Guiding a Journey to Safe and Reliable Healthcare

Karen Frush, BSN, MD

Chief Quality Officer

Stanford HealthCare

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Objectives

• Describe a framework for guiding a journey to safe and reliable care

• Discuss the link between teamwork, culture and patient outcomes

• Describe the importance of well-being as an integral component of a comprehensive approach to safety and quality

Agenda

• The early journey at Duke University Health Systemo A framework to guide the journey

• Insights and lessons learnedo Teamwork and the link to patient outcomes

• Taking the quality journey beyond Duke and into the Community

• Achieving safe and reliable care at Stanford HealthCare

The Journey at Duke Health

Insights & Lessons Learned

Translation to Duke LifePoint

Achieving Safe and Reliable Care at Stanford

James B. Duke Rebecca Kirkland, MD

U.S. tobacco and electrical power industrialist best known for the introduction of modern cigarette manufacture and marketing

Rebecca Kirkland, MD, MPH, is a Pediatric Endocrinologist and Professor Emerita, Baylor College of Medicine, Houston, TX.

Dr. W.C. Davison, Founding Dean of

DUSOM

“Culture of Continuous Improvement”

“collaboration and cooperation make

medical care possible”

Jesica Santillan

December 26, 1985 - February 22, 2003

Improving Healthcare Safety and quality

• Framework for providing safe and reliable careoLeadership Patient safety and QI leaders at all levels in organization

oPerformance improvement Data driven; improvement science; Lean Six Sigma

oCulture High performing teams and effective communication

Psychological safety and mutual respect

Partnering with patients and families

The Journey at Duke Health

Insights & Lessons Learned

Translation to Duke LifePoint

Achieving Safe and Reliable Care at

Stanford

CSU Structure

• Patient care services are grouped according to Clinical Service Units (CSUs),which is an operational structure that aligns physicians, staff and administration to DUH priorities.

• Co-lead by Vice-President, Medical Director, & Associate Chief Nursing Officero Hearto Oncologyo Musculoskeletalo Neurosciences and Psychiatryo Transplanto Emergency Serviceso Med/Surg/Critical Care o Perioperative Serviceso Women’s o Children’so Ambulatory Practice

Organizational Priorities

Balance Scorecard Metrics

Operational Work Plan

How do we decide what is important to the organization?

Mission/Vision/ValuesAdvancing health together

Institute of Medicine’s Six Aims of Quality

Performance Improvement

Culture: A Major Challenge

• Darrell Kirch: The courage to changeo AAMC 2007 President’s Address

o Traditional Academic Medical Center

Individual Experts → Expert Teams

Hierarchy → Mutual Respect

Punitive → Accountability

• Leading Culture changeo Bryan Sexton, PhD

o Safety Culture Surveys

Measuring, analyzing, understanding and using culture data to drive improvement

Reporting Culture Just Culture

Teamwork Culture

Learning Culture

Informed Culture

• The clinical environment has evolved beyond the limitations of individual performance, so we have to work as teams

• Teamwork is not the focus of most clinical education efforts, so few staff are well equipped to work as teams

• Good teamwork has been linked to better surgical outcomes; trauma resuscitation and time to OR; hospital acquired infection rates; birth trauma; mortality ratios, operational efficiencies, resilience and well being

• We work in teams, but we train in silo’soNursing School, Medical School

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Teamwork is not Natural, but Critically Important

Speaking a Different Language

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Paradigm Shift to Team System Approach

Team of Experts

Expert Team

Single focus (clinical skills)

Individual performance

Under-informed decision-making

Loose concept of teamwork

Unbalanced workload

Having information

Self-advocacy

Self-improvement

Dual focus (clinical and team skills)

Team performance

Informed decision-making

Clear understanding of teamwork

Managed workload

Sharing information

Mutual support

Team improvement

Role Clarity

“Achieve a mutual goal through interdependent and adaptive actions”

Teamwork at Duke

Changing Culture at Duke

• TeamSTEPPSo National Training Site since 2007

o Patients (PFAC members) as co-faculty

• Duke Patient Safety Center for Training and Researcho Patient Safety Leadership Training

o Physician and Executive Leadership in Patient Safety and Quality

o NPSF Certification as Professional in Patient Safety (CPPS)

o Resilience Courses

o Just Culture - D Marx, JD

o Professionalism - Gerald Hickson, MD

o Beryl Institute and patient partnership, co-design

Evolution of DUHS Service Line PFACs

DUHS Patient

Advisory Council

Oncology Patient

Advisory Council Peri-operative

services PFAC

Medical school collaboratives

DRaH PAC

groups/ activities

PDC/PRMO CSU PAC groupsDHCH

Patient Advisory Councils

DPC local patient advisory

committees

DRaHOncology

PFAC

Emergency Services

PFAC

DUH Children’s

PFAC

Overall improvement

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"Serious Safety Events"RCAs, ADE>SI 2, PSIs, HACsRate per 10,000 Adj Pt Days

# Events (RCAs)

# Med Events > SI 2 (Preventable)

# PSIs

Running 12 Month All Events Rate Per 10K Adj Pt Days

is better

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HIP/KNEE LOS INDEX

HIP/KNEE 30 DAY READMISSION RATE

Total Joint LOS and Readmission Trends and Knee LOS and Readmission Trends

The Duke-LifePointPartnership

• Founded in 1999; one of largest health care systems in U.S. • More than $6.5 billion in revenues and one of the best balance

sheets in the industry• 71 hospital campuses in 22 states;

approximately 47,000 employees; and more than 6,300 physician relationships

• Leading healthcare provider in its communities and committed to keeping healthcare local

Duke LifePoint HealthcareLifePoint Mission: “Making Communities Healthier”

The Journey at Duke Health

Insights & Lessons Learned

Translation to Duke LifePoint

Achieving Safe and Reliable Care

at Stanford

DLP Healthcare, LLC (Duke LifePoint) formed in Jan 2011 to improve health care throughout NC & surrounding regions through a network of community hospitals (Duke LifePoint Regional Strategy)

‒ Governing Board oversight with Duke & LifePoint representation‒ Quality Program overseen by joint Duke LifePoint QOC with resources & support provided by DQN

Separate Quality Program Affiliation with LifePoint established to ensure a consistent quality & patient safety platform across LifePoint & Duke LifePoint Hospitals (LifePoint National Quality Program – NQP)

Duke LifePoint Healthcare

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Network of Hospitals, Physicians and Healthcare Services that are Quality Driven, Adaptive to Change, Financially Strong

2011: CMS Hospital Engagement Network

In December 2011, Duke and LifePoint began a relationship with the CMS Innovation Center as one of 26 organizations designated as a

Hospital Engagement Network.

This was the most widely regarded and most highly anticipated program in the Partnership for Patients.

IMPROVE SAFETY: Reduce preventable harms by 40%

COORDINATE CARE: Reduce readmissions by 20%

ENGAGE PATIENTS AND FAMILIES

Hospital Board or Patient Advisory Council

Bedside Shift Report At the Point of Care

In Process Improvement

In Governance

Patient Safety and Patient Experience

Patient & Family Engagement

Culture that Supports Safety & Learning

• Environment that fosters teamwork and accountability; psychological safety and speaking up

• Engaging patients & their families

Process Improvement Methods

• Foundational tools and skills

• Technology and data analytics

• Evidence based clinical processes

Leadership• Every level of the

organization• Accountability that is

fair & expected• Engagement of all

stakeholders

Duke-LP HEN Reliable

Framework

Duke LifePoint Framework

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LifePoint Harm Rate for Original HEN Harms(Excludes hip fracture, punctures, pneumothorax, MRSA, sepsis, & wound dehiscence;

excludes data for Central Carolina, Conemaughs, Fleming,& Frye)

Harm Rate 2010 Baseline Original HEN Goal

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HEN Inpatient Harms and Readmissions

64% reduction April 2017 compared to 2010 Baseline

Improvement in Culture of Safety

Frush K, et al. National Quality Program Achieves Improvements in Safety Culture and Reduction in Preventable Harms in Community Hospitals. Jt Comm J Qual Patient Saf.

2018. Jul:44(7)389-400. doi 10.1016/j.jciq.2018.04.008. Epub 2018 Jun 6

Achieving Safe and Reliable Care at Stanford

The Journey at Duke Health

Insights & Lessons Learned

Translation to Duke LifePoint

Achieving Safe and Reliable Care at

Stanford

Safe and Reliable Care: Sociotechnical

• Leadership• Technology, data analytics• Transparency and reliability• Organizational learning

– Psychological Safety– Feedback

• Teamwork and mutual respect– Trust– Inclusion

• Resilience, purpose driven work

Frankel, et al. IHI 2017

Placeholder - - Stanford Data

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Non-verbal messages

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Effective Leadership

Edgar Scheino Humble Inquiry: The gentle art of asking rather than telling Communication is essential in a healthy organization. But all too often when we interact

with people—especially those who report to us—we simply tell them what we think they need to know. This shuts them down. Humble Inquiry is the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person. It’s an essential art to collaboration, culture, change and leadership.

o Humble Leadership: The power of relationships, openness and trust The more traditional forms of leadership that are based on static hierarchies and

professional distance between leaders and followers are growing increasingly outdated and ineffective. As organizations face more complex interdependent tasks, leadership must become more personal in order to insure open trusting communication that will make more collaborative problem-solving and innovation possible.

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Why is Culture Important?

• At the core, healthcare is about people taking care of people• Culture reflects the behaviors and beliefs of the people within

an organization, “the behavioral norms”oThere are behaviors that create value individually, for the

patient and the organization.oThere are behaviors that create unacceptable risk.

• These attitudes and behaviors are reflected in how people interact with each other both internally and externally with patients and their families

• Culture is the social glue• Culture is linked to outcomes

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Teamwork Climate Scores Across Facility

Patient Satisfaction 9250

Medication Errors per Month 2.06.1

Days between C Diff Infections 12140

Days between Stage 3 Pressure Ulcers 5218

Better Culture: Better Patient Outcomes

Illustrative Data:Extracted fromBlinded Client DataMichael Leonard, MD

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Teamwork Climate Scores Across Facility

Employee Satisfaction 9155

Employee Injury per 1000 days 0.116

Employee Absenteeism per 1000 days 1015

RN Vacancy Rate 19

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Talk about people behind their backs.Intentionally exclude others from the group.

Use a personal phone in ways that interfere with work.Treat new people harshly.

Bully other people.Turn their backs before a conversation is over.

Yell at other people.Fail to respond to phone calls, pages, and/or requests.

Try to publicly humiliate others.Set others up to fail.

Violate HIPPA.Hang up the phone before a conversation is over.

Make comments with sexual, racist, or ethnic slurs.Show physical aggression (e.g., grabbing, throwing,…

Touch people in overtly sexual ways. ≥80 good teamwork

While you are waiting for us to start, perhaps you could send a quick text to someone important to you, to send a kind thought their way.

Thriving vs. Surviving During Times of Change: Resilience as QualityWith thanks to:J. Bryan Sexton, PhDDirector, Duke Patient Safety Center

What are the causes??

Work-life imbalancePoor sleep hygiene

LonelinessNegative thoughts

Production pressureLack of control over job

Leadership supportConflicts with colleagues

Building Personal Resilience: Three good things

Seligman, Steen, Park & Petersen, 2005

• Based on positivity research

• Each night, record 3 positive events in a journal

• As effective as SSRI for 6+ months

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Resilience

93% would recommend 3 GT to a Friend / 91% Supervisor

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Teamwork Climate Safety Climate Threat Awareness Resilience Work Life Balance

DUHS 20143GT Yes3GT No

Mean

of th

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rea s

core

sDUHS Safety Culture &

Resilience

 

Mean of the clinical area scores

DUHS Safety Culture & Resilience

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Teamwork Climate, 68

Safety Climate, 71

Threat Awareness, 50

Resilience, 40

Work Life Balance, 49

Teamwork Climate, 77

Safety Climate, 80

Threat Awareness, 52

Resilience, 45

Work Life Balance, 51

Teamwork Climate, 64

Safety Climate, 67

Threat Awareness, 50

Resilience, 37

Work Life Balance, 47

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DUHS 2014

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Desired Safety Culture

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Guiding a Journey to Safe and Reliable Healthcare

Safe and Reliable

Healthcare

TechnicalClinical Science and SkillsSystems and Processes

Data AnalyticsTechnology

SocialTeamwork & Communication

Psychological SafetyHumble Leadership

Well-Being

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Thank You!

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Guiding a Journey to � Safe and Reliable Healthcare ObjectivesAgenda James B. Duke Rebecca Kirkland, MDSlide Number 5Slide Number 6Jesica SantillanImproving Healthcare Safety and qualityCSU StructurePerformance ImprovementCulture: A Major ChallengeTeamwork is not Natural, but Critically ImportantSpeaking a Different LanguageParadigm Shift to Team System ApproachSlide Number 15Changing Culture at DukeEvolution of DUHS Service Line PFACsOverall improvementThe Duke-LifePoint �PartnershipSlide Number 20Slide Number 212011: CMS Hospital Engagement NetworkDuke LifePoint FrameworkSlide Number 24Improvement in Culture of SafetyAchieving Safe and Reliable Care �at StanfordSafe and Reliable Care: SociotechnicalPlaceholder - - Stanford DataNon-verbal messages Effective Leadership Why is Culture Important?Better Culture: Better Patient OutcomesBetter Culture: Better Employee OutcomesSlide Number 34�����While you are waiting for us to start, perhaps you could send a quick text to someone important to you, to send a kind thought their way.Slide Number 36What are the causes??Building Personal Resilience: Three good thingsSlide Number 39Slide Number 40Slide Number 41Slide Number 42Desired Safety CultureGuiding a Journey to Safe and Reliable HealthcareSlide Number 45