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Building a Culture of Patient Safety

In our last issue of Pathways, we introduced you to the systemwide work being done by the Patient Safety and Clinical Performance System Team through the Centers for Medicare and Medicaid Services’ Partnership for Patients (PfP) program. PfP initiatives are mobilized through Hospital Improvement Innovation Networks (HIIN 3.0), which include 16 national, regional, or state hospital associations, and health system organizations to serve as Hospital Improvement Innovation Networks (HIINs). The goals of the HIINs are to reduce the overall patient harm, hospital acquired conditions and infections by 20 percent, and reduce all-cause 30-day readmissions by 12 percent. In this article, we will share how our system team built a dynamic management debriefing process to help reach these goals and support rapid implementation of a 360-degree view of our performance and safety metrics across the system.

Prior to the Partnership for Patients (PfP) initiative, each member hospital tracked patient safety and readmission data in different ways. Additionally, the system did not have a unified approach to address patient and employee safety issues or a platform to communicate practices and lessons learned. Therefore, to create a culture of patient safety, the first step was to work together, as a system, to collect, map, inform, and create action plans. This information was then incorporated into developing a systemwide management process that would nurture patient and employee safety.
In the fall of 2015, the PfP EMHS system coordinators and member quality leaders got to work identifying multiple issues of inconsistency, as well as barriers to obtain data needed for measurement purposes. The patient safety system team worked diligently to create standardized system-level reports essential to the advancing patient safety work. For the first time, we began to map patient safety to the unit level of each hospital, which helped us identify our priorities. Once patient safety priorities were identified, they were shared with each hospital patient safety leader, unit manager and their staff, and quickly came up with action plans to address those priorities. In March 2016, system leaders, quality leads, and frontline staff from each system organization engaged in a performance improvement methodology clinical design workshop where attendees shared current practices and how their work culture influences patient safety. The design day engaged frontline clinicians to redesign or enhance practices and as a result, produce a greater level of engagement from the frontline clinicians. Each team created a visual blueprint of their current practice which allowed them to visualize the components of their practice and see and understand the broader picture. The action plan design techniques complement and enhance performance improvement methodologies such as LEAN, Six Sigma, and Plan-Do-Study-Act (PDSA) and patient safety at the unit level. Moving forward, we will repeat this management process as we identify new potential risks to patient safety.
To better assist communication, teamwork, and sharing of practices across the system, we incorporated the Partnership for Patients (PfP) Committee member monthly calls, which include quality leaders, leadership, infection prevention/control specialists, educators, and key stakeholders from each member organization. These meetings provide an opportunity to continuously share information as a system, including successes, challenges, and barriers faced during the performance improvement process.  

The quality leaders at the member organizations, along with our frontline staff champions, are implementing the science of patient safety and the key involvement needed to drive improvements around readmission, hospital acquired conditions, and the culture of safety to prevent patient harm. In the end, preventing patient harm can happen with each member of a patient’s care team within a comprehensive unit-based patient safety program. As a united front, we are developing a mature culture of high reliability that is preoccupied with our failures, including close calls and mistakes, and does not oversimplify actions to prevent patients from harm.

Next month, we will share stories from the front lines and recognize some of the past success over the last year. Click here to learn more about CMS’ Partnership for Patients or here to learn about Hospital Improvement Innovation Networks.