Kootenai Health's Culture Change Advances Safety, Experience & Engagement

Added on Sep 19, 2019

medicalStaff_discussingChartsAt Kootenai Health, an Integrated Approach to Performance Drives Improvement in Safety, Patient Experience, and Engagement
By Audrey Doyle

Kootenai Health Way isn’t just the name of the road directing patients and visitors around the main campus of Kootenai Health. It’s also the name of the transformational culture directing the behaviors of everyone in the Idaho-based organization, from executive leaders to clinical and nonclinical staff.

“The Kootenai Health Way influences how we conduct ourselves, make decisions, and interact with patients and each other,” said Chief Nursing Officer Joan Simon. “By designing the Kootenai Health Way to support our core values of safety, compassion, and engagement, we’re providing an exceptional experience for our patients, their families, and our staff.” 

By reinforcing these values through strategies including annual systemwide culture training and a reward and recognition program, the organization has also seen meaningful improvements in safety, patient experience, and quality outcomes.

Making Safety a Priority 

A Magnet®-designated health system and member of the Mayo Clinic Care Network, Kootenai Health provides comprehensive medical services to patients in Idaho and the Inland Northwest through a 330- bed community-owned hospital, a Level II trauma center, a staff that includes more than 500 physicians and advanced practice providers, and a multispecialty clinic with more than 220 physicians and advanced practice providers.

According to Simon, the system had implemented numerous individual safety, patient experience, and employee engagement improvement initiatives in the past, but this siloed approach didn’t produce long-term gains. “There was nothing to tie the initiatives together, so whenever a new initiative was introduced, it received all the focus, and prior initiatives often drifted into the background,” she said. “As a result, most improvements we had were short-lived.”

Then, in 2013, at a time when Kootenai Health was expanding and patient acuity was rising, a patient was harmed during surgery. Although a root cause analysis was begun to determine why the serious safety event occurred and prevent it from recurring, the analysis couldn’t be completed, because employees were afraid to speak up. This served as a warning to leaders that their culture of safety wasn’t as robust as they thought it was, said Simon.

Also at this time, CEO Jon Ness identified safety, compassion, and engagement as the organization’s core values. Aware of the negative impact that deficiencies in safety culture can have on employee engagement and patients’ perceptions of their care experience, leaders launched a multiyear initiative to design, build, and nurture an organizational culture that promotes the interdependencies of the system’s core values and ties them back to its mission and vision.

Since their transformational journey began in 2014, leaders have taken several steps to instill the Kootenai Health Way throughout the organization. Chief among these steps is identifying and promoting the following behaviors that all employees are expected to exhibit.

  • Safety Behaviors
    • Make patient, guest, and co-worker safety a personal priority.
    • Remain mindful of the many ways mistakes can happen.
  • Compassion Behaviors
    • Create a positive, compassionate experience for patients.
    • Be courteous and respectful to everyone.
  • Engagement Behaviors
    • Be committed to doing my best work every day.
    • Be committed to the success of my co-workers.
In addition, leaders formed three executive steering committees—one on safety, one on patient experience and compassion, and one on engagement—to help implement policies and best practices that support these behaviors.

The safety committee, chaired by Chief Physician Executive Dr. Karen Cabell, ensures that employees consistently follow standard safety processes and protocols, including a SafetyFirst Toolkit of best practices. Developed by HPI, now part of Press Ganey, the toolkit includes such strategies as paying attention to detail and doing a self-check using STAR (Stop, Think, Act, Review); communicating critical information using Write Down, Read Back, and ISBARD (Introduce, Situation, Background, Assessment, Recommendation, Documentation); using I-Pass, a standardized framework for safe patient handoffs; and using safety tools such as Peer Check, Validate and Verify, and ARCC (Ask a question, make a Request, voice a Concern, use the Chain of command).

To stay on top of safety concerns, department leaders participate in 15-minute daily check-ins to openly discuss safety issues with staff, and executive leaders conduct purposeful rounding on patients every Monday throughout the organization and safety rounds in each area annually. According to Dr. Cabell, the results of the check-ins and rounds are given to the safety committee to act on, and follow-up actions are shared with the staff, instilling a sense of reliability and trust between staff and management.

The patient experience/compassion committee is led by Simon, and the engagement committee is led by Dan Klocko, executive vice president of human resources. In addition to monitoring patient experience and employee engagement metrics, these committees assist in tying patient experience and engagement initiatives into the Kootenai Health Way, assessing resources, and researching and recommending policies and best practices and ways to implement them into care processes.

To continue instilling the Kootenai Health Way throughout the organization, all three committees are also responsible for helping to implement comprehensive multidisciplinary training that focuses on the organization’s mission, vision, and values. As part of annual strategic planning, leadership develop a training program that addresses the coming year’s strategic goal. The 90-minute training is conducted by the Organizational Development team during Q1 of each year. Leaders receive the training first, and then it’s rolled out to the rest of the workforce, including contracted physicians and clinic employees. All new clinical and nonclinical staff, independent or employed, also receive the training as part of orientation.

Board members are offered an opportunity to participate as well, and many of them do, according to Simon. “It’s not unusual during a training session to have a board member, housekeeper, nurse, and radiology technician all talking with each other about what’s important in terms of our values and culture,” she said. “Having the board participate sends a strong message that everyone takes this seriously.”

Although safety, compassion, and engagement are discussed in each year’s training, one of those three values is chosen as the focus. For instance, the focus for 2018 was safety, so a main part of the training consisted of a refresher on the Safety-First Toolkit. Last year’s program also included just culture training using HPI’s Safety Event Classification algorithm, which ensures that the organization responds to safety errors and events in a consistent manner.

For 2019, the training program focused on engagement. Using as the program’s framework the Lean Six Sigma “8 Wastes of Lean”—Defects, Overproduction, Waiting, Nonutilized Talent, Transportation, Inventory, Motion, and Extra Processing—leaders engaged employees in identifying ways to be more efficient in the delivery of care.

A cultural learning map that depicts Kootenai Health’s identity, purpose, and vision for the future is also part of the training each year. “The learning map allows everyone, regardless of their position, to gain a clear understanding of our culture transformation journey—where we’ve been, where we are now, where we’re headed, and what it will require to get there,” said Dr. Cabell.

Being recognized and rewarded for good work is an important driver of employee engagement. To that end, leaders also implement a reward and recognition program to let employees know they’re exhibiting behaviors that align with the Kootenai Health Way.

For instance, each time an employee makes a great catch—that is, identifies an issue that had the potential to cause a safety event or serious safety event but didn’t, thanks to the employee’s timely action or intervention—the employee receives a Great Catch Award in the form of a small bead slipped onto a safety pin that’s attached to the employee’s badge. “It gives instant recognition that the employee is safety-conscious and practices the safety behaviors routinely,” explained Dr. Cabell.

In addition, each steering committee is responsible for recognizing front-line staff members who exhibited outstanding behavior and performance tied to the organization’s core values. The safety committee chooses award winners whose use of a safety tool, process, or procedure prevented an instance of harm. The patient experience/compassion committee chooses winners based on patient comments received through personal letters or the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. And the engagement committee chooses winners based on co-worker comments entered into Momentum, the organization’s Web-based employee recognition program.

Each quarter, each committee has one month in which it selects an employee to receive a Spark Award. The executive team delivers the award to the winner on their unit, and the vice president of their department presents the award in front of the winner’s peers. Each Spark Award winner is also recognized in The Wayfinder, the organization’s quarterly Kootenai Health Way newsletter.

Thanks to all of these efforts, the organization has achieved and sustained a number of meaningful improvements in performance across care domains. For instance, on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety, “Teamwork within Units” rose from the 50th percentile in 2015 to the 75th percentile in 2017, and both “Communication Openness” and “Nonpunitive Response to Error” rose from the 25th to the 75th percentile during the same period. Also, serious safety event reporting increased 4%, and the organization’s Leapfrog Hospital Safety Grade went from a “D” rating in the fall of 2015 to an “A” rating in the fall of 2016. According to Dr. Cabell, Kootenai Health continues to maintain this positive momentum.

In addition, the system has not only seen an increase in employee engagement but also has improved in several domains on the HCAHPS survey. For instance, the hospital’s “Overall Rating” increased from the 20th percentile in 2014 to the 72nd percentile in 2018. Other domains improved as well, including “Recommend the Hospital” (from the 43rd to the 72nd percentile), “Communication with Nurses (from the 16th to the 71st percentile), and “Communication with Doctors” (from the 54th to 74th percentile).

Kootenai Health has also ranked consistently above the mean in several NDNQI® RN Satisfaction Survey measures, including Practice Environment Scale and Job Enjoyment, both overall and at the unit level. In addition, the system maintained a ranking near the 75th percentile from 2017 to 2019 on questions pertaining to nurses’ working relationships with other health care professionals on their unit.

To continue driving improvement in these areas, leaders this year launched a daily management process that includes executive rounding on each unit. As part of this program, each unit has a learning board where employees document issues they’re experiencing. Through the learning boards, executive leaders are made aware of these issues, can escalate them quickly to the appropriate change agents, can monitor the unit’s progress toward resolving the issues, and can offer guidance and feedback as necessary.

Although each rounding session lasts only five to six minutes, “that’s 25 to 30 minutes per week that front-line staff have access to senior leadership,” said Simon. “It really helps us understand their issues, and sometimes empower them with ways to resolve them. It’s a great way to keep staff engaged and motivated.” Daily executive rounds will be conducted throughout the hospital by the end of 2019, and will go live in the Kootenai Clinic in 2020.

According to Dr. Cabell, the Kootenai Health Way is succeeding in developing a common language and understanding of the organization’s commitment to the overarching ideals of safety, compassion, and engagement.

“Our employees understand that safety, compassion, and engagement are equally important and that they’re a part of everything we do here,” Dr. Cabell concluded. “That’s the Kootenai Health Way, and it will continue to be our path to improvement.”