Effective measures to reduce serious security events include security rallies, security advocacy, and implementing a “just” culture.
Ward’s former health system had worked toward the same goal, and she found the process “transformative” and highly effective in reducing serious safety events.
Ward, who has more than 30 years of experience in health care administration and has held senior nursing positions in organizations across the country, spoke with HealthLeaders about what has worked to reduce the events of serious security.
This transcript has been lightly edited for brevity and clarity.
Lanie Ward, MBA, BSN, RN, is CNO of Cambridge Health Alliance. Photo courtesy of Cambridge Health Alliance.
HealthLeaders: What are the most common patient safety issues in hospitals and healthcare systems?
Lanie Ward: The most common patient safety issues that I see through my eyes as a NOC are [these] three: medication errors, nosocomial infections and patient falls. There is no doubt that medical errors occur with the greatest frequency. Many of them cause no harm to the patient, but some cause serious harm and even lead to the death of the patient. This is why it is so important that we carefully evaluate all medical errors, even if there has been no harm.
At CHA, we focus on two nosocomial infections: catheter-associated urinary tract infections and central line-associated bloodstream infections. The frequency of these infections is much lower than that of medical errors, but they are harmful to our patients. And I have to tell you, my infectious disease experts would be really mad at me if I didn’t mention hand washing. This is the first thing to do to prevent the spread of infections from patient to patient.
Patient falls are a big safety issue, and they happen everywhere, from our outpatient clinics to our emergency departments, to our medical surgery units, and even in our intensive care units, as some patients are more prone to falls than others.
We find that in our hospitals, patients are more at risk of falling when they go to the toilet – when entering the bathroom, while in the bathroom and when returning to bed – which is why the use of targeted rounds is so important. Targeted rounds are proactive and frequent rounds and in these rounds we will be grooming the patient.
And even though many disciplines play an important role in eliminating or reducing these patient safety issues, there is no doubt that nursing plays a huge role because it is there all the time.
HL: What is one of the most effective quality improvement initiatives you have participated in to reduce serious safety events?
Hall: I feel lucky to have been part of a healthcare system that has embarked on the path to becoming a highly trusted organization. In my career, I have found this trip to be the most transformational of any I have been on, and it has resulted in a sharp reduction in our serious safety events. Now that I work at CHA, we are embarking on the same journey to become a highly reliable organization.
I’ll start by saying that the foundation of a highly reliable organization is that there must be total management commitment to the goal of zero injuries. They must commit financially to this trip, over time, and support all staff.
Everyone in our organization received training on the security principles and the measures we were going to take and the expectations for them. We have borrowed many of our principles from other industries, aviation and nuclear power, because those industries have been much more successful than health care in those areas.
There have been many milestones in this whole journey, but the three that I believe had the most impact in reducing our serious security events were:
1. Setting up safety meetings
2. Waiting to talk for security
3. The establishment of a just culture.
Daily safety meetings focused on patient safety issues, concerns, resolution and follow-up, and they were implemented not only at the hospital level every day, but also at the department level. . In these caucuses, we even spoke using safety language and clarifying language so that we had the skills we needed for verbal transfer orders, and other times that clarification was needed along with the communication.
Have you heard of the NATO phonetic alphabet [Alfa, Bravo, Charlie, etc.]? I said in caucus, “This is Lanie Ward; this is Lima Whiskey for L and W, and today we have 15 patients – that’s one in five patients – who have Foley catheters. permanently.” I found that using this language every day, and repeatedly, kept the focus on all of us knowing we were doing something different. We work on patient safety, and to be honest, it was a lot of fun. This, and the daily caucuses, have helped us focus on patient safety at all levels.
The second was the expectation that everyone speaks out and can, let’s quote “stop the line [meaning to stop a procedure in its tracks]”We were all taught to speak up and escalate it, and also how we should respond appropriately if we were on the receiving end of someone speaking. This training eliminated the power distance or hierarchy between a nurse and a doctor or between a cleaner and a nurse.
Just to give you an example of how it happened, using aviation parlance, a housekeeper might see a doctor walk into a room and not wash their hands. The housekeeper was expected to say, “Don’t forget to wash up” – a soft voice – and the doctor was expected to say, “Thanks for the cross-check”, not “Who are you?” you tell me to wash my hands?
If the doctor didn’t respond in the expected way, our staff learned to step in and say, “For patient safety, it’s important that we wash our hands.” If he was still ignoring me, then the key word was “concerned”. Anyone in our organization could say, “I have a problem,” and that phrase was supposed to end the line. It really helped stop the power distance and put people at ease. And they had to because that was our expectation.
Third, we have implemented a “just culture”. In the past, health care held individuals accountable for all mistakes, and in a just culture, people are not held accountable for system failures. We developed an algorithm that would help leaders and staff understand why a particular error had occurred.
An example would be: Was the medication barcode scanner not available or did the nurse choose not to use it? And [that would help determine] whether it was a system problem or whether we needed to hold our staff to account.
One of the things I learned on this trip was what I call “measuring abundance,” where… I asked nurses to report how many days their unit was fall-free, not how many falls they had. It’s more of a positive thing.
HL: What should nurse leaders do to help improve their organization’s culture of patient safety?
Hall: It is my responsibility and the responsibility of all nurse leaders to make it as easy as possible for nurses to practice safely and to prevent them from making mistakes, and we must do this by doing things like making sure we provide them with the most up-to-date modern technology; that good processes and systems are in place; that staffing is where it should be; and that their environments are conducive to safety.
Second, nurse leaders need to listen to and use the voices of nurses who are in contact with patients. We often sit in offices, so we have to listen.
Third, each unit should prioritize not 10 patient safety goals, but two or three depending on the specifics of their unit, and then identify and implement best practices to help achieve those goals.
Fourth, I talked about measuring abundance while looking at each fall incident to understand why it happened. Nurse leaders should measure abundance and celebrate, celebrate, celebrate success. It’s so motivating for the staff.
Fifth, I am a firm believer in learning from near misses and mistakes that do no harm. Don’t ignore them because they could have easily gone the other way.
Finally, always remember that “to err is human” and support your staff. They need our support.
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.