Local hospitals are working hard to be safer places for patients. Representatives of the three major health systems on the Peninsula, independently of each other, describe it as a "culture shift" in progress.
The drivers behind enhanced accountability include greater transparency and reporting requirements along with changes in health care delivery under the 2010 Patient Protection and Affordable Care Act. The provisions of "Obamacare" are pushing health systems to provide quality care to more patients for less; and the move away from a fee-for-service model to bundled payments puts the emphasis on both safety and efficiency for providers. For example, based on numbers reported in 2011, Medicare reimbursements for hospitals with higher than expected readmission rates will decrease, starting in fiscal year 2013.
Coincidentally, in spring 2011, the Virginia Hospital & Healthcare Association launched its quality and patient safety initiative with the goal of placing Virginia hospitals in the top 10 percent nationwide. The committee was chaired by Dr. Barry Gross, OB/GYN, who is the chief medical officer of Riverside Health System.
The association is committed to addressing quality measures such as health-care associated infections; serious reportable adverse events (e.g. wrong site surgeries); 30-day readmission for acute myocardial infarction, heart failure and pneumonia; 30-day mortality for the same; and patient satisfaction. Of the more than 720 recognized quality measures, these handful are the most often cited in rankings — and those that local health systems are working to improve.
Putting safety first
In sync with this, Riverside last year began a partnership with Healthcare Performance Initiative, a consulting firm, to help meet its goals. "It will take about 18 months of planning and education — going through a discussion with all employees. Then it will be ongoing," says Gross. Every employee receives four hours education, talking about behaviors that could lead to safety issues. An all-inclusive initiative, it includes everyone from office staff to physicians.
"It's adopting safety as a core value," says Steve Kreiser, a former Navy pilot and senior consultant for the initiative. "We draw from industries like aviation and nuclear power, High Reliability Organizations, known as HROs, which operate under very challenging circumstances and have few accidents." Referencing the difficult fiscal environment, Kreiser emphasizes that safety and reliability must still take precedence over speed, efficiency and the profit margin. "There are times we have to pause and take more time because it's the right thing to do," he says, likening it to delaying a flight for weather issues or mechanical failure. "It has to be part of the mindset."
Likewise at Bon Secours, Timothy Willox, chief medical officer at DePaul Hospital in Norfolk, says, "Safety is at the top of our strategy. It's never off the radar."
Sentara Healthcare has taken the same tack, looking outside health care to HROs to implement changes over the past decade. "That's been very helpful to us along the way. We've received national recognition for it," says Gary R. Yates, senior vice president and chief medical officer. He notes a 70 percent decrease in that time frame in the "serious safety event" rate and a 98 percent reduction in the ventilator-associated pneumonia rate, or VAP. For the past eight years, Williamsburg Regional Medical Center has posted a clean record without a single incidence of VAP. "We've been encouraged by the progress we've made," says Yates.
Taking a proactive approach
Each of the three local health systems has an organized approach to safety and error reduction. At Sentara, a "clinical effectiveness" group comprised of nurses, doctors and statisticians works as a central resource to review best practices and assist in implementation of new standards. For example, when they became aware of the detrimental effects of inducing births before 39 weeks, they changed their practice systemwide. "They weighed the social requests for inductions against outcomes and the health of the baby," says Vicki Gray, a senior vice president.
"Other industries work hard to anticipate failure," says Kreiser, noting strategies that can cross disciplines. Borrowed from the nuclear industry is the daily safety check-in, when managers huddle to review the past 24 hours and look at vulnerabilities for the next 24. "We work together to create situational awareness and to be sure we're focusing on the right thing," says Gray. This includes noting community events, such as Hampton's Bay Days, and their potential impact, and becoming more aware of potential dangers, such as IV bags containing different fluids that look too similar.
At Riverside, a root cause analysis program is employed to ensure an error — whether or not it caused harm — won't be repeated. "You can't solve problems unless you can see and measure them, whether a near miss or a great miss," says Alan Bennett, director of patient safety. "We're trying to create a blame-free approach to increase transparency and accountability." Kreiser reports that using that "prevent, detect, correct" approach, the 300 hospitals that Healthcare Performance Initiative works with have seen an 80 percent reduction in serious events of harm.
Bon Secours dubs its safety efforts as "clinical transformation"; it is currently concentrating on sepsis and mortality rates. "If you do the right thing up front, then you're avoiding costs down the road," says Willox of DePaul. To address this high-impact issue, it has opted to use sepsis-certified nurses in the intensive care and emergency departments, and to use "bundles," or standardized protocols for care. These measures to improve early recognition and standardized evidence-based treatment have already brought tremendous improvement, he says.
Repetition, repetition, repetition
Across the board, standardization is proving key to improved safety. All use a "process checklist," which means doing something the exact same way every single time, and then instituting it across the entire health system. This takes the emphasis away from the individual and reduces opportunities for human error.
"There's a lot of electronic prevention in place, but human error is still a big factor," says Gross of Riverside, reciting the mantra for what has to happen to prevent medication errors — "the right patient, the right time, and the right condition." As an additional safeguard to bracelet checks, Riverside requires the stating of the patient's name and date of birth prior to administering medication. "It's to institute a focused mindset, to get them off auto-pilot," says Kreiser of the rigorous policy.
Another measure designed to reduce human error is the use of "repeat-back" borrowed from aviation — if a physician gives an instruction, then the nurse parrots it back to ensure understanding and accuracy.
Electronic health records
The transfer to computerized health records has improved safety markedly, health representatives agree. "The clinical information is more accessible across venues. With e-Care, the look and feel is the same at the physician's office as at other providers. All the information is there and the clinical team can access it readily," says Yates of Sentara. The records also eliminate the handwriting issue, he adds.
Warren Austin, chief medical officer for Maryview Hospital describes Bon Secours electronic records system, ConnectCare, as "an epic product, a must for us to do what we're able to do across all hospitals, a key step in improved quality and efficiency." By measuring everything, they shine a bright light, adds spokeswoman Lynne Zultanky, citing how they immediately highlighted a need for an additional pharmacist at one location to reduce the time delay for delivering medications.
When errors occur
Transitions, whether staff shift changes or patient discharges, offer increased risk for error. To minimize the disruption in care, Bon Secours has implemented case management at the time of admission in order to follow a patient through discharge and beyond. DePaul has piloted the use of life coaches to make sure that the most vulnerable and those with chronic illnesses get appropriate follow-up care. Tele-medicine, by which patients, primarily those with heart issues, are monitored electronically at home has helped bridge the transition for some. "We educate the patient and family on the disease in the hospital. We review their meds, we make an appointment for them for a primary care follow-up, and we call them," says Austin.
He asserts that safety involves more than individual processes and regulations. "Overriding all of it is getting the health system to a culture of patient safety. It's an ongoing, consistent goal, a team effort for non-clinicians and clinicians. … If you deliver good quality, you'll still consistently do well."
How safe is your hospital?
Hospitals currently report 100 measures to the Centers for Medicare & Medicaid Services, but there are many other reporting initiatives. There are multiple resources for checking hospitals' performance. They include: Virginia Hospital & Healthcare Association, http://www.vhha.com/quality.html; the federal government's Hospital Compare site, http://www.hospitalcompare.hhs.gov; The Leapfrog Group, http://www.leapfroggroup.org; and Consumer Reports, http://www.consumerrreports.org.