By Lauren Keeley

Inspira Health Network’s systemwide high reliability organizing (HRO) training created a strong foundation for safety culture. When Inspira was formed, in the wake of a large merger between South Jersey Healthcare and Underwood-Memorial Hospital, it also helped break down cultural incongruities that emerged. However, when leaders sought to instill these principles in the ambulatory division, they quickly learned that the ambulatory care setting presents unique challenges to improving safety and achieving high reliability.

As a result, the ambulatory leadership team adjusted the HRO training, moving away from hospital-based examples and leveraging their own internal data to build a model that would resonate with staff in the outpatient setting. Safety culture elements, which include daily safety briefings, safety coaches, monthly safety messages and tools, and local learning systems, have led to gains in physician recruitment, improvements in data transparency, and an uptick in staff reporting quality concerns and safety events.

Trusting the Foundation, Adapting to Nuance

As a Press Ganey patient experience, engagement, and safety client, Inspira Health’s ambulatory division had a wake-up call three years into its HRO journey. Press Ganey presented a visual representation of the division’s data elements from patient experience and employee engagement surveys via a critical metrics map. This map helps organizations quickly determine where they have opportunities to improve organizational culture and patient experience. For Inspira Health’s ambulatory division, a significant portion of the map was red, signaling “low performance” across domains. It was time to hit the reset button.

With assistance from Press Ganey Safety & Reliability consultants, the ambulatory division relaunched the system’s HRO training, this time with necessary modifications. By working from their own internal data—as shown in the critical metrics map—Inspira Health’s ambulatory leaders achieved higher staff buy-in than in the first round of HRO education. “We realized our staff was having difficulty translating the hospital-based examples into their work setting,” said Beth Anne Rambo, the organization’s director of ambulatory quality and patient safety. “Incorporating Inspira’s ambulatory data into the training, coupled with examples of potential safety events that are unique to our clinics, opened their eyes to the importance of this work.”

Overcoming Geographical Challenges to Leading Safely in Ambulatory Care

Inspira Health’s ambulatory care sites span five counties in southern New Jersey, comprising urgent care, primary care, and specialty care practices. On top of the problem of staff buy-in, Inspira Health’s large geographical footprint made it difficult to unify operations and culture across several practices.

“We decided to tag a safety coach at each service location,” said Rambo. “That person becomes a constant for that office and helps communicate the monthly safety message. They also act as a resource to staff for voicing any safety concerns or questions.”

The monthly safety message is a way for Inspira Health to reinforce certain HRO behaviors and tools. It has continued to prove critically useful during the COVID-19 pandemic, when shifting best practices and protocols can give rise to safety misses. Recently, the monthly safety message focused on urging vaccinated staff members to remain vigilant with mask wearing, hand washing, and physical distancing.

Inspira Health’s ambulatory division also introduced a daily safety briefing, which occurs Monday through Friday and lasts about 15 to 20 minutes. During that time, ambulatory leaders from over 100 touchpoints, as well as support services housed in the hospital, gain situational awareness of what’s going on in the network’s various ambulatory settings.

For example, “I recently reported a defective procedure mask at the ambulatory safety briefing, and the information was subsequently circulated at the hospital’s safety briefing,” said Rambo. “Within an hour, situational awareness was created across the network and everybody knew to look out for this mask and take it out of service.”

To promote continuous improvement and transparency, each location has learning boards that visually represent new ideas, ideas in action, and the results of those ideas, coupled with relevant data and action plans. Updates to the learning boards are frequently relayed in the daily safety briefing.

Speaking Up for Safety

Although circumstances may be different in the ambulatory care setting than within the walls of a hospital, it is important to remember that the concept of harm is not hospital-centric, according to Dr. Christopher Trotz, executive medical director of Inspira Medical Group. In fact, outpatient visits occur 25 times more frequently than hospital admissions—meaning the chance of error is magnified.

With the steps it has taken to implement safety training unique to the ambulatory setting, Inspira Health has been able to maintain zero harm at its medical practices and urgent care centers, as measured by its Serious Safety Event Rate®. The health system has also fostered a heightened level of transparency and a nonpunitive culture that rewards speaking up for safety at any of its service locations. Consequently, there has been an increase in reporting of safety events and quality concerns, with 84% of issues brought up during the daily safety briefing resolved the same day.

Even with the zero harm safety event rate, Paul Lambrecht, vice president of quality and patient safety at Inspira Health, is quick to point out that leaders and staff must never become complacent. “We’re constantly looking to broaden the definition of ‘harm,’” he said. “The more we do that, the more we can really get at preventability.”

For now, Inspira Health’s ambulatory division is looking forward to reviewing the results of its culture of safety survey, which was conducted in October. Leaders continue to work with Press Ganey to connect the dots between safety, quality, experience, and engagement. “Our improvement is not a siloed approach—we share similar teams; we share similar conversations,” concluded Lambrecht. “And high reliability is at the foundation of it all.”