Published in the March 2005 issue of Today’s Hospitalist
When it comes to improving patient safety, health care often turns to experts in aviation for help. But for one health care system in Virginia, the path to improve both quality of care and patient safety lay not only with strategies used by the airlines, but also those from the nuclear power industry.
Sentara Healthcare, which operates hospitals, long-term care facilities and ambulatory practices in the Norfolk area, has used a variety of approaches to improve patient safety. While those efforts produced some success, officials were not satisfied with the incremental gains and wanted to accelerate the pace of improvement.
So when a physician executive heard about a consulting firm that applied its experience with industries including nuclear power to health care, he was intrigued. Sentara officials wanted to learn about that industry’s ability to manage complex systems, particularly the interaction between humans and technology.
“What interested us was the perspective on how the nuclear power industry maintains a safe operating environment,” says Carole A. Stockmeier, MHA, director of Sentara’s patient safety initiatives. “That industry has proven structures and tools to make sure it’s aware of the status of operations. It is constantly doing analysis to examine why errors and events occur, and it has a rigorous approach to correcting problems .”
By borrowing some key error-prevention tools from the nuclear power industry, Sentara found ways to hold its staff more accountable for patient safety. And while changing employees’ attitudes may seem like an intangible goal, the health system has seen improvements in areas like patient falls with injury and how patients are handed off from one clinician to another.
Setting expectations
When Sentara began to gather information for a baseline assessment for its patient safety initiative, officials quickly realized that the events that had occurred in the past were the result of several common causes. Data showed that roughly 90% of all events were related to four key areas: lack of attention to detail, lack of critical thinking on the part of staff, noncompliance with policies, and high-risk behaviors in high-risk situations.
Based on that analysis, Sentara got to work setting clear behavioral expectations to prevent errors, which the health system calls behavior-based expectations (BBEs). The purpose of these expectations is simple: Give staff the tools they need to detect and avoid mistakes.
For instance, to help employees pay attention to detail, one of the five expectations, Sentara adopted a mnemonic used in the nuclear power industry, STAR, which calls on staff to take four actions: stop, think, act and review.
“It’s a self-checking technique where you stop and think for a couple of seconds about whether you’re doing what you think you’re doing,” explains Shannon M. Sayles, RN, MA, who is also a director of Sentara’s patient safety initiatives. She says that a goal is to avoid the kinds of errors “where you slap your head and say, ‘I can’t believe I forgot to do that.’ ”
Another of the five expectations urges staff to use a questioning attitude to critically review the actions of themselves and others. “A big source of problems was that people would see something that might seem odd,” Ms. Sayles explains, “but they wouldn’t follow through. They would assume that someone else smarter than them like a doctor must know what they were doing.”
Sentara’s three other expectations focus on making sure that patient handoffs go smoothly, that staff communicate with others clearly (using techniques such as repeat backs), and that staff work with each other (like a wingman) to make sure that everyone is following the same quality principles.
The goal of establishing behavior-based expectations is to give staff the tools that give them the courage to speak up. Instead of being nervous about questioning a peer or a physician who may be about to do something wrong, staff members can simply explain that they are following the principles of their training.
In addition to developing behavior-based expectations for staff, a group of physician leaders developed behavior expectations specifically for physicians. Besides calling for attention to detail and clear communication, these expectations try to improve physician-to-physician consultation and call for the designation of a coordinating physician when multiple services are caring for a patient.
Sentara collects success stories that illustrate how staff members have prevented patient harm by using these behaviors. Ms. Stockmeier cites one such story to illustrate how a relatively simple concept like critical thinking can produce tangible results.
When an order for two different types of insulin crossed the desk of a unit secretary, she noticed that they seemed to be reversed. She knew that the one type of insulin was usually ordered in a high dose, so the secretary got the physician and explained that she noticed that he usually wrote his insulin orders differently, in reverse.
After realizing that he had been distracted when writing the order, the physician changed his instructions for the patient. He also passed the story along to Sentara safety officials as an example of how the behavior expectations had helped improve care for at least one patient.
Streamlining safety processes
To help staff better focus on safety, Sentara streamlined many of its procedures. One result was a series of “red rules” that highlight principles that should never be violated.
“Red rules are about helping us focus on those things that are most critical to patient and employee safety,” Ms. Stockmeier explains. “We define red rules around the things that have the highest level of consequence or risk to safety.”
One rule that applies to all hospital staff, for example, focuses on patient identification. Before any action is taken with a patient, staff verify and match a patient’s identity using name and social security number.
Individual departments and units also have their own red rules. In telemetry, for instance, one of the red rules says that volume on the telemetry monitors should be not be modified downward.
The health system also redesigned many of its policies and procedures to help reduce errors. While Sentara’s policies and procedures previously were part of long documents, many now appear in a chart format that spells out specific actions staff are expected to take. When necessary, an individual action is then further described through supplemental guidance.
The tool for initiating and maintaining IV sites, for example, contains pictures and gives examples of how to treat major complications. It also uses images to demonstrate the major types of complications of an IV site and how to respond to them.
Sentara removed some items from its PCA order set and put them on a small laminated card that is attached to the PCA pump. “If the patient gets in trouble and you see these signs and symptoms, it tells you what do,” Ms. Sayles explains. “The idea is to put the information where you’re going to use it.”
Improvements
About a year and a half after the patient safety initiative began, Sentara has seen some definite improvements. Falls with injuries are down by 42 percent, for example, and patient handoffs have shown significant improvement.
At the same time, Sentara has seen an overall improvement in how its employees are meeting its behavior-based expectations and the red rules. To gauge employees’ success in this area, the health system sends staff into units to watch how well other staff are following those guidelines.
In the first year, those observations focused primarily on how well staff followed communication protocols. This year, the focus is on effective handoffs and questioning attitude.
The performance of all staff, not just physicians and nurses, was assessed. Sentara officials believe what’s going on in an individual unit is less important than how the overall organization is doing. A monitor on a nursing unit could be watching how a dietary worker pays attention to detail, for example, by observing whether he checks for an NPO sign before giving the patient a meal.
While Sentara’s patient safety initiative has improved staff attitudes toward error prevention, it is still a work in progress. That’s why Sentara has made reducing serious and sentinel events a goal for the current year.
Other goals for this year will focus on serious medication events and events that happen with some regularity, like patients falling and breaking their hip.
