High Reliability Principles Fuel Garnet Health’s Multiyear Journey to Zero Harm

Added on Sep 10, 2020

High Reliability Principles Fuel Garnet Health’s Multiyear Journey to Zero Harm
By Audrey Doyle

To drive toward their goal of eliminating preventable patient harm, leaders at Garnet Health began organizing for high reliability in 2015. Since that time, the New York-based health system has decreased harm events by more than 40% and risk-adjusted mortality has dropped 76%. Organizational commitment to identifying and measuring the incidence and severity of patient safety events in a valid and reliable way and training service line leaders in the principles of high reliability have played key roles in their success.

Garnet Health is a three-hospital system that offers inpatient, outpatient, primary care, and multispecialty care to residents of New York’s mid-Hudson and Catskill regions. The organization began its journey to zero harm nine years ago. Through efforts that included a systemwide culture transformation and a new safety event reporting process, leaders made good headway during the first few years of their quest.

In 2015, they began documenting every patient safety and near-miss event that occurred at the organization in a HARM Index, a high reliability tool for calculating instances of harm and displaying the results in simple charts that are easy to understand.

The Garnet Health HARM Index includes 16 components based on risk, volume, trends, never events, externally reported data, and pay for performance. Each week a team of quality, risk, nursing, and medical staff reviews the data. The team discusses the more serious events and identifies trends in specific event types that need follow-up action. In a separate harm meeting, a Safety Event panel reviews each event to identify whether the patient sustained harm and suffered, and whether it was due to error or, more often, a flawed system process. “Learnings from these meetings are then used to identify patient safety initiatives and a process improvement focus,” said Mary Ellen Crittenden, RN, vice president of quality and a patient safety officer at Garnet Health.

Every month, a scorecard that shows the number and type of events that occurred is shared with leaders, front-line staff, and physicians. Because the scorecards reflect actual numbers of harm, not rates or statistics, they’re easy for front-line staff to interpret, which engages them in the organization’s safety work, according to Ann DiAgostino, patient experience administrator at Garnet Health Medical Center (GHMC).

“When you tell staff that their unit’s rate of C. diff infections last month was 0.37%, to them it’s statistical mumbo jumbo. But when they can see that their unit had two C. diff infections last month, they see that as two infections, two people who were harmed. It resonates and motivates,” DiAgostino said.

The HARM Index data are also tracked monthly, which enables leaders to determine whether their efforts to improve care quality and patient safety are working. In addition, it enables them to spot negative trends that require immediate action. For example, when the HARM Index showed a trend in high rates of C. diff infections among inpatients, leaders developed a safety improvement plan that involved placing C. diff patients in isolation rooms, developing protocols for testing based on symptomology, and ensuring there was heightened awareness of the plan and protocols among clinical and nonclinical staff in departments including admissions, registration, and the emergency department. “As a result, we reduced our C. diff rates to below the national average,” DiAgostino said.

The HARM Index also helps leaders quickly spot near-miss events and develop ways to prevent them from recurring and possibly causing patient harm. For example, as part of a routine safety check of patient rooms in GHMC’s Behavioral Health Unit, a staff member discovered a homemade weapon a patient had hidden within the zippered panel of their mattress. The event was fed into the HARM Index through the safety event reporting program. Although the event wasn’t counted as a patient harm, it did prompt an inventory of mattresses in the unit, which revealed that more than half had zippered panels. As a result, new mattresses without zippers were immediately ordered, and safeguards were put in place so that only mattresses without zippers would be ordered in the future.

Training in High Reliability Principles

An important part of any health care organization’s commitment to achieve zero harm is a commitment to practice the principles of high reliability: preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and commitment to resilience. To bolster Garnet Health’s existing quality and safety infrastructure, more than a dozen clinical service line leaders and executives recently received eight full days of training in high reliability organizing (HRO) principles from HPI, a Press Ganey solution.

The training “changed their mindset” about patient safety, according to Crittenden. “For example, the whiteboard by the main desk in the OR used to only list metrics related to throughput and efficiency. Now it also lists metrics related to patient safety,” she said. “Each morning, when the department leader and staff huddle at the whiteboard to talk about the day’s cases, the focus is on patient safety and includes updates on past safety events and any safety risks for the day.” At press time, the leaders were incorporating the high reliability principles into a revamped version of the organization’s LEAD leadership development program to educate unit directors and staff champions in HRO as well.

In addition to a sharper focus on patient safety, the HRO training has also prompted development of high reliability tactics that have had a positive impact on safety as well as patient experience and workforce engagement.

One of these tactics is the “HRO 60-Day Challenge,” in which nursing and clinical units compete for a prize based on their knowledge and implementation of HRO concepts. Another is daily safety huddles that include the chief nursing officer, patient flow coordinator, surgical and emergency department leaders, nursing and unit directors, front-line registered nurses, and partnering ancillary areas. “Communication across the enterprise is a challenge for any organization. These multidisciplinary huddles are an efficient, evidence-based way of making sure everyone is communicating and working as a team to deliver safe, high-quality care,” DiAgostino said. The response among leaders and staff has been so positive that starting later this month, these safety huddles will be held nightly as well.

Following are some additional tactics Garnet Health employs for improving safety, patient experience, and workforce engagement.

  • A Ring of Quality, which is a large metal ring with pages looped through it that list the unit’s quality data. Each unit has its own Ring of Quality, and it’s brought to staff and process improvement meetings to keep everyone apprised of the unit’s progress in quality and safety work.
  • Clinical and nonclinical department scorecards that have been aligned and simplified to include one patient experience measure, one safety measure, and one department-specific measure, which is consistent with board priorities. The nonclinical leader partners with the clinical unit to support rounding and patient experience efforts.
  • Real-time review of mortalities for severity of illness and risk of mortality to identify opportunities in clinical documentation and care.
  • Mandatory training to educate the workforce on ways to listen better to patients and one another. According to Jodi Goodman, director of patient experience at GHMC–Catskills, the training has led to improvements in patient experience survey scores, including an increase in the Overall Rating top-box score for GHMC–Catskills’ emergency department, which rose from 6​6 in 2018 to 74.3 YTD 2020.
  • A robust peer review program led by physician champions.
  • Use of a clinical analytics platform with a focus on clinical documentation and coding to accurately reflect care that was rendered.
Thanks to its work over the past nine years, Garnet Health has made significant progress on its zero harm journey. However, Crittenden, DiAgostino, and Goodman are quick to point out that their journey is in no way complete.

“Achieving zero harm requires an ongoing commitment and continued innovation,” Crittenden said. “We’ll keep striving to reach this goal by coming up with new ways to reduce harm and keep staff engaged in that work.”