How to incite the transformation to a culture of patient safety and accountability

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Health systems need more than short-term patient safety improvements to achieve better patient outcomes; they must also have just cultures, transparency and accountability.

At the Becker's Hospital Review 2nd Health IT + Clinical Leadership + Pharmacy 2019 event on May 3 in Chicago, Thea Rosenbaum, MD, associate chief medical quality officer and associate CMO for patient safety at Little Rock-based University of Arkansas for Medical Sciences (UAMS) presented initiatives for sustained quality improvement. The example Dr. Rosenbaum used in her presentation highlighted UAMS' cultural transformation around one of the most challenging behaviors to encourage in health care workers — hand hygiene.

"Hand hygiene compliance is not a unique issue for any hospital. What is though was the overwhelming success we had achieving a major behavioral change using a three-pronged approach: One, promoting a workplace culture focused on patient safety; two, emphasizing a just culture; and three, holding individuals accountable for their efforts," she said. "Hand hygiene initiatives are notoriously tricky to carry out, and when successful, difficult to sustain. Like our counterparts, UAMS has failed with previous campaigns. Previous attempts at, say, a two-week enterprise-wide hand hygiene campaign just showed us that employee compliance rates would raise for a while, but then — as they do for every short project — go back to baseline. Something had to be done because the symbolic healing touch of a clinician is at odds with the possibility that those hands could transmit infection."

UAMS is a 514-bed academic medical center and the only Level I trauma center in the state of Arkansas. Dr. Rosenbaum outlined the steps in process to change its culture, the challenges it encountered along the way, and results achieved so far.

Charting the course for a culture of patient safety
Several months ago, Dr. Rosenbaum and her team set out to meet the Agency for Healthcare Research and Quality's Culture of Safety standards, including:

1. Understanding the high-risk nature of UAMS' activities
2. Creating a blame-free environment
3. Encouraging interdisciplinary collaboration enterprise-wide
4. Committing resources to address safety issues

Dr. Rosenbaum acknowledged that achieving sustained patient safety culture improvement is difficult, particularly given bias toward individual blame for errors and complications. The approach UAMS adopted flipped that coin on its head, shifting any blame from an individual onto the system and environment around the individual.

"Individual human error is often not the cause of a failure, but rather a symptom of the root cause," said Dr. Rosenbaum. "When one within an organization of any size makes a fatal error, look around and examine both the environment in which that individual is placed and the elements within that environment that lead the employee to make an error."

After receiving an error event report, the UAMS patient safety department conducts a root cause analysis to identify and eliminate those environmental elements that influenced the event. They also pinpoint opportunities for process improvement.

The novelty of the UAMS approach led by Dr. Rosenbaum takes a unique twist underscoring the value of the physician administrator. Dr. Rosenbaum is also a practicing anesthesiologist who on an average day in the operating room will interact face-to-face with one of the most diverse groups of clinical services including surgeons, internists, nursing staff, the blood bank, and the clinical lab. Infection prevention and control through hand hygiene represents a major first step. However, Dr. Rosenbaum understands the importance of supplementing cultural improvement efforts with diagnostic tools, like the Accelerate Pheno™ system, a laboratory technology UAMS carefully selected that allows clinicians to intervene faster than ever before when making decisions about the best and safest antibiotic therapy for patients with bloodstream infections. UAMS has integrated the system into the clinical workflow.

"We are excited about the Pheno™ as another vital tool for us to fight infection faster and better, and we've shown this," said Dr. Rosenbaum. In a UAMS study comparing the Accelerate Pheno™ system to the previous method for antibiotic susceptibility testing, the clinical research group found that implementation of the Accelerate Pheno™ system resulted in a 3-day decrease in length of stay, a 2-day reduction in days of antibiotic therapy, and a 36-hour reduction in time to optimal antibiotic therapy — all statistically significant.

Leading the charge
To set the tone for a culture of safety, UAMS leadership embraced the tenets of patient safety as a core value. The leaders set expectations and modeled best behavior to inspire others. They took steps to reinforce good habits — paying compliments to those who consistently demonstrated proper hand hygiene protocol — and took a closer look at those who were susceptible to error.

The leadership team identified 17 individuals from within the system who were passionate about hand hygiene to become certified hand hygiene coaches and trainers. Beginning in November 2018, coaches were able to train 8,000 individuals across departments and ranks in hand hygiene best practices, including physicians, chief executives and front-line staff.

The team also rolled out a series of administrative changes to align with the culture of patient safety. Historically, the organization had two disciplinary policies: One for tenured employees and another for non-tenured employees. That had to change.

The health system adopted a single seven-step policy based on transparency and accountability to en-force hand hygiene compliance, as follows:

Dr. Rosenbaum and her team met with the chancellor of the university medical center to develop the policy and consulted with the human resources and legal departments to ensure its regulatory compliance. Multiple layers of disciplinary action were intentionally developed to ensure staff members have ample opportunity to reform their behaviors. The seven steps took effect on April 1. Through the first month, hand hygiene practice soared to 90 percent compliance.

Effectively communicating the 'why'
For the new initiative's rollout to succeed, every executive and frontline employee has to understand the danger of hospital acquired infections and their link to hand hygiene. The CDC lists good hand hygiene protocol as the No. 1 way to prevent the spread of HAIs, which cost the healthcare system roughly $30 billion annually. Along with medical errors, HAIs account for 210,000 hospital patient deaths annually, according to the Journal of Patient Safety.

"It's not solely about changes in the way we understand the importance of hand hygiene," said Dr. Rosenbaum. "It's about a workplace supportive of a just culture and a culture of patient safety. These latter elements have proven not only their short-term importance to UAMS in meeting significant patient safety initiatives, but long-term value in sustaining these healthy practices for months and years to come."

Anyone within UAMS is empowered to call out noncompliance when they see it, and everyone, including patients, knows where the health system stands in hand hygiene compliance. Instead of only sharing data with key stakeholders as the system did in the past, it aims to share data at system wide meetings and through use of display-monitors outside hospital departments showing hand hygiene compliance and infection rates.

"This is a peek into the interactive future of healthcare, medicine and the growing expectations of patients," Dr. Rosenbaum said. "Patients are interested. They want to know the rates of HAIs at the facility where they plan to undergo surgery."

For about six to nine months after the initiative's launch, the health system expects to experience increases in the number of hand hygiene noncompliance events and medical error reports because staff are empowered to report without retribution; however, the numbers will adjust and plateau.

Conclusion
UAMS has taken the important initial steps to instill a sustainable culture of patient safety throughout the health system. By investing time and financial resources into developing a culture where individuals are not afraid to report an error, the system can conduct root cause analyses and remove environmental roadblocks to success. Their policies now also align with the just culture and culture of accountability ideologies. Over the next four to five months, the system will track and report whether their efforts lead to long-term behavior change and better outcomes.

 

Health systems need more than short-term patient safety improvements to achieve better patient outcomes; they must also have just cultures, transparency and accountability.

At the Becker's Hospital Review 2nd Health IT + Clinical Leadership + Pharmacy 2020 event on May 3 in Chicago, Thea Rosenbaum, MD, associate chief medical quality officer and associate CMO for patient safety at Little Rock-based University of Arkansas for Medical Sciences (UAMS) presented initiatives for sustained quality improvement. The example Dr. Rosenbaum used in her presentation highlighted UAMS' cultural transformation around one of the most challenging behaviors to encourage in health care workers — hand hygiene.

"Hand hygiene compliance is not a unique issue for any hospital. What is though was the overwhelm-ing success we had achieving a major behavioral change using a three-pronged approach: One, pro-moting a workplace culture focused on patient safety; two, emphasizing a just culture; and three, holding individuals accountable for their efforts," she said. "Hand hygiene initiatives are notoriously tricky to carry out, and when successful, difficult to sustain. Like our counterparts, UAMS has failed with previous campaigns. Previous attempts at, say, a two-week enterprise-wide hand hygiene cam-paign just showed us that employee compliance rates would raise for a while, but then — as they do for every short project — go back to baseline. Something had to be done because the symbolic healing touch of a clinician is at odds with the possibility that those hands could transmit infection."

UAMS is a 514-bed academic medical center and the only Level I trauma center in the state of Arkan-sas. Dr. Rosenbaum outlined the steps in process to change its culture, the challenges it encountered along the way, and results achieved so far.

Charting the course for a culture of patient safety
Several months ago, Dr. Rosenbaum and her team set out to meet the Agency for Healthcare Re-search and Quality's Culture of Safety standards, including:

1. Understanding the high-risk nature of UAMS' activities
2. Creating a blame-free environment
3. Encouraging interdisciplinary collaboration enterprise-wide
4. Committing resources to address safety issues

Dr. Rosenbaum acknowledged that achieving sustained patient safety culture improvement is difficult, particularly given bias toward individual blame for errors and complications. The approach UAMS adopted flipped that coin on its head, shifting any blame from an individual onto the system and envi-ronment around the individual.

"Individual human error is often not the cause of a failure, but rather a symptom of the root cause," said Dr. Rosenbaum. "When one within an organization of any size makes a fatal error, look around and examine both the environment in which that individual is placed and the elements within that en-vironment that lead the employee to make an error."

After receiving an error event report, the UAMS patient safety department conducts a root cause analysis to identify and eliminate those environmental elements that influenced the event. They also pinpoint opportunities for process improvement.

The novelty of the UAMS approach led by Dr. Rosenbaum takes a unique twist underscoring the value of the physician administrator. Dr. Rosenbaum is also a practicing anesthesiologist who on an average day in the operating room will interact face-to-face with one of the most diverse groups of clinical services including surgeons, internists, nursing staff, the blood bank, and the clinical lab. Infection pre-vention and control through hand hygiene represents a major first step. However, Dr. Rosenbaum un-derstands the importance of supplementing cultural improvement efforts with diagnostic tools, like the Accelerate Pheno™ system, a laboratory technology UAMS carefully selected that allows clinicians to intervene faster than ever before when making decisions about the best and safest antibiotic ther-apy for patients with bloodstream infections. UAMS has integrated the system into the clinical work-flow.

"We are excited about the Pheno™ as another vital tool for us to fight infection faster and better, and we've shown this," said Dr. Rosenbaum. In a UAMS study comparing the Accelerate Pheno™ system to the previous method for antibiotic susceptibility testing, the clinical research group found that imple-mentation of the Accelerate Pheno™ system resulted in a 3-day decrease in length of stay, a 2-day reduction in days of antibiotic therapy, and a 36-hour reduction in time to optimal antibiotic therapy — all statistically significant.

Leading the charge
To set the tone for a culture of safety, UAMS leadership embraced the tenets of patient safety as a core value. The leaders set expectations and modeled best behavior to inspire others. They took steps to reinforce good habits — paying compliments to those who consistently demonstrated proper hand hygiene protocol — and took a closer look at those who were susceptible to error.

The leadership team identified 17 individuals from within the system who were passionate about hand hygiene to become certified hand hygiene coaches and trainers. Beginning in November 2018, coaches were able to train 8,000 individuals across departments and ranks in hand hygiene best practices, in-cluding physicians, chief executives and front-line staff.

The team also rolled out a series of administrative changes to align with the culture of patient safety. Historically, the organization had two disciplinary policies: One for tenured employees and another for non-tenured employees. That had to change.

The health system adopted a single seven-step policy based on transparency and accountability to en-force hand hygiene compliance, as follows:

• First violation in a 12-month period: Immediate verbal feedback
• Second violation: Record names into a database
• Third violation: Review hand hygiene, meet with supervisor and undergo coaching
• Fourth violation: Receives oral warning and subject to disciplinary action
• Fifth violation: Receives written warning
• Sixth violation: One week leave without pay
• Seventh violation: Termination

Dr. Rosenbaum and her team met with the chancellor of the university medical center to develop the policy and consulted with the human resources and legal departments to ensure its regulatory compli-ance. Multiple layers of disciplinary action were intentionally developed to ensure staff members have ample opportunity to reform their behaviors. The seven steps took effect on April 1. Through the first month, hand hygiene practice soared to 90 percent compliance.

Effectively communicating the 'why'
For the new initiative's rollout to succeed, every executive and frontline employee has to understand the danger of hospital acquired infections and their link to hand hygiene. The CDC lists good hand hy-giene protocol as the No. 1 way to prevent the spread of HAIs, which cost the healthcare system roughly $30 billion annually. Along with medical errors, HAIs account for 210,000 hospital patient deaths annually, according to the Journal of Patient Safety.

"It's not solely about changes in the way we understand the importance of hand hygiene," said Dr. Rosenbaum. "It's about a workplace supportive of a just culture and a culture of patient safety. These latter elements have proven not only their short term importance to UAMS in meeting significant pa-tient safety initiatives, but long term value in sustaining these healthy practices for months and years to come."

Anyone within UAMS is empowered to call out noncompliance when they see it, and everyone, in-cluding patients, knows where the health system stands in hand hygiene compliance. Instead of only sharing data with key stakeholders as the system did in the past, it aims to share data at system wide meetings and through use of display-monitors outside hospital departments showing hand hygiene compliance and infection rates.

"This is a peek into the interactive future of healthcare, medicine and the growing expectations of pa-tients," Dr. Rosenbaum said. "Patients are interested. They want to know the rates of HAIs at the facil-ity where they plan to undergo surgery."

For about six to nine months after the initiative's launch, the health system expects to experience in-creases in the number of hand hygiene noncompliance events and medical error reports because staff are empowered to report without retribution; however, the numbers will adjust and plateau.

Conclusion
UAMS has taken the important initial steps to instill a sustainable culture of patient safety throughout the health system. By investing time and financial resources into developing a culture where individu-als are not afraid to report an error, the system can conduct root cause analyses and remove environ-mental roadblocks to success. Their policies now also align with the just culture and culture of account-ability ideologies. Over the next four to five months, the system will track and report whether their efforts lead to long-term behavior change and better outcomes.

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