After several years of progress, Hartford HealthCare, a seven-hospital system based in Connecticut, is using case-based learning to move beyond a plateau regarding its reduction of serious safety events. This new effort is part of the health system’s commitment to eliminate medical errors.

  • Leaders created a curriculum that includes learning sessions based on more than two dozen cases of harm or medical error that actually occurred in the Hartford system.
  • The specific cases used have been selected from various disciplines, ranging from incidents that involved heart or vascular events to harm that transpired because of hospital transitions or diagnostic errors.
  • Administrators note these sessions create powerful learning opportunities whereby clinicians and staff perform their own root cause analyses before discussing how the errors can be prevented moving forward.
  • The sessions are used to enforce high reliability behaviors and to encourage staff at all levels to raise safety concerns.

The term “high reliability” had not come into focus when the quest to become a high reliability organization (HRO) began a decade ago for Hartford HealthCare.

That is when Hartford, a seven-hospital system based in Connecticut, adopted its H3W operating model, according to Rocco Orlando, MD, FACS, the health system’s chief academic officer, who spoke about the health system’s journey at the Institute for Healthcare Improvement’s national forum in December 2019.

“It’s really about culture and respect. It’s about how we get along with one another. We thought that platform was essential to the high reliability part of the journey,” Orlando noted.

However, over time, health system leaders have layered on additional aspects to the operating model, such as Lean quality improvement techniques, the creation of new metrics, and organized rounding.

“We were incrementally adding to the capabilities of our model over time because we think it is essential that you can’t drive your people crazy,” Orlando explained. “You have to keep the lessons simple and straightforward. You have to really convince folks that [new steps] are really part of an organic process.”

However, the explicit “high reliability” piece of Hartford’s journey really began in 2013. That is when leaders committed to eliminating medical errors, Orlando recalled. Fortunately, leaders were not walking this path alone. Hartford joined the Connecticut Hospital Association and its member facilities in committing to the same goal. “It was really a commitment to cultural change,” Orlando added.

Since then, Hartford has used techniques to enhance reliability processes, with a keen focus on systems thinking and preventing errors before they occur. “We have paid more attention to detection,” Orlando reported. “We are looking at our near-misses, we are looking at our precursors to safety events, and we are really harvesting that data to look for trends to find times when we might be able to head off something at the pass.”

Hartford’s leaders also have focused on the organization’s approach to root cause analysis to examine serious safety events and ensure lessons learned are shared widely.

“Our serious safety events and our high-risk near-misses are shared ... at all of our leadership groups, and then again cascaded down [to staff],” Orlando explained. “There is a richness in those experiences that needs to be shared.”

As part of this effort, Hartford has focused on ensuring staff use the same process to assess and document harm, Orlando observed. “We make sure that the way we categorize serious safety events, precursor safety events [that reach the patient but cause minimal or no harm] and near-misses ... is the same across the entire organization,” he added.

To facilitate this process, the health system maintains a centralized quality structure in which adverse events and near-misses are reviewed to ensure a consistent approach is used in categorizing and analyzing the cases. This helps keep data reliable, Orlando said.

“We are using our electronic reporting systems to harvest and mine these data,” he shared. “We are presenting this [information] in dashboards so that we have data and trends that we can then feed back to all of our system members to help in the improvement process.”

Use Case-Based Learning

All these techniques have paid dividends. In five years, Hartford has reduced serious safety events by more than 70%. But with improvements plateauing in recent years, leaders reached for a new approach to their operating model that would help them continue the march toward high reliability.

They concluded that any new approach should begin with broad buy-in from the entire leadership team, including Hartford’s board and CEO, and that it should become part of the rounding process, Orlando explained. “We have to make it tangible when we are meeting with staff, whether in informal meetings or in rounding,” he said.

Ultimately, in 2019, the leadership team concluded they needed to re-educate using case-based learning or storytelling to illustrate how errors occur.

“We were really feeling that we needed staff to engage in questions and learning and really probe what we should be doing differently,” shared Stephanie Calcasola, MSN, RN-BC, CPHQ, vice president for quality and safety at Hartford HealthCare. “Our quality and risk manager leaders created 27 case-based sessions based on our harm events, not our proud moments.”

These cases were categorized by specialty. For instance, some involved heart or vascular events, while others pertained to inpatient transitions, ambulatory care, or medical diagnostic errors, Calcasola explained. “We then created a standard one-hour template program with all credentialed HRO trainers,” she added.

Thus far, the training sessions have been deployed to Hartford sites throughout Connecticut, engaging more than 1,500 clinical leaders. “Our goal was to rearticulate what high reliability behaviors are,” Calcasola noted.

For instance, the sessions include a review of how to use the Stop, Think, Act, Review (STAR) mnemonic. “The other major cultural commitment was [for attendees] to understand their role as a leader in modeling high reliability, particularly for our numerous staff,” she said.

There also is an emphasis on empowering staff to use “red alerts” if they need to express a safety concern, Calcasola noted. “That flattens the power base, and we have another chain of command that we follow for that,” she observed.

Revisit Harm Events

Each case session provides an opportunity for participants to conduct their own root cause analysis to figure out what went wrong.

For example, one case involved a 53-year-old patient who was brought to the ED suffering a stroke. There was bleeding in his brain, and it was determined that he required a hemicraniectomy, where part of his skull would be removed to relieve pressure on one side of his brain, Orlando observed.

Luckily, one of the health system’s best neurosurgeons would be performing the operation, supported by an excellent team. The patient was brought to the operating room, there was a time out taken before the procedure began, and the surgery was completed, Orlando reported.

However, when the neurosurgeon immediately reviewed a post-operative CT scan of the patient’s brain to assess the results, he realized he had operated on the wrong side of the brain.

Hartford leaders are using this incident as a case-based opportunity for learning. A relevant multidisciplinary group will work to figure out what went wrong and how another similar situation can be prevented. In this instance, the patient had dark skin. The purple marker the surgeon used to label the side of the brain requiring surgery was not visible, Orlando explained. The surgeon marked the correct side, but later turned the patient’s head to the wrong side, resulting in the wrong-site surgery.

This is despite the fact the team went through the time out and the verification process that is part of operating room procedure. “This tells you that it really wasn’t a good time out,” Orlando observed.

In this case, investigators discovered that there was an inappropriate deference to authority. Everyone was thinking that the surgeon was the smartest guy in the room, that he is never wrong, Orlando explained. “We are all wrong [sometimes], and we need our teams to help us,” he added.

Listening to clinicians in the room reliving that event through the case study, Calcasola was impressed hearing how each participant rethought what he or she might have done in that situation, and whether that event could have happened to them, she explained.

“It indirectly supports some of our just culture work, recognizing that errors happen to all people, and what we could we do differently as a way to even support that practitioner because of that error,” she said. “That kind of learning is quite powerful.”

Storytelling is about not fearing transparency, Orlando added. “[It’s] being out there and sharing the good and the bad with the team in the drive to get better,” he explained.