It took a shell-shocking adverse event at two of the nation’s leading health systems to put a spotlight on the need to improve safety culture.
At Houston-based Memorial Hermann Health System, it was a pair of blood transfusion errors in 2006 that left one patient dead and another critically ill, and for the Virginia Mason Health System in Seattle it was the 2004 death of a patient, Mary McClinton, from a preventable error.
Both organizations were taking steps to improve patient safety prior to these incidents, but the tragedies highlighted the importance of those efforts, the systems’ CEOs said during a webinar hosted by the Institute for Healthcare Improvement/National Patient Safety Foundation's Lucian Leape Institute.
Since then, Memorial Hermann has forged full speed ahead on its “journey to safety and zero harm,” said Charles D. Stokes, R.N, president and CEO. While “zero harm” may seem like a far-fetched goal, he said the system has proven it’s possible: Since 2007, it has performed more than 1.2 million blood transfusions with no adverse events.
"A lot of people are very skeptical: ‘We don’t really know that zero is realistic,’” said Stokes, who also serves as executive vice president and chief operating officer of the system. “But if you don’t put the stake in the ground, and you don’t put that out there, you will certainly never get to zero.”
One of the key steps for Memorial Hermann was to convince all executive leaders, including the board of directors, to talk about safety. Clinical representation on the board is critical for a health system that wants to get serious about a safety culture, Stokes said.
Virginia Mason also got its leadership involved in safety, said Gary Kaplan, M.D., chairman and CEO, by first offering physicians a compact, which laid out clearly what the system expects from doctors it employs and what they can and should expect from Virginia Mason. The C-suite team expressed interest in compacts of their own, and soon the board of directors wanted one as well.
The process was “foundational and fundamental” to improving safety, Kaplan said, as it aligned expectations among different groups.
“It was the groundwork and allowed us to create an understanding that we needed to better hold each other in our organization accountable,” he said.
Memorial Hermann also recognizes clinical teams that lead the charge on safety with annual awards to promote accountability and recognize staffers who are committed to safety. The “certified zero” awards are offered to teams that had no adverse events over the course of the year, and since 2011 the system has handed out 257 of the awards for reducing hospital-acquired infections and other preventable errors.
Virginia Mason’s safety culture transformation began in 2001, Kaplan said, when system leaders realized that a physician-centered approach was not going to improve patient care, and instead they needed to take a patient-centered approach.
With that goal embedded in a strategic framework, the system could move toward improved safety and quality, he said.
“We had to challenge our old paradigms,” Kaplan said. “Physicians are instrumental in setting the tone, and unless the physicians believe we’re on the right path we don’t have the kind of alignment that will help us move forward.”
Hospitals or health systems that want to build or improve their own cultures of safety must keep six “domains” in mind, according to a guide released by IHI/NPSF:
- Establish a compelling vision for safety
- Build trust, respect and inclusion
- Select, develop and engage the board
- Prioritize safety in selection and development of leaders
- Lead and reward a Just Culture
- Establish organizational behavior expectations
The goal of the guide, which Kaplan and Stokes both contributed to, is to motivate and energize executives around the importance of improving safety.