Spectrum Health: Safety Culture Transformation in the Post-Acute Setting

Added on Oct 20, 2016

Spectrum Health Continuing Care: Safety Culture Transformation in the Post-Acute Setting
By Erin Graham
From Industry Edge October 2016

West Michigan-based Spectrum Health has long championed the importance of a safety culture in its acute-care operations. Recently, it has taken its safety transformation journey into the post-acute territory. Over the past 18 months, Spectrum Health Continuing Care (SHCC) has begun to apply what it has learned from nearly 10 years of High Reliability work in its 13 hospitals and medical groups to the continuing care arena—an ambitious undertaking given that it has more than 500 specialized team members who provide rehabilitation, home health care, nursing, long-term care and other specialized services to more than 1,500 patients every day.

“Making safety truly a top priority meant making our safety behaviors and error prevention consistent,” said Deb Cress, MSN, RN, SHCC nursing officer. “We need to provide a safe experience, whether our patient/client is at home, with hospice or in a sub-acute space. The big question we had to ask ourselves was ‘How?’”

Although safety culture interventions in hospitals are associated with improved safety practices and outcomes, post-acute settings often report a poorly developed safety culture and a lack of best practices.

For Kris Pohlmann, director of Safety and Reliability at Spectrum Health, extending the High Reliability work was a matter of understanding gaps in patient care and potential harmful events, and then closing them. “We wanted to address events—such as medical record issues during handoffs to sub-acute facilities or rehabilitation—and connect the dots,” she said. “Why not use the same behaviors, all speak the same language and really push for 100% accountability?”

Different Settings, Different Challenges

While Cress, Pohlmann and Sonja Beute, director of Risk, Compliance and Safety at Spectrum Health, knew that safety practices in a community or home environment differ from those used in a hospital setting, they were surprised by just how dramatic the contrast was.

“The typical safety culture application is in the acute setting, where other staff are 10 feet away; and since they’re always together in a building, there is a rhythm and predictability,” Beute said.

Outside of these larger, institutional environments, however, there are a host of different factors to consider. “Our staff who work in people’s houses spend 90% of their time away from co-workers. So we have spent a lot of time putting our heads together to understand how the principles of High Reliability apply when you are traveling and working alone a lot.”

When leadership started meeting with staff to identify safety events in these settings, they made some unexpected—and disconcerting—discoveries about staff safety. “We’ve found that clinicians tend to be superheroes in every setting and put the patient first,” said Beute. “In the post-acute environment, that translates to putting up with unsafe situations as part of the job and not differentiating between kinds of safety risks for themselves.”

For example, what should homecare workers do if they are caring for a patient in the patient’s home and hear a gunshot? Or if they encounter frightening pets? Or notice big holes in the floor, a weapon or drug paraphernalia? What reporting mechanisms are in place if they find themselves caught in the middle of a domestic dispute or are harassed by a patient?

“All of these things happen, and it has become a matter of normalized deviance,” Beute said. “There are different degrees of being at risk. We need to help staff decide what are emergent, urgent or concerning safety issues so that they can use the right safety tools to address them.”

Another unique safety concern has given the team pause: Mother Nature. “In our area of the country, we have nurses trapped in patients’ homes because there are black bears circling the house, and we’ve had reports of nurses not being able to reach their patients because wild turkeys are blocking the route,” Beute said. Then, of course, there are weather conditions that jeopardize patient and staff safety differently than in an acute facility, with power outages and blocked roads. “It’s a matter of redefining what a safety situation is,” she explained.

Help from Colleagues

In creating a model of how to apply foundational High Reliability safety elements to home and community settings, the team looked to trailblazing colleagues at Holy Redeemer Health System as an example. Through Press Ganey, they worked closely with Holy Redeemer leaders to learn what worked well during their three years of post-acute safety culture training and implementation.

At the core, they learned that the proven High Reliability plan—making safety the top priority, constantly tracking serious safety events, methodical staff education and behavior training on error prevention—was largely transferrable. Holy Redeemer outlined the three must-have components for Spectrum Health to implement: a fanatical champion, safety coaches and daily communication huddles.

Planning how to enact this, however, posed a challenge. SHCC has about 800 staff who travel to 23 counties, caring for 1,500 patients a day. “The use of safety coaches or gathering around a table together in this environment is more complicated, so we have to be creative,” said Pohlmann.

Among the tried-and-true tactics, the team identified the following.

  • 15-minute daily huddles: Instead of in-person daily briefs, the SHCC home and community care huddles are done by phone. Supervisors from areas such as hospice, for example, take information gathered from their respective in-person meetings and call in to a shared line to talk about concerns and address pressing safety issues.

After a few months, some areas found that members were frequently finding needs for input from IT, so the team included IT in the daily huddles to quickly address issues, such as remote access to electronic medical records. The same was true with the Security department, which is now also part of the huddles; this collaboration led to situational awareness training for caregivers and new safety checks, such as caregivers calling in before and after a remote appointment.

“There was a lot of hesitancy among leaders at first because they thought this wouldn’t work—but it did, almost immediately,” said Beute.

Other early barriers included pushback from those who thought there was no way to carve 15 minutes out of their day, or that a 15-minute time frame was unrealistic. “They were overwhelmed by the thought of stopping work to connect by phone, but by day three, we felt we could get through the calls efficiently and truly end after 15 minutes,” Beute said.

  • Safety coaches: Because using the facility-based model of having coaches available on every shift, on every floor, isn’t feasible in an off-site context, the team worked to build awareness among staff on the role of a safety coach. They wanted staff to understand that the safety coach is someone they can go to as a peer to ask questions about safety.

The SHCC team designed a system in which one safety coach is assigned approximately 25 peers. Safety coaches are trained to be proactive: They choose a safety behavior of the month and text or email a communication regarding that behavior to their group. The idea is not only to reinforce the coaches’ presence as a resource, but also to get staff used to being in communication with the coach so that when they do have a concern they can turn to a familiar source of support.

Beute is building the network of coaches carefully and is determined to have them all be voluntary roles. “I feel strongly from my talks with Holy Redeemer that long-term success depends on these safety coaches, and I didn’t want to force people into the role,” she said. “That wouldn’t do it justice. We need people who are passionate about it.” To date, the team has trained 54 coaches and enrolls about five more each month as new people step forward.

  • Fanatical champions: Just as in the acute environment, Beute and her team have found that the safety message needs to be a top priority for executive leaders. Chad Tuttle, SHCC president, has been a fully engaged High Reliability leader who hasn’t wavered from the core safety and error prevention message. “Anyone doing this work will say that the leader makes the difference between doing something and saying it,” Beute said. “Our president personifies walking the walk.”

Tuttle personally sent out the invitation for safety behavior staff training and asked for volunteers who were just as passionate about safety as he was. His message was one of “join me” rather than “do this,” Beute said. Tuttle is also actively involved in the daily operations briefs, and when it comes to budgets he prioritizes based on what will most affect safety, she noted.

Going forward, the implementation group thinks that consistency in the messaging from leadership will be key; in particular, delivering the message to off-site workers that “Your safety is just as important as your patients’ safety—if we can’t keep staff safe, we can’t keep patients safe.”

Over the past 18 months, the SHCC safety team has uncovered safety areas that can be immediately addressed, as well as problems that are so complicated they may take years to solve. After all, the system cares for patients under age 1 to those celebrating their 100th birthdays, with the attendant range of clinical needs. “We see serious safety events in this area as opportunities to dig in and look at a problem systemwide,” said Cress.

Having completed staff training and increasing the number of safety event reports, Spectrum Health is on target for its postacute strategic safety goals—a reflection of staff being aware and engaged, according to Cress.

The team is also eager to help other hospital systems, just as Holy Redeemer helped them. “We lived by their advice for the first few months, and we would love to share what we learned with anyone interested,” Beute said.