Comprehensive Initiative to Create a Culture of Safety Significantly Reduces Harm Caused by Medical Errors, Mortality, Length of Stay, and Hospital-Acquired Pneumonia and Infections

Problem Addressed

• Too many preventable errors and deaths: Achieving high levels of patient safety is critical to the quality of health care and one of the six Institute of Medicine quality aims for improving the health care system.¹ However, levels of patient safety remain below where they should be, with between 44,000 and 98,000 people dying in the United States each year due to preventable medical errors. Although Sentara Healthcare did not have any significant safety events that led to the initiation of this effort, there was recognition that the number of serious safety events was higher than desired.
• Culture of safety critical to prevention: The key to reducing errors is the development of a “culture of safety” that allows workers and processes to focus on improving the reliability of patient care.²

Description of the Innovative Activity

• Thorough assessment of the current safety culture: Using state-of-the-art approaches provided by the experts, a team reviewed past adverse events to identify common causes of patient harm and conducted an evaluation of present management systems and programs for preventing, detecting, and correcting human error. In addition, a safety culture survey of all staff and physicians was conducted.
• Development and implementation of core strategies: As a result of the assessment, four key strategies were implemented:
  1. Make safety a core value: Sentara aligns strategic goals around safety and incorporates safety behavior expectations into performance standards. Compensation systems for all levels include incentives for meeting improvement goals. In fact, 40 percent of executive variable compensation is based on the accomplishment of quality and patient safety goals. An employee gainsharing plan, known as Performance Plus, sets “line-of-sight” goals, 50 percent of which must be focused on quality/patient safety measures. Other awards are given for individual or team efforts in achieving safety and quality improvement.
  2. Adopt safety behaviors for error prevention and convert these behaviors to work habits: Specific behavior-based expectations were identified that articulate how staff, physicians, and leaders will act to prevent errors. Three lists of behavior-based expectations and techniques were developed based on a common cause analysis of past events—one list for all staff and two other lists for leaders and for physicians. A grassroots group of staff and leaders was appointed to develop the behavior-based expectations for staff and leadership, whereas physician advisory groups identified behavior-based expectations for physicians. All stakeholders received extensive training on the behavior-based expectations and associated techniques in a series of 4-hour classes. Two-thirds of the time spent in these classes consisted of hands-on practice with the tools and techniques, led by trainers from all levels of staff and a variety of departments. Error-prevention techniques that were discussed during training include use of tools to do the following: increase attention to detail, communicate clearly, question when necessary, handoff effectively, and coach and support peers to carry out the correct safety behaviors.
  3. Develop a state-of-the-art root cause and common cause analysis program: To effectively learn from events that cause harm to patients or staff, technology-based analytical tools and common cause analysis are used as an adjunct to the existing event-trending approach. Emphasis is placed on the application of diagnostic charts focusing on human error and system and process failures. Improvements made to the analytic process include the involvement of people outside the quality department, increased emphasis on collection of information and verification of facts, better identification of root causes, and corrective actions to prevent recurrence.
  4. Focus and simplify work processes and procedure documentation: Work processes and policies have been simplified to ensure that they add value and that procedures make it easy for all employees to understand expectations and adhere to requirements. Typically, policies and procedures are written either to meet regulatory requirements or to guide the most inexperienced worker, thus making them less effective as a tool for safety. The revised approach includes assessment of process workflow with the aim of identifying risks and simplifying work steps. Policies and procedures have been revised to make them short and focused and, thus, easy to use effectively by staff. In addition, clear, simple aids have been developed that are located as close as possible to where they will be used. Staff involved in this new approach to process design and procedure writing have been trained on process mapping, identifying process failures, and principles of intuitive procedure and job aid documentation. Priority in this effort was given to processes characterized by high risk and complexity. For example, work on the intravenous (IV) management process led to a dramatic simplification of written IV procedures, with a document that was previously more than 20 pages being reduced to just 2 pages. In addition, a tool to aid in recognition of the types of IV complications was also created.
• Red Rules: To focus attention on key actions critical to safety, "Red Rules" were adopted after the initial education phase. Red Rules are clear, discrete, decision-based actions that, if not adhered to consistently, pose the highest degree of risk to patient safety. Red Rules, which are consistent across hospital departments and units, must be followed; failure to comply results in a written warning. Red Rules are not a tool to be taken lightly without proper grounding in the general concepts of behavior accountability. Departments that have successfully implemented Red Rules have found that staff have learned valuable lessons about creating safe habits and have even used the learning to improve processes in their work environment. Examples of Red Rules include verify and match patient identification with two identifiers, make sure all ventilators are plugged into emergency outlets, and make sure that all alarms are audible.
• Department-based safety coaches: These front-line employees serve as representatives from each department. Their role is to be department-based experts on safety behaviors and to perform realtime monitoring of behaviors. Facility-based groups of safety coaches meet regularly to inform and educate each other and to receive feedback on the progress and impact of various patient safety initiatives.
• Ongoing evaluation: The overall initiative is assessed on a monthly basis, with quarterly reports developed for the hospital board. Measures include leading indicators (annual safety culture survey), realtime indicators (monthly monitoring of safety behaviors and numbers of safety success stories), and lagging indicators (e.g., serious safety event rate, number of claims and suits, and employee injury and illness rate).
• “Philosophy-of-fairness”: Sentara developed and incorporated a “philosophy-of-fairness” that emphasizes the need to avoid punishing staff members for honest mistakes, to learn from mistakes, and to expect accountability from staff members for their actions. These concepts incorporated a culpability evaluation (based on James Reason’s Managing the Risks of Organizational Accidents) into a performance management tool. In 2007, the organizational employee conduct policy was also revised to incorporate this material.

References/Related Articles

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Results

• Reduced patient harm: A monthly event rate calculation found that the number of harmful events per 10,000 adjusted patient days fell by 61 percent between November 2003 and January 2008.
• Reductions in hospital-acquired pneumonia and infections: The incidence of ventilator-associated pneumonia fell by 93 percent from 2002 through 2007, while device-associated bloodstream infections fell by 70 percent over the same time period. As these data suggest, both of these conditions are highly preventable with the use of appropriate evidence-based protocols and safety practices.
• Reduced ICU mortality and LOS: ICU severity-adjusted relative mortality rates fell by 18.3 percent and average ICU LOS fell by 14.5 percent over a 12-month period, due primarily to the use of online life-monitoring equipment and software to enhance the ability of remote intensivists to monitor critically ill patients.
• Increased adherence to expected behaviors: Staff compliance with expected safety behaviors increased by 42 percent from 2003 to 2004, with compliance rates now averaging 95 percent. Further evidence of culture change and better adherence to expected behaviors can be seen in the growing number of safety success stories (employee-submitted accounts of adhering to behavior-based expectations and, thus, preventing possible adverse outcomes) that are being shared throughout the organization.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Establishment of site-based safety leadership teams: Safety leadership teams, composed of operational leaders, had responsibility for leading the safety initiative implementation and ensuring effective communication across the facility, thus giving it a grassroots feel.
• Involvement of the medical staff in safety initiatives: Medical staff leaders were engaged in the program through a physician advisory group, medical staff grand rounds that focused on quality and safety, resident education on behaviors to prevent errors, and physician participation in the root cause analysis process.
• Involvement of leadership in safety initiatives: At Sentara, every leadership meeting begins with a discussion about patient safety. The senior leadership also reprioritized its annual goals to ensure that this effort received the highest priority—to that end, senior leaders made goals and expectations very visible, conducted patient safety rounds, served as administrative sponsors of projects, and made sure that needed resources were available for training and other activities.

Resources Used and Skills Needed

• Staffing: No additional personnel were necessary to launch the initiative. As it moved across the organization, two operational leaders were reassigned to guide the process.
• Costs: The costs of the program consisted initially of fees charged by the outside consultant. On an ongoing basis, the primary costs consist of staff time engaged in education, training, and other patient safety–related activities.

Funding Sources

Getting Started with This Innovation

• Engage institutional leadership: Engage leaders to include the board of directors, senior executives, and medical staff leadership in the program.
• Make patient safety a number one priority: Make sure the workforce knows the importance of safety to organizational leaders. The development of organization-wide safety goals and the allocation of scarce resources (e.g., time, money) to safety can help in communicating this message.
• Encourage leaders to prioritize management tasks: Prioritizing tasks is an important step, especially early in the initiative to avoid "task saturation."
• Engage local leadership: Engage local leaders and employees in the project; their visible, constant support and ownership of the program is vital to its success.

Sustaining This Innovation

• Develop ongoing mechanisms: Keep front-line employees involved in ongoing safety initiatives and processes (e.g., patient safety coaches).
• Create incentives: Create financial incentives, reward and recognition programs, and human resource policies to support patient safety, as continuous reinforcement of desired behaviors is critical to sustaining momentum. Effective accountability systems need to ensure that error-prevention behaviors are used 100 percent of the time. Both leaders and coworkers should encourage and support the behaviors and actions that are desired and discourage those that will not lead to desired outcomes in safety.
• Remain vigilant in monitoring success: Focus measurements on real progress and not just activity.

Additional Considerations and Lessons

• This program received the 2004 AHA Quest for Quality Award and the 2005 John M. Eisenberg Patient Safety and Quality Award from the Agency for Healthcare Research and Quality.

Use By Other Organizations

• More than 80 other hospitals around the country have instituted similar programs.