'High reliability' hospital obsessed with safety
'High reliability' hospital obsessed with safety
Akin to airlines, nuclear power
When you get on an airplane, you expect layers of precautions to prevent any error that could lead to failure and injury. You demand the same or even greater care from the nearby nuclear power plant. And now, you can expect that serious attention to safety from a growing number of hospitals.
St. Vincent's Medical Center in Bridgeport, CT, is an example of a "high-reliability organization," a hospital that is "obsessively" focused on safety.
It has welcomed scrutiny from the U.S. Occupational Safety and Health Administration (OSHA) to work toward the Voluntary Protection Program. It has attained recognition as a "magnet" hospital from the American Nurses Credentialing Center, a subsidiary of the American Nurses Association.
And it was profiled by The Joint Commission accrediting agency as a best practice for linking patient safety and worker safety. "Safety at St. Vincent's is not viewed as a 'program' but rather the core foundation of their work — a job that will never be completed," The Joint Commission monograph said.
This focus on safety has translated into savings, both in dollars and human terms. For example, the hospital had a 22% decrease in needlesticks and a 30% decrease in serious employee falls in 2012 compared with 2011.
"[Our CEO and president, Susan Davis, EdD,] has made it very clear, and it has to be clear from the top down, that our number one pillar, our foundation, is safety," says Karen J. Nefores, RN, BSN, MBA, executive director for quality, case management and patient safety.
To have a culture of safety, you have to take a broad view, says Joseph Lavenziana, executive director of safety and security. "Zero patient harm was where high-reliability started. We said, 'Why not zero employee/associate harm?'" he says.
St. Vincent's was one of three Ascension Health hospitals that began working toward high-reliability and comprehensive employee safety in 2008. The Connecticut Hospital Association has since launched a statewide collaborative to promote a high-reliability culture.
Days begin with safety huddle
Every day at St. Vincent's starts with safety — even the weekends. The hospital CEO or a vice president leads a hospital-wide "safety huddle," which lasts from 15 to 30 minutes, depending on the issues being discussed.
Each huddle begins with a report on how many days it has been since a medical error or worker injury. If there has been an event — for example, a nurse who fell or a sharps injury in the OR — then there is a short synopsis and discussion of the root cause and what might be done to prevent future similar events.
Anyone in the hospital can come to the huddle and express a concern. "I attend hospital-wide huddle every day, and the room is so full sometimes that there's no standing room," says Nefores. "It goes beyond our 15 minutes sometimes because so many people want to share concerns."
That is a huge shift from the days when people were reluctant to speak up because they feared being blamed for an error or accident, she says. "That is absolutely a change in culture," she says.
In fact, that openness is rewarded. Employees who took steps to prevent injury or who identified a potential hazard are recognized with a safety pin. Employees who shared an idea that improved safety or quality can receive a quarterly reward of up to $100.
There are also safety huddles every day in every unit, and monthly "culture of safety" meetings geared toward frontline workers. The safety huddles encompass patient, environmental or worker safety.
"There's always an accountable person who has to come back to the meeting with either a resolution or why there hasn't been a resolution to the problem," says Kathleen Ventura, RN, coordinator of employee health.
Serious safety events aren't the only items on the agenda. They also target "precursor safety events," which result in minimal or no harm, and near-misses. Safety coaches on the units help spread information and train other employees to use safety techniques or devices.
Employees learn to 'CUSS'
"High reliability" has a lingo all its own. The hospital's 2,400 employees have been trained in high-reliability concepts, as have all physicians with privileges.
For example, an S-BAR might be communicated in an email or reviewed at a safety meeting. That stands for "situation, background, assessment, recommendation." Employees are reminded to STAR — stop, think, act, review.
Everyone has "200% accountability," which means they are 100% accountable for their own safety practices and also 100% accountable for making sure others are working safely. That gives employees permission to CUSS — or speak up when they see someone doing something unsafe by saying, "I'm concerned, I'm uncomfortable, this is a safety concern. Stop."
"If they see someone who is not in compliance or they feel it's a safety issue, they are able to approach that person and say 'Do you know we do it this way now?' or offer an intervention or device," says Ventura.
The hospital uses "dashboards" to monitor safety metrics, from hand hygiene audits to needlesticks. The dashboards keep people focused on goals, says Ventura. "Our dashboards are a good way to maintain our sustainability," she says.
Reliability in three steps
Reliability is "failure-free operation over time," according to the Institute for Healthcare Improvement. IHI identifies these basic steps toward reliability:
1. Prevent failure (a breakdown in operations or functions). This includes tools to implement guidelines, feedback on compliance and awareness training.
2. Identify and mitigate failure. Identify failure when it occurs and intercede before harm is caused or mitigate the harm caused by failures that are not detected and intercepted. Use strategies to "error-proof" the system, such as color-coded reminders, computer alarms, and decision aids.
3. Redesign the process based on the critical failures identified. Analyze processes to determine where they could fail and how that failure could be prevented.
Source: Adapted from: Nolan T, Resar R, Haraden C, Griffin FA. Improving the reliability of health care. IHI Innovation Series White Paper. Boston: Institute for Healthcare Improvement; 2004. Available at www.IHI.org.
Task forces address injuries
With this intense focus on safety, St. Vincent's has systematically addressed some of the major causes of injury among hospital employees.
A workplace violence task force is implementing a comprehensive prevention program, including training employees to recognize risks and respond to patient agitation or aggression. Employees can call for assistance from a behavioral health emergency response team. And medical records may be flagged if patients have a pattern of repeated aggressive behavior.
From Jan. 1 to Nov. 30, 2012, St. Vincent's had 9 lost work days related to workplace violence, compared to 42 lost work days in the same period of 2011.
To reduce back injuries, St. Vincent's conducted a comprehensive review of patient handling and added ceiling lifts and other devices.
While injury rates dropped, needlesticks persisted. A needle safety task force met for four months and discovered that some nurses were not activating the retractable devices. The needles and syringes were a single unit, so some nurses had stashed conventional needles that could be removed from the syringe.
St. Vincent's switched to a product that sheathes the needle with a one-handed action. A blunt needle is used to draw medication, and then it is removed and replaced with the safety needle. All other needles have been removed from the hospital, so nurses can't revert to a conventional needle. Needlesticks declined to 25 in the first 11 months of 2012 from 32 in 2011, and St. Vincent's hopes to reduce that even further.
The cycle of identifying safety concerns and seeking solutions never ends, says Nefores. "[We're] keeping it alive, constantly, every day, being relentless," she says. "If we have a huddle where it's quiet, the leader will be prompting and encouraging people to speak up and share."
As serious events decline, the hospital will focus on precursor events and near-misses, so there will always be a safety goal, she says.When you get on an airplane, you expect layers of precautions to prevent any error that could lead to failure and injury. You demand the same or even greater care from the nearby nuclear power plant. And now, you can expect that serious attention to safety from a growing number of hospitals.
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