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As people coming to us in a time of need, our patients trust we will do everything and anything to keep them safe.
As an industry, we have seen many articles about the findings of "To Err is Human," the 1999 study conducted by the Institute of Medicine, which estimated that 98,000 preventable deaths and 1 million injuries occur in our hospitals every year.
It has been more than a decade since that study was published. How much progress have we made in reducing these incidents?
Many hospitals and health systems around the country have done amazing work in decreasing ventilator-acquired pneumonia and central line infections, eliminating birth trauma, preventing serious falls with injury, eliminating pressure ulcers and the list goes on.
However, in spite of these improvements, we still find that patients in our hospitals are harmed. It is fair to say that no one comes to work in a hospital with the intention of harming a patient. Healthcare providers at all levels choose to work in healthcare because they want to make a difference in patients' lives.
So, if healthcare providers are dedicated to making a difference, where is the disconnect? What are we as healthcare leaders missing?
Changing the Culture
The missing link is far deeper than protocols and checklists, albeit these tools are a vital component in keeping our patients safe.
The missing link is the absence of a true culture of safety within our organizations. If we are going to live up to the trust that patients place in us, we must first consider our own core behaviors, acknowledge our failures and then intentionally build an environment where safety is the cornerstone value.
Changing the culture in a hospital is not for the weak of heart, but we should also realize that we are not blazing new territory.
We can look to industries such as naval aviation, nuclear power, commercial airlines and nuclear submarines for examples of culture change and the development of safety as a core value.
These industries found that accidents happened because employees cut corners, were afraid to speak up, didn't follow protocols, or didn't look out for one another and use others' expert knowledge to validate that they were doing the right thing.
These industries realized that at the heart of these problems were people practicing high-risk behaviors during high-risk activities, resulting in serious safety events. They needed to adopt low-risk behaviors in order to minimize inadvertent harm.
The staff in our hospitals is no different then those who work in industries outside of healthcare. What is different is how we lead and manage expectations around these high-risk behaviors.
Starting at the Top
Creating a culture of safety starts at the top. To change a culture, start with the practice of transparency. We have to be transparent about our errors and use stories to bring the harmed patient to life for our healthcare providers.
Transparency must be coupled with a belief in a "just culture," where disclosing unintentional errors or near misses are recognized and rewarded to enable learning and change to occur. However, transparency and just culture are only the beginning. Leaders must walk the talk, making purposeful safety rounds to ask staff about what barriers exist in keeping their patients safe.
Beyond transparency and just culture is training, giving the staff the tools they need to lead this change.
We work in a high-risk environment in hospitals, and practicing high-risk behaviors only serves to put our patients at risk for harm. It is not easy to change behaviors, but with the proper tools it can be done.
St. Vincent's Health Services in Bridgeport, CT, is part of the Ascension Health System, the largest Catholic healthcare system in the country. We started our own journey to creating a culture of safety in 2009 with the support of HPI (Healthcare Performance Improvement), a Virginia Beach, VA-based firm.
HPI conducted an analysis of our serious safety events - events that caused serious permanent or temporary harm, including death, due to error - and identified the root cause issues that resulted in harm to our patients. They also measured the number of days between serious safety events. We presented HPI's findings about our own performance to our board, medical staff and hospital staff, and there was no turning back.
Employee Training
HPI worked with our staff - starting with me - on owning the necessary changes.
Our staff developed a toolkit to help the organization learn the new skills required to practice safe behaviors and speak up for safety. The toolkit evolved into a training program for all employees, regardless of their job. Class size was limited to 20 participants and lasted 3 1/2 hours, so with a work force of more than 2,500, you can calculate the number of classes we conducted over a 7-month period.
The medical staff wanted to be part of this change. We started with a retreat where HPI principal Kerry Johnson and a physician member of his staff helped the physicians understand the need to change and their role in that change. In large part, it was the telling of our own stories of inadvertent harm, coupled with the advice from HPI, that captured the hearts and minds of our physician leaders and drove their support for the project.
The medical executive committee voted that a physician could not be part of our staff without attending a 1-hour class on high-reliability behaviors. With more than 750 members of the medical staff this, too, was no easy task to accomplish.
Daily "Safety Huddles"
Other recognizable changes include that we start every meeting, including the board meeting, with a safety story. Every morning we have a 15-minute stand-up "safety huddle" with about 60 members of our management team. We start the huddle with the number of days since the last serious safety event for our patients and staff and ask:
• What happened in the past 24-hours to put our staff or patients at risk?
• What concerns do you have in the coming 24-hours that could cause harm to patients or staff?
• Is there anyone we should recognize as a safety hero?
Issues raised are categorized in either a 24-hour follow-up or a 7-day follow up, depending on the risk. A member of the management team is responsible for working with others on the team and reporting back on the resolution. This same activity is repeated in every department in the hospital. This short huddle sets the stage for the day and has been invaluable in our transition to a culture of safety.
We also post the days since a serious safety event for both staff and patients on our intranet, as well as all the details about the events including the changes made as a result of the event.
Our chief administrative officer posts a safety blog on the intranet as well. Staff who have good catches are recognized as safety heroes and receive a letter from the CEO and vice president of their service line along with a pin. They are highlighted in our internal newsletter and their photos are posted in the lobby.
Now that training is completed, our next phase is to develop front-line safety coaches. We fully understand this is a continuous journey, one that will always require the full attention of leadership.
Results
So what's changed as a result of all this effort? Lots. Our serious safety events have declined by 55 percent in the last year. Staff are speaking up about safety concerns and physicians are thanking them for it. There is increased collaboration across departments and improved accountability at multiple levels. Problems are solved more quickly, no matter how small.
We are far from done, but we have made significant progress. Most importantly, our patients are safer. We are building a culture of reliability and changing our behaviors.
Susan L. Davis is president and CEO of St. Vincent's Health Services, Bridgeport, CT.
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