Safety Strategy Shows Promising Results at Penn State's Hershey Medical Center

Added on Oct 18, 2018

New Safety Strategy Shows Promising Early Results at Penn State’s Hershey Medical Center
By Audrey Doyle

Less than one year into a journey to transform its safety culture, Penn State Health’s Milton S. Hershey Medical Center has already reduced serious preventable harm by 20%, increased overall event reporting by 29% and increased the reporting of near misses by 94%.

In mapping out their safety journey, leaders at Hershey Medical Center (HMC) followed an initiative that Penn State Children’s Hospital began when it joined the Children’s Hospitals’ Solutions for Patient Safety (SPS) Network in 2013. The SPS Network is a collaborative effort of more than 100 pediatric facilities around the country that work together to reduce harm and ensure a safe, healing environment for children. By following a number of SPS strategies, Penn State Children’s was able to reduce its Serious Safety Event Rate by 72% and increase its near-miss event reporting by 94% in just a few years.

Buoyed by that success, in 2017 HMC senior leadership decided to launch a similar safety initiative, which they named “It Takes a Team to Reach Zero,” to advance patient safety throughout the HMC system. In addition to adopting some of the HPI safety tools and methodologies implemented at Penn State Children’s, HMC’s quality and safety teams worked with Press Ganey’s HPI to tailor its evidence-based leadership methods and error prevention tools to HMC’s needs.

These methods and tools are now being introduced on a rolling basis to the entire HMC workforce and to the system’s 68 Medical Group practice sites. Eventually, they will be implemented at Penn State College of Medicine and Penn State Health St. Joseph.

Building a Solid Safety Framework

Dr. Margaret Mikula is the vice president and chief quality officer of HMC and the Penn State Medical Group practices. Prior to this, she was the medical director of quality and safety at Penn State Children’s Hospital. When Penn State Children’s joined the SPS Network, Dr. Mikula worked with the nursing director of quality and safety to build the children’s hospital’s safety program.

“One of the things we did was establish a safety event review team that started using the SPS strategies to analyze our safety events as they were being reported. We also partnered with our Patient Safety Department, which was just being formed at the time, to learn what was causing our safety events to occur and identify opportunities to improve,” Dr. Mikula said.

When system leaders were preparing to launch a similar safety initiative at HMC, they consulted directly with HPI. “We saw that the HPI-based strategies being used at Children’s had been having a positive impact there,” said Steve Mrozowski, director of patient safety at HMC. “So in addition to adopting many of those strategies, we also partnered with HPI to embed their leadership methods and error prevention tools throughout the HMC system.”

One of the safety strategies HMC adopted from the Children’s initiative is the formation of hospital-acquired conditions teams, whose members are responsible for teaching and modeling the proper behaviors for preventing safety events such as catheter-associated urinary tract infections, central line-associated bloodstream infections, Clostridium difficile infections and patient falls.

Another strategy that came from the Children’s initiative is the practice of conducting daily safety briefings. Developed for Children’s by Dr. Mikula, these briefings bring together physicians, administration and staff from the clinical and nonclinical departments across HMC to proactively discuss and correct equipment, facilities, staffing and other issues that could affect the quality and safety of patient care. When the Patient Safety Department was formed in 2015, the expansion of the daily briefing across the entire hospital was an initial priority.

“A third idea that we brought to HMC from Children’s is a different way to look at our organizational work as it pertains to quality and safety,” said Dr. Mikula. “Like other health systems, HMC set organizational goals each year around quality, safety and patient experience, but they were focused on what the system felt was important—things like efficiency of care, for example. Working out of the Children’s Hospital mindset, we focused HMC’s organizational goals around the patient instead of the system.”

According to Dr. Mikula, HMC has five patient-related organizational goals. The first three—Keep Me Safe, Heal Me, and Be Nice to Me—are based on HPI’s Science of Safety. “At HMC, Keep Me Safe is about eliminating preventable harm and hospital-acquired conditions. Heal Me is about getting the best-quality outcomes for the patient. And Be Nice to Me is about respecting the patient and providing an exceptional care experience,” Dr. Mikula said.

The remaining two goals were added by HMC. “Help Me Navigate is a promise to provide equitable and timely care for all patients, and Keep Me Healthy is about staff and employee resilience, population health and following patients through the care continuum,” Dr. Mikula explained. “All five of these goals together give us a solid framework that allows us to center everything we do on the patient, so the patient becomes the focus as opposed to the organization.”

Also part of HMC’s framework are a number of HPI leadership methods and error prevention tools. According to Mrozowski, HPI analyzed the system’s overall safety culture and assessed a year’s worth of its serious safety events to identify common drivers. This diagnostic evaluation helped determine the leadership methods and error prevention tools the system would implement.

It also motivated leaders to commit to the initiative. “As part of the diagnostic assessment, HPI interviewed 150 of our employees and asked them what they thought were the priorities of our senior leaders. Only 3% said that safety was a leadership priority and only 1% said that employees were a leadership priority,” Mrozowski said. “Learning that this is what our employees felt were the organization’s priorities made a big impact on our senior leaders and helped us get the resources we needed to do this work and change those impressions.”

According to Mrozowski, the HMC safety bundle is called TEAM SAFE. Each letter in the word “TEAM” refers to a leader expectation.

T = Talk Safety—HMC is committed to establishing safety as a core value through words and deeds. This is done by starting meetings with a safety moment and reflecting safety in decision making.

E = Expect Ownership and Accountability—HMC is committed to reinforcing adherence to safety and reliability expectations by knowing and reinforcing safe behaviors, rounding to influence and promoting a fair and just culture.

A = Act on Opportunities—HMC is committed to finding and fixing problems that impact safe and reliable performance. One way it does this is by conducting safety huddles.

M = Monitor—HMC is committed to setting the tone for safety and reliability every day, on every shift, and prioritizing its resources by encouraging reporting and responding rapidly to safety issues.

Each letter in the word “SAFE” refers to safety behaviors.

S = Support the Team—Use team checking and coaching, and speak up for safety using ARCC.

A = Ask Questions—Embrace tools such as Validate & Verify and Stop & Resolve.

F = Focus on Task—Reduce skill-based errors by self-checking with STAR.

E = Effective Communication Every Time—Use tools for each patient encounter that embrace the principles of closed loop communication, communication clarifiers, structured handoffs and SEAT (the organization’s standard for guest and patient communication).

As part of this bundle, HMC is expanding on the following behavior expectations and their associated safety culture processes and procedures, which had previously existed in place of the SAFE bundle described above:

Everyone Makes a Personal Commitment to Safety

- SEAT (State name, Explain role, Ask for questions, Thank them)
- STAR (Stop, Think, Act, Review)
- ARCC (Ask a question, Request a change, voice a Concern, use the Chain of Command)

Everyone Is Accountable for Clear, Concise, Complete and Timely Communication

- SBAR (Situation, Background, Assessment, Recommendation)
- Three-way communication using clarifying questions
- Standardized handoff

Everyone Supports a Questioning Attitude

- QVV (Qualify, Validate, Verify)
- Stop and Resolve (Do not proceed in the face of uncertainty)

Additional safety practices at HMC include putting safety first on every meeting agenda; rewarding and recognizing departments and staff members for safety successes; creating an atmosphere of trust by protecting those who speak up when they see a possible lapse in safety; facilitating a nonpunitive culture for unintended errors or mistakes; and ensuring that there are fair consequences for intended decisions to act against hospital safety rules.

To ensure that the use of these behaviors and tools remains habitual, the organization will be providing additional reinforcement through a Leading for Safety & Reliability Mentor Program. Leader mentors are physicians and staff who are being selected by HMC’s leadership to mentor and engage their peers in reliability and safety, as well as to check their progress with implementing the leadership TEAM bundle, provide feedback on challenges and successes, and participate in open discussions.

In total, HMC plans to train approximately 60 people as mentors. “They’ll be grouped by area, so leaders in the ambulatory sites will mentor other leaders in the ambulatory sites, physician leaders will mentor other physician leaders, and so on,” Mrozowski said.

Staff-level mentors will also support their peers by recognizing through positive reinforcement when they use safety behaviors and error prevention tools in the course of care delivery, and coaching them when they appear to need guidance in the use of those behaviors and tools. The coaching program is expected to launch in early 2019.

Although the HMC initiative has only just begun, leaders are optimistic that its results will be as impressive as those realized at Children’s. “We’re only now beginning to get ready to train the masses, so this initiative is really still at the beginning stages,” Mrozowski said. “But we’ve already started to see some positive results, and I expect that in 12 to 18 months those results will be more profound.”