Over the past year, we have shared numerous posts on the characteristics of High Reliability Seeking Organizations (HRSO), and their drive to zero serious safety events (see Travel Buddies…, Reporting on Near Misses…, Mindlessness vs Mindfulness, and more). A number of healthcare organizations who have been on this HRSO journey for a number of years have experienced remarkable decreases in preventable patient harm across their system.
MedStar Health (MSH) is excited to be working with Healthcare Performance Improvement (HPI) on our own HRSO journey. By layering on the different “competencies” shown in HPI’s “Road to Reliability” diagram, it has been their experience that client hospitals can achieve higher levels of reliability. The diagram also highlights why we believe we can achieve a high level “Reliability Culture” at MedStar by integrating human factors engineering on top of all this work through our very own National Center for Human Factors Engineering led by Terry Fairbanks MD and his team of clinical care engineers.
When I first saw this diagram, however, I immediately wondered what would happen to to the outcome curve if a fourth “competency”, patient engagement, was added. Was there a way to bring high reliability training and tools to our patients and families? In my mind, the best way to start this conversation was to have Marty Hatlie, JD, CEO-Project Patient Care, President-Partnership for Patient Safety, and one of our Patient and Family Advisory Council for Quality and Safety (PFACQS) members, join us for an all-day High Reliability Boot Camp so he could add the patient’s voice into the training session, as well as share his thoughts with other PFACQS members. Carole Hemmelgarn, another of our PFACQS members, has already been working with the Children’s Hospital HRSO HEN network. Marty, as he always does, added a number of unique perspectives and new ideas to the high reliability discussions throughout the day, and those that have followed.
Here are a few of Marty’s thoughts that need to be shared. First, Tracy Granzyk, in her recent post, High Reliability Boot Camp, highlighted three things patients want: (a) Don’t harm me, (b) Heal me, and (c) Be nice to me. Marty astutely added two additional things patients want: (d) Listen to me, and (e) Give me the opportunity to engage and partner in my care.
Marty also pointed out that several of the safety and resilience training tools used by caregivers could also be customized and given to patients and family members. There would need to be some basic training but we believe this could be accomplished. HPI’s Judy Ewald, who was leading the day-long training session, underscored this point in sharing how she uses two tools – SBAR (Situation, Background, Assessment and Recommendation) and STAR (Stop, Think, Act and Review) – in her personal life. Additionally, if we have Safety Coaches for our caregivers, why couldn’t we create Safety Coaches for our patients and families? Thanks to Marty, and to all those who added reminders on what patients want as we seek high reliability, I came away excited that we could take HPI’s outcomes curve on this diagram to a higher level.
Please enjoy this message from the National Patient Safety Foundation and Dr. Lucian Leape. This video serves as the foreword to the NPSF Online Patient Safety Curriculum.
Have a safe and happy holiday weekend!
MedStar Health is partnering with HPI (Healthcare Performance Improvement) to take this innovative health system to zero preventable harm utilizing the principles of high reliability organizations we have discussed previously on ETY (see Travel Buddies…, Reporting on Near Misses…, Mindlessness vs Mindfulness, and more!)
With the depth of data now available to patients, providers and administrators, it’s much easier for all to see how well we are doing and where our challenges exist in healthcare. And while data allows for benchmarking, reimbursement, transparency and more, Judy Ewald, Senior Consultant from HPI reminded all in the room that what patients want while in our care remains very simple:
- Don’t Harm Me
- Heal Me
- Be Nice to Me
Since the number one goal of all healthcare providers is to do no harm it would seem everyone is aligned. Not to mention, medical harm is costly — per HPI’s data, 16% of patients sampled who experienced an adverse event had increased hospital costs associated with that event, which amounted to $387M in a 2008 sample of Medicare patients. And that’s just the dollars and senselessness of it. Too many patients and families pay for medical harm with both mind and body. But this isn’t new information — we know this. So how do we change it?
HPI provides some tangible tools and a road map that health systems can turn to in order to embed a transparent culture of safety–a reliability culture, designed for safety that integrates human factors engineering making it intuitive for healthcare providers to do the ‘right’ thing, and harder to do the ‘wrong’ thing. MedStar Health, with its own National Center for Human Factors Engineering led by Terry Fairbanks MD, is poised to embed this crowning skill set into their high reliability journey.
Nationwide Children’s Hospital in Columbus, OH is part of the HPI family and provides an excellent example of the transparency high reliability seeking organizations also embrace along the way. The link above takes you directly to their external website, and an open discussion on their serious safety event rate. The video below models an excellent example of leadership around the type of transparency needed to be successful.
And finally, here are some key takeaways from Monday’s high reliability boot camp:
- The role of a leader in a safe and reliable culture includes: 1) Defining values & expectations; 2) Finding and fixing problems, and; 3) Reinforcing and building accountability
- Safety has to be the Number One organizational focus. No other agenda takes higher priority.
- A summary from the work of Edgar Schein, Society of Sloan Fellows Professor of Management Emeritus and a Professor Emeritus at the MIT Sloan School of Management — If you want to change culture, remember it will be a result of what your employees see you doing as a leader — the behavior you reward, the stories you share openly, how transparent you are as a leader and how you respond in the critical moments.
- Practice 5:1 Feedback with all associates — 5 positive reinforcements to every one negative.
- Communication is key. Find a tool that works and make it standard work. I liked SBAR.
- Situation (What’s the situation, patient or project?)
- Background (What’s the important information/problems/precautions?)
- Assessment (What’s your read of situation, problems/precautions?)
- Recommendation (What’s your recommendation, request or plan?)
If you too are on the journey to high reliability, we would love to hear about it! Please share the solutions and tools that have helped, and the challenges along the way.
Always intrigued by what the future of healthcare might look like, I’m sharing a video that was shown at a research retreat hosted by the MedStar Health Research Institute, led by Neil Weissman and Kelly Smith.
With a call from AHRQ, NIH, PCORI and more, to include patients and families in research that can be quickly implemented at the point of care, how far away do you think the healthcare environment envisioned by Microsoft above really is? What is your vision of healthcare delivery for the future? The research paradigm, like the educational paradigm, is shifting and all are being invited to contribute their ideas. Jump in!
And finally, one more example of future care delivery provided by Kaiser Permanente’s Center for Total Health:
The @Edutopia Big Thinker Series presents Katie Salen, Executive Director of the Institute of Play, and Professor in the School of Computing and Digital Media at DePaul University. From the Institute of Play website, Katie:
- Has co-authored or edited several books, including Rules of Play, a textbook on game design, The Game Design Reader and The Ecology of Games: Connecting Youth, Games, and Learning
- Was co-lead designer on Gamestar Mechanic, an award-winning online game with built-in game design curriculum
- Has been involved in the design of slow games, online games, mobile games and big games in the commercial and independent games sectors around the world
The overarching theme from her short video below is that games provide excellent learning environments by allowing for collaboration, team building, exploration of identities, and also a forgiving space where students have the ability to take risks and fail. There is a growing movement toward using these playful environments to uncover the needs of a future yet to be defined in many industries.
Much of medical education has traditionally been the antithesis of this new order for education — where collaboration, continuous exploration and discovery are just as valuable as having what is believed to be the “right” answers for today. Will health sciences schools be willing to adopt a new culture of learning? Are some already doing so? Please share!
- A standard of excellence, achievement, etc., against which similar things must be measured or judged.
- Any standard or reference by which others can be measured or judged.
When I was young, my friends used to say I was too competitive for my own good–though they described my competitive tendencies with a little more color. They even accused me of “bending the rules” at times just to gain a competitive advantage. Whether it was the testosterone of my teens, or just something inbred in my character, I hated losing. As I grew older and entered healthcare, the competitive fire mellowed and my vocabulary changed to phrases like “win-win” situations, collaboration, shared learning…and benchmarking.
Benchmarking is a very important tool used in most industries including healthcare. I have always been a big believer in benchmarking one’s outcomes against others. From an improvement standpoint, how else can we assess where we stand against a norm, and then use those benchmarks to focus on quality and safety improvements? Made total sense to me. Besides, from a safety and quality standpoint, hospitals are constantly being benchmarked against one another by numerous organizations that publish grades, scorecards, self-developed rankings, and more.
A few things have now made me re-think some of my beliefs related to benchmarking, and the possible unintended consequences that may be occurring in the quality and safety domain. One challenge to my thinking occurred when Paul Levy (Not Running A Hospital) recently spoke to over 100 quality, safety and risk management leaders from across our health system. Paul spoke on transparency, and the ground-breaking work done at BI Deaconess while he was CEO there many years ago. During his talk, he also shared his thoughts on benchmarking and stated:
“There is no virtue in benchmarking to a substandard norm. Eliminate. Don’t benchmark!”
Wow – Don’t Benchmark?? His statement reminded me of a quote I have often heard throughout the years…”In the land of the blind, the one-eyed man is king”.
As I connect with safety colleagues and friends across the country, it seems we have all set the quality and safety benchmarking goal of being in the top 10% of hospitals across the country. Math was never my best subject, but even I can figure out we can’t all possibly be in the top 10%. It also means those that benchmark to the top 10% still have a long way to go to eliminate harm, as Paul points out.
Striving to achieve quality and safety greatness is vital for all us; using outcome measures to track our progress is a necessary component in achieving that highest level of care. However, my growing concern is that benchmarking might be used only to gain the “competitive advantage” for increasingly uncertain healthcare dollars. If this mindset takes hold, then why share safety and quality best practices with others for fear you might lose your ranking to a competitor? I don’t believe safety and quality people think this way…but am concerned many CFO’s have to. Competing on safety is something other high-risk industries, like aviation, have never done. Airlines may compete on things like on-time arrivals, lost baggage, or customer service, but they always share safety learnings and best-practices.
Paul is right. As far as safety goes, if we strive to eliminate (versus benchmark against a substandard norm), we only compete against ourselves. We know what the ultimate measure of success is – zero harm. More thoughts on competitive concern to come…
From legendary film director, Martin Scorsese to Sir Kenneth Robinson (ETY post, The Changing Educational Paradigm) to John Seely Brown (ETY post, A New Culture of Learning) and Constance Steinkuehler, Asst. Professor in the Digital Media program in the Curriculum & Instruction department at UW-Madison, and a founding fellow of the Games+Learning+Society Initiative whose video follows–all are contributing their expertise to the redesign of education via Edutopia, a product of The George Lucas Educational Foundation. Lucas’ Foundation has produced the Big Thinkers on Education video series, and is enlisting the impressive list above, along with others at the top of their fields to contribute their ideas to the changing educational paradigm.
Following is the first in a series of short synopses from the Big Thinkers on Education series for ETY–
In the above video, Steinkuehler, who recently left her White House post as Senior Policy Analyst at the Office of Science and Technology Policy in the Executive Office of the President to return to UW-Madison, shares that she:
…studies thinking and learning in the form of online games…the intersection between videogames and online cultures and social networks like Facebook. [She performs] large empirical studies on what kids are doing [as well as studies] the intellectual side of online play in all forms, how games matter, what matters about them, and how do we save the world?
Where are medical educators flocking to join, learn and contribute to the conversations on innovation in education? There is much to learn from those working to engage the minds of students — young and old — in new, and meaningful ways. Please share what you have found in medical education innovation here on ETY!