety culture baseline.  Now, we’re moving on to using the information gained from those survey tools to make improvements.

It’s important to make safety culture survey results relevant to individual units. Rather than sharing only hospital-level results, leaders who share unit-level results with hospital teams can start conversations that lead to unit buy-in and successful quality and safety improvement initiatives.

The information you share at the unit level will likely not be a great surprise to unit team members because the data will echo their survey responses. However, presenting them with the survey data provides leaders with an opportunity to find out why team members responded the way they did, and an opportunity for both leadership and unit members to fully understand how the data can lead to better quality and safety. This can be accomplished when an approachable individual who has built up a lot of internal trustinitiates an open conversation with unit staff. 

Follow-Up Questions
Edgar Schein, an organizational culture expert and former professor at the MIT Sloan School of Management, wrote a book titled “Humble Inquiry: The Gentle Art of Asking Instead of Telling.” Schein says that the mistake many organizations make is simply asking people what they think and then telling them what they said. It’s important to take it a step further – to ask “why did you say what you said?”

For example, if units score low on a certain aspect of safety culture, try and understand the reason. The “why” will vary by unit, but it’s very important to understand it before moving into an improvement initiative. In addition to comparing the latest data with previous results, look at factors such as:

  • unit response rate

  • the make-up of respondents by job function

  • changes occurring within the unit, such as staff turnover, layoffs, or a change in unit leadership

And since many survey responses tend to be dominated by nurses – due to their sheer number– having discussions at the unit level about safety culture provides an opportunity to hear the viewpoints of other unit team members.

Reinforcing the Importance of Reporting
These discussions also provide organizations with an opportunity to reinforce their commitment to just culture in regard to error reporting or unsafe conditions. Most hospitals still struggle to alleviate team members’ fear of disciplinary action or retribution after a report – that something bad is going to happen if they report something. Discussions about safety culture survey results give leadership an opportunity to thank unit members for their frank feedback and to express how valuable it is to the organization. 

The most common answer to the question "How many things have you reported in the last 12 months?" is none. This shouldn’t be the case if your assumption is that just about everybody has witnessed an error or adverse event. To create a true safety culture in the health care industry, leaders still need to work on establishing a just culture in which honest mistakes are seen as learning opportunities.

Setting Priorities with Survey Data
There are many aspects of care with great opportunity for improvement – handoffs, transitions of care, and teamwork across units, for example. There’s a perception among unit members that they are doing a great job within the units but not so great a job handing things off and communicating beyond their unit.

Medication administration from beginning to end is one of the most complex processes in a hospital, from the time a physician prescribes a medication, through the ordering process, checking the order, filling the medication, getting it to the unit, and administering it to the correct patient, at the correct time and correct way. The opportunity for error is huge and it makes sense that this is where many mistakes occur. Multi-step procedures also present an increased risk of error. 

Safety culture surveys give organizations the information they need to develop unit-level action plans to help improve areas of low scoring. Not every unit will work on  the same problem, but each unit should work on improving an aspect of safety culture they determine to be a high priority. 

Hospitals can then aggregate these individual unit efforts to demonstrate their organizational commitment to having a safe and just culture. Leaders can take the first step toward building this organizational-wide culture by examining unit-level data and having frank discussions with unit team members on how to make improvements. The data are a start. The discussion and buy-in from team members are the crucial next steps to improving quality and safety.

Use Insight Gained From Safety Culture Surveys to Make Improvements

Aug 22, 2017 | Comments (0) | 1931 Views

Smith_C_09-13By Coleen Smith,
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the sixth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic.  In this post, we examine the sixth tenet: Determine an organizational baseline measure on safety culture performance using a validated tool.

Joint Commission-accredited hospitals must regularly evaluate their safety culture using valid and reliable tools, according to Standard LD.03.01.01, Element of Performance 1. How they choose to meet this performance standard is up to them. For many hospitals, it’s an ongoing challenge to accurately assess safety culture without burdening employees with another survey.

Two survey tools designed to help meet this accreditation requirement and mentioned in the Sentinel Event Alert are the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) and the Safety Attitudes Questionnaire (SAQ). Another more recently developed tool is called SCORE, an integrated survey of safety, communication, organizational reliability, resilence/burnout, and engagement.

The HSOPS measures hospital performance on 12 dimensions of safety culture: 

  1. communication openness
  2. feedback and communication about error
  3. frequency of events reported
  4. handoffs and transitions
  5. management support for patient safety
  6. non-punitive response to error
  7. organizational learning (continuous improvement)
  8. overall perceptions of safety
  9. staffing
  10. supervisor/manager expectations and actions promoting safety
  11. teamwork across units
  12. teamwork within units.

Introduced in 2004, the HSOPS has been used by hundreds of hospitals. The most recent HSOSP database report (2016) presents safety culture data compiled from 680 U.S. hospitals comparing its safety culture results. The 2016 report also includes a chapter on trending that presents results showing changes over time for the 326 hospitals that administered the survey and submitted data more than once. Participating in the database is voluntary; therefore, more hospitals than what are included in the report may be using the survey.

The SAQ was developed by the University of Texas and was the subject of a 2006 study. The SAQ measures six culture domains: 

  1. teamwork climate
  2. safety climate
  3. perceptions of management
  4. job satisfaction
  5. working conditions
  6. stress recognition. 

The SAQ also enables users to compare themselves with other organizations.

A 2012 study compared the HSOPS and the SAQ, finding them both reliable and advising prospective users to consider survey length, content, sensitivity to change, and the ability to benchmark when selecting one of these surveys.

Introduced in 2014 by a partnership of Safe & Reliable Healthcare, LLC, and the Duke Patient Safety Center, SCORE creates detailed unit-level indicators and provides in-depth and actionable insights into organizational clinical and operational performance and risk, according to the Safe and Reliable Health care website. SCORE touts itself as an advance over its predecessors in the safety culture survey space.

Survey Fatigue
When surveying staff, hospitals sometimes struggle with “survey fatigue,” since team members may be asked to complete questionnaires on various topics in addition to safety culture. High participation rates means more reliable data, and hospitals must strike a balance between choosing a tool that gains in-depth information but is not intimidating or difficult to complete.

No matter what survey tool is used, it’s not enough only to survey, from a high reliability standpoint. Hospitals must use the information gained to make visible improvements. Otherwise, they will continue to receive subpar participation from team members on surveys. Team members will say, "I complete this survey every year, and I don't see that you've done anything with the information that I've given you.” Hospitals must view the feedback gained from team members as opportunities to make improvements all the way down to the unit level because culture varies by unit.

Goal Setting 
Drs. Mark Chassin, president of The Joint Commission and Jerod Loeb, Ph.D, late executive vice president, Division of Healthcare Quality Evaluation, wrote about this dynamic in their influential 2013 Milbank Quarterly article on high-reliability health care. “Today, many hospitals regularly use one of several available staff surveys to assess their safety culture. Few, however, analyze the meaning of the survey data, evaluate where each area of the hospital is falling short, and undertake specific, focused interventions to remedy those shortcomings. As hospitals make more progress toward high reliability, they will include safety culture metrics as part of their strategic planning programs, set goals for improving on those metrics, and report on those metrics to their boards, just as they report on metrics related to financial performance or patient satisfaction.”

Recognizing Those Who Contribute to Safety Culture: The Trust-Report-and-Improve Dynamic

Jul 31, 2017 | Comments (0) | 2478 Views

Smith_C_09-13By Coleen Smith
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the fifth 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 fifth tenet: Recognize and praise care team members who report adverse events and close calls, identify unsafe conditions, or present good suggestions for safety improvement.

The “trust-report-and-improve” dynamic is a crucial aspect of establishing high reliability in health care. When team members report adverse events or share concerns or ideas about safety, it’s important for team leaders to recognize their contributions, use their information to make improvements, and communicate back to team members how safety was enhanced as a result.

Establishing a process for consistently recognizing individuals who identify safety improvement opportunities reinforces the importance of both identifying and responding to unsafe conditions. This recognition also creates a bond of trust with leadership and contributes to building a safety culture. 

Personal Recognition Works Best
Expressing personal thanks for safety-related contributions within the unit or organization is so appreciated by team members.  Many organizations offer small incentives for reporting safety issues such as: 

  • providing “good catch” awards in the shape of a baseball mitt for reporting close calls
  • large trophies for the most improved adverse event reporting
  • raffles for a close-by parking space among contributors of safety ideas
  • recognizing individuals in newsletters and on bulletin boards
  • paying for a unit pizza parties 
  • providing gift cards 

Pre-Emptive Mentality

In developing both recognition and a safety culture initiative, it is important to progress from simply reporting adverse events, to reporting close calls, and then to thinking more broadly about unsafe conditions or situations that could lead to adverse events or suboptimal outcomes. It’s a challenge to expand safety mindfulness from identifying mistakes that have or nearly happened to include what may happen.

What may happen because two patients on the floor have the same or similar names? What may happen because a particular piece of equipment is difficult to find or obtain? Situations that team members may currently view as daily annoyances may actually be unsafe conditions. After a potentially unsafe situation is found, it’s even better to devise a solution. For example, to prevent venous thromboembolism after surgery, a nursing unit decided to stock sequential compression devices on the unit, rather than in central storage, to reduce the time post-surgical patients waited for this intervention.

Hallmark of High Reliability
Getting team members to identify these kinds of situations is a definite evolution toward a safer culture. High-reliability health care is more than not harming patients; it’s making sure patients receive recommended care as soon as possible and without overuse. This highly reliable performance is particularly important for the diagnosis and treatment of sepsis, heart attack, stroke, and many other conditions. Proactive thinking leads to the best treatment and reduces the chances of errors.

As safety cultures within organizations become more adapt at anticipating and responding to potentially unsafe conditions, they move further away from the “sharp end of the stick” where adverse events occur. Reporting adverse events and close calls, and then further evolving toward identifying unsafe conditions and making safety suggestions is crucial work within a safety culture. Leaders must recognize and praise those contributing to this work; this creates the trust, report and improve dynamic that makes high-reliability health care possible.

Beyond the Study: A Q&A with Eisenberg Patient Safety and Quality Award Recipients: Part 3

Jul 06, 2017 | Comments (0) | 1290 Views

By David W. Baker, MD, MPH, FACP
Executive Vice President, Division of Health Care Quality Evaluation
Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety
The Joint Commission



Tabassum Salam, MD, FACP, CHCQM
Medical Director of Carelink CareNow
Christiana Care Health System



This is the final post in a three-part series highlighting the quality improvement and patient safety achievements of this year’s John M. Eisenberg Patient Safety and Quality Award recipients, showcased in the July 2017 issue of The Joint Commission Journal on Quality and Patient Safety. This post examines the quality and patient safety efforts of Christiana Care Health System’s Christiana Care Care Link, recently renamed Carelink CareNow, recognized in the award’s local achievement category. Carelink CareNow is a technology-driven, care coordination program based in Wilmington, Delaware. 

Here are the highlights of a conversation between the Journal’s Editor-in-Chief Dr. David Baker and Carelink CareNow’s Dr. Tabassum Salam. 

Dr. Baker: Can you speak to how Carelink CareNow addresses the needs of patients whose co-morbid conditions would place them into a number of population health groups?

Dr. Salam: We fully recognize that it is not realistic to compartmentalize patients under the assumption that each patient only has a single co-morbidity or need. For patients with multiple, interwoven medical and socioeconomic risk factors, we take a multi-professional complex case management approach. There is a lead case manager for each patient, and he or she reaches out to a multi-disciplinary team member who can best address the patient’s needs at any moment. Even though a patient may have diabetes, heart disease and chronic obstructive pulmonary disease (COPD), at any time, the lead case manager must assess which of these co-morbidities is currently significantly affecting the patient’s health. 

For example, immediately after a hospital admission for COPD exacerbation, the case manager determines whether the pulmonary disease is on the forefront, and he or she will subsequently reach out to the Carelink CareNow respiratory therapist for detailed support of the patient. Once the pulmonary issues are stabilized, the case manager will reassess the issue and ascertain, again, which co-morbidity is most active and significantly affecting the patient’s health. From there, the case manager will pivot to a different Carelink CareNow colleague(s) for in-depth support. 

Dr. Baker: Patients’ behavioral health needs have generally been conceptualized as separate from their physical health needs. What is Carelink CareNow’s role in addressing behavioral health needs?

Dr. Salam: We have realized that behavioral health and physical health needs cannot be separated, so we take a holistic approach to each patient. Here too, we use the multi-disciplinary Carelink CareNow team model in the case management of these patients. We have team members, such as registered nurses and social workers, with experience in working with patients who have behavioral health disorders to:

  • Meet with patients in their home or community. Seeing patients outside of the clinical environment significantly augments our ability to engage patients with behavioral health disorders. 
  • Hold case conferences with patients’ medical and behavioral health providers in order to create a multi-faceted care plan.
  • Conduct bi-weekly group conferences with a psychiatrist in order to brainstorm about new intervention options for challenging cases.

Dr. Baker: You mention the “next step” of developing new data sources, such as biometric monitoring, may expand your predictive analytics capabilities, even to the point of redefining the state of rapid response systems for clinical deterioration. How would that fit into your other goals

Dr. Salam: We partner with patients to ensure they receive the best health care and support in a timely manner. We also plan to use new data signals, such as real-time results from ambulatory biometric devices (e.g. blood pressure cuffs or glucometers) in order to identify patients whose medical conditions might worsen. We strive to proactively reach out to our patients in order to guide them off what otherwise could be the inevitable trajectory toward exacerbations of medical conditions that lead to unnecessary emergency department or hospital utilization.

The Joint Commission Journal on Quality and Patient Safety provides open access to articles about the Eisenberg Award recipients in its July 2017 issue. 

Beyond the Study: A Q&A with Eisenberg Patient Safety and Quality Award Recipients: Part 2

Jun 29, 2017 | Comments (0) | 1229 Views

Baker_DavidBy David W. Baker, MD, MPH, FACP
Executive Vice President, Division of Health Care Quality Evaluation
Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety
The Joint Commission



ClancyCarolyn M. Clancy, MD
Deputy Under Secretary for Health for Organizational Excellence
Veterans Health Administration, U.S. Department of Veterans Affairs (VA)



This is the second post in a three-part series highlighting the quality improvement and patient safety achievements of this year’s John M. Eisenberg Patient Safety and Quality Award recipients, showcased in the July 2017 issue of The Joint Commission Journal on Quality and Patient Safety. This post examines the quality and patient safety efforts of Dr. Clancy, recognized in the award’s individual achievement category. 

Here are the highlights of a conversation between the Journal’s Editor-in-Chief Dr. David Baker and Dr. Carolyn Clancy.

Dr. Baker: The VA has enormous riches in its electronic health record (EHR) database. What plans do you have for developing its big-data role in evidence-based clinical decision making? 

Dr. Clancy: For nearly three decades, the VA has led the way with foundational contributions to the delivery of clinical care, including advanced EHR and performance measurement systems that have been integrated into alerts and clinical reminders. Without question, these advances have improved quality. In recent years, however, the limitations of these approaches, in terms of information overload and inefficiency, have become apparent.

The VA clearly recognizes that future improvements hinge upon advanced analytics to capitalize on the full value of our vast data systems in a manner that is seamlessly integrated into defined clinical workflows. To this end, we are working with partners such as Oakridge National Laboratory, Google and IBM Watson to construct analytic environments. These environments are capable of delivering critical information, including predictive analytics, to the point of clinical decision-making in a manner that is viewed by providers as both constructive and as “making it easy to make the right choice”. Although ambitious and challenging, we view these efforts as essential to the next quantum improvements in providing optimal care to both individual veterans and larger populations. 

Dr. Baker: In your interview in the Journal, you state “Patient empowerment is critical to quality”. The latest talk in this area concerns co-production, an approach that emphasizes the collaboration between care providers and patients, such as in the redesign of care. Is this an area of interest for the VA? 

Dr. Clancy: We are truly privileged at the VA to say that for decades we have been collaborating with veterans in the design of their care—from our 90-year-old research program where veteran volunteers participate in studies such as the Million Veteran Program, a voluntary research study on how genetics effect health—to our joint Department of Defense effort on clinical practice guidelines (CPGs) where veteran focus groups discuss topics such as the management of opioid therapy for chronic pain. More recently, we have been working with veterans regarding our new Access to Care website. 

Dr. Baker: What are your exact quality and safety priorities, as evaluated in terms of specific measures, for the next year or so?

Dr. Clancy: As noted by our new Access to Care website, we have already embarked upon a path toward greater transparency and accessibility by addressing: 

  • Access. We report on wait times by facility, patient-reported experiences regarding routine care and how often veterans received needed care right away. 
  • Quality. Our new website shows how each VA medical center performs compared with private sector counterparts in their market area. 
  • Patient safety. We continue to build upon a solid foundation that includes reporting (e.g. patient harms and near misses) and routine disclosure to veterans and their families when patients are harmed by care. 

In addition, we sponsor several extensive educational training programs which remain a key quality and safety focus for the VA, including:

  • The VA Chief Residents in Quality and Safety program, which trains approximately 60 chief residents yearly
  • A Quality Scholars program for physicians and nurse leaders
  • Clinical team training for groups of clinicians and allied health professionals

We take an enterprise approach to assessing risks at all stages of care so that we may detect potential vulnerabilities at the earliest stages. This approach takes into account:

  • Enterprise risk management 
  • Expressed concerns of leaders and frontline clinicians and staff
  • Regular review of findings from external entities such as The Joint Commission and other accreditors, the U.S. Government Accountability Office (GAO) and the U.S. Inspector General  

The Joint Commission Journal on Quality and Patient Safety provides open access to articles about the Eisenberg Award recipients in its July 2017 issue. 

Our next post in the series will publish next week, featuring more from the interview with Christiana Care Health System’s Carelink CareNow and its quality and patient safety priorities.