The cab driver that took me to the Cincinnati airport as I left the HPI Safety Summit last week was from Ethiopia. He had made a point to say “east Africa” when I asked where he was from, as the Ebola virus had greater than average attention in the Queen City due to one of the two nurses who contracted the virus having recently passed through northern Ohio. Even though she never came any closer to Cincinnati than almost 250 miles away, almost every cab driver encountered during our stay mentioned Ebola. This gentleman, in broken but completely intelligible English, shared that he had been in Cincinnati for nine years, and was lamenting the fact that his accent remained far too apparent while his young children now spoke perfect English. Our conversation continued on the beauty of different cultures and their languages, and he told me 80 different languages are spoken in his small country of origin. A quick Google search confirmed this, as well as that anywhere from 1,500 to 3,000 different languages are spoken across the African continent. It dawned on me that the magnitude of such disparate means of communication might not only contribute to a lack of understanding, but with it, the slow-moving development experienced across Africa on the whole. He agreed, which led to an impassioned explanation on how the inability to communicate in a common language leads to a lack of trust among clans, violence and often the need to hire a translator just to travel from the north to the south of Ethiopia. I told him he had inspired an ETY post, as it is becoming increasingly clear that data and fact lose almost every time to fear, ignorance, poor communication and a good old-fashioned wives’ tale spun by a convincing storyteller.
Communication was one of the overriding themes at the Safety Summit as well. HPI is endeavoring to make the language of patient safety universal across healthcare by providing consistent, process-driven training that gives healthcare professionals a vocabulary in high reliability, resilience and a systems approach to care. The number of partnerships HPI has formed with healthcare organizations across the US seeking to join the high reliability journey is growing, and with it, so follows the number of patient lives positively impacted by those employing their teachings at the frontlines of care. Their teaching excels in parallel with a clients’ ability to communicate the learning, and the session my colleague Erin Agelakopolous and I presented on the topic was standing room only. With newer clients in attendance at this year’s Safety Summit, there were many who wanted to understand how we were communicating the HPI learning across a health system of 30,000. We shared the tool kit designed by MedStar’s Communications team, our 60 Seconds for Safety videos, patient and provider stories, and a Good Catch program recognizing the excellent work at our frontlines while reinforcing the learning culture HROs need to thrive. And we shared that this has indeed been a journey—with our internal communications efforts growing in tandem with a collective comfort level in the new just culture tenets being increasingly embraced.
There were many excellent sessions at HPI’s Safety Summit. Of particular note was the keynote given by nationally recognized patient advocate, DePaul University Professor, Mom, MBA and former McKinsey consultant, Beth Daley Ullem. Beth emphasized the need for healthcare consumers to have access to data and information about the healthcare procedures they are purchasing. “We spend more time evaluating the purchase of mutual funds,” she said, “than heart surgeries.” Having lost a child to preventable medical harm directly related to the culture of medicine, Beth and her approach to this work, provided yet another inspirational reminder that we need a greater sense of urgency around the change we were all in Cincinnati to support.
The Children’s Hospital of Philadelphia shared their Good Catch program in a session. Cancer Treatment Center’s of America shared their HRO internal communication campaign and Safety Superheroes. Piedmont Healthcare shared how they are trying to communicate taking transparency to the next level. All expressed how important it is to find ways to communicate HPIs high reliability teachings and culture change across the health system. Being at the Summit was spending time with those already drinking the Kool-Aid of culture change. With all the social media and content development tools available to us, we now need to figure out how to take this excellent work along with the messages of just culture, transparency and open, honest communication in healthcare viral–
For more information on HPI and the Safety Summit, go to: www.hpiresults.com
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.
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.