AUSTIN, Texas - (June 13, 2013) - The following story appears in the May/June issue of Texas Hospitals magazine and spotlights safety efforts at University Medical Center Brackenridge, which recently became the first Level 1 trauma center in the U.S. to receive a top worker safety designation from the Occupational Safety and Health Administration (OSHA).
Good, Better, Best: Advances in Quality and Patient Safety Improve Care at the Bedside
By Karen Branz, Texas Hospitals Magazine
Good, better, best
Never let it rest
Until your good is better
And your better is best
Sometimes old rhymes say it best. Texas hospitals remain unified around a single goal: to provide the safest, highest-quality care to every patient, every time. As with anything else, there's always room for improvement, which is why hospitals voluntarily implement evidence-based best practices that save lives, reduce harm and lower costs.
Texas hospitals are making serious strides in quality and safety improvement through a multipronged approach that is changing culture, engaging patients and digging deep to find and fix the root causes of issues.
Engaging Patients and
While hospitals are under increasing pressure to improve quality, there's only so much they can impact alone. The best results come when patients themselves take an active role in their own care. Case in point: El Paso's 101-bed Fort Duncan Regional Medical Center. There, the hospital's focus on building patient engagement has helped it eradicate central line-associated bloodstream infections and ventilator-associated pneumonia in recent reporting periods.
According to Director of Education Wilma Carbonel-Mason, RN, the process begins before patients are even admitted. All scheduled surgery patients learn about their condition and the procedures they will be receiving before they arrive at the hospital.
"They show up better prepared and ready to actively participate in their care," Carbonel-Mason said.
In addition, patients are encouraged to speak up for themselves and pay attention to their care. The hospital also welcomes involvement from family members.
"We recommend patients have someone who can act as their care partner to advocate for them," Carbonel-Mason said. "We also tell them to be assertive and not to let anyone touch them who has not washed their hands or give them medicine or draw blood samples unless they have confirmed their name and date of birth."
Empowering patients and care partners to take ownership for their care helps reinforce routine protocols that reduce infection and errors. Role modeling is key to educating patients and family on the importance of handwashing.
"I can't hold staff accountable unless I do it myself. I have to set the example," said Scott Lethi, RN, chief nursing officer. "And when visitors see me using the sanitation station before I get on the elevator, they do it, too."
At Fort Duncan, whether you are an employee or visitor, hand-washing now is a part of the hospital culture.
"We have hand-sanitation stations everywhere," said Infection Preventionist Trinidad Justo, RN. "Staff and visitors use them regularly. I see moms in bathrooms helping their kids wash their hands properly."
Fort Duncan's patient engagement strategy also has helped significantly reduce errors.
Seven days a week, members of the executive team do rounds, checking in with managers, frontline staff and patients to monitor any issues and ensure compliance with all patient safety protocols.
"We have a condition helpline for patients and family to call if they are worried about any aspect of their care or if they have questions or problems that aren't being addressed," said Carbonel-Mason. "When patients call that number, a rapid response team is called that includes the primary nurse, the house officer, the emergency department physician and staff from respiratory therapy and the lab."
Patients don't use the line very often - only three calls were placed in the past year - but it acts as a safety net if something is being overlooked.
"None of the situations were life-threatening, but patients had issues that weren't being addressed," Carbonel-Mason said.
Keeping patients informed and engaged in their care doesn't end with discharge, noted Carlos Diaz, the hospital's quality director.
"A nurse manager must review each discharge packet and check to see that medications and precautions are explained thoroughly. If a patient must be alerted for any indicators, such as weight gain for congestive heart failure patients, that alert must be highlighted and explained.
Within 72 hours of discharge, patients receive an automated call to check on their condition. If they indicate questions or concerns, a nurse follows up with a personal call.
The results? For the past two years, Fort Duncan Regional Medical Center has made significant gains in its quality indicator scores. In addition, the hospital received no penalties from Medicare for readmissions in 2012 - a big accomplishment for a hospital of any size.
"We're small, but we're mighty," said Lethi.
The Tie between Workforce Safety and Patient
Health care is populated by workers who are self-sacrificers, noted Darryl Jordan, vice president of risk management for Seton Healthcare Family.
"Health care workers are trained to protect patients from harm and tend to overlook their own safety," Jordan said. "Worker safety programs have long been overshadowed by patient safety programs. It's not easy to change the culture, but improved worker safety also means improved patient safety."
Last fall, Seton's University Medical Center Brackenridge in Austin became the first Level I trauma center to earn the Voluntary Protection Program designation from the U.S. Occupational Safety and Health Administration (OSHA). Just 14 other hospitals are VPP-certified, and none are Level I facilities.
"The VPP program goals are aligned with The Joint Commission guidelines, so we saw that there could be some benefit for us," Jordan said.
The VPP program has worked well in other industries. It creates a partnership between private organizations and OSHA to proactively protect workers. Rather than inspecting and handing out fines, OSHA takes the role of advising program participants and helping them design systems to prevent injury.
"The key to making this work in health care is creating a culture of 'All Things Safe.' Rather than having disparate safety processes for workers, patients and building and environmental safety, the program brings all three areas under one umbrella," Jordan said. "That can produce dramatic benefits."
For Seton, like other health care organizations, two areas of perennial danger for health care workers are patient lifting and transfers and handling of sharp instruments, such as needles and scalpels.
"What other industry would allow a 100-pound person to move a 180-pound weight without assistance?" Jordan asked. "Nursing staff suffer from years of micro-tears from moving patients around in bed."
To make that process safer, UMC Brackenridge now uses a "slippery sheet" designed to allow a nurse to slide a patient across a bed easily. It reduces strain for the nurse and improves safety for the patient.
In the operating room, where surgeons and assistants transfer sharp instruments back and forth, the danger of contaminated sticks or lacerations is very high.
"To stop the hand-to-hand combat, we instituted a safe pass transfer zone," Jordan said. Now sharp objects are placed on a bright orange tray kept near at hand. The receiver then picks up the instrument, avoiding the risky direct transfer.
In both of these examples, an in-depth root-cause analysis led to simple, low-tech solutions to longstanding issues.
The four cornerstones of the VPP system, he explained, are:
• Hazard prevention and control;
• Training in worksite analysis, safety and health;
• Leadership commitment; and
• Safety driven by frontline workers.
"One key differentiator of the VPP system is the use of in-depth, root-cause analysis to ensure that you understand safety issues before trying to fix them," said Jordan. "All people inevitably will make mistakes, and the goal is to design a system that prevents harm in the face of human failure."
He added that transparency is key. All workers must feel that it is safe to report failures and honestly evaluate the causes.
"You have to rally the troops around a failure and do a thorough investigation. You have to have a culture that is reluctant to simplify or to simply add more controls to processes that are broken. More controls without analysis and redesign are counterproductive," Jordan said.
Another important aspect is cultivating deference to expertise. That means that rather than expecting leaders to have all the answers, hospitals should look to the most knowledgeable staff members. Sometimes that results in executives deferring to others in decision-making.
One way that UMC Brackenridge does that is through the use of a simulation lab, where patient care teams go through exercises that mock stressful situations and procedures. The teams analyze videotapes of the simulations to find better ways to handle care and mitigate risks to patients and workers.
"It's all about becoming a highly reliable organization," said Jordan.
Everyone in the hospital - executive leaders, staff and physicians - are required to go through high-reliability training to learn to think about failures and ways to prevent harm. Even contractors who are in the hospital for just a few days are assessed prior to starting a job and monitored for safety throughout the work.
"With the VPP program, I think the government got it
right. OSHA, the Centers for Medicare & Medicaid Services
and The Joint Commission are now working together. This not
only will make regulatory inspection easier but also will lead
to future safety improvements," said Jordan.