November 3, 2021

Episode 62: Creating a strong culture of patient safety

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Podcast

Description

Our guest for this episode is Nan Henderson, DNP, MSN-Ed, RN, a former critical care nurse who is an expert in patient safety, particularly as it relates to handoffs. 


After a series of internal surveys revealed that handoffs were consistently an issue within her organization, Nan and her team focused on completely overhauling their process. Starting with a literature review and focus groups with the organization’s nurses, Nan was eventually drawn to I-PASS, a standardized method for handoffs that greatly reduced the amount of errors involved in care transitions. Today she and Dan talk about this process in detail, as well as her overall efforts to create a strong culture of safety and reduce harm events at her facility. 

Links to recommended reading: 

Podcast

Transcript

Dan:
Nan, welcome to the show.

Nan:
Thank you very much. So my name is Nan Henderson. I am the Director of Patient Safety. I have worked over the last several years with the I-PASS Institute for handoffs, improving the work that was already started at my organization. We've worked through the HRQ, culture safety, surveys to identify things that we can make a stronger safety culture. And handoffs was a very integral part of that, both doing bedside reporting and then hand off across the organization using standardization.

Dan:
I love it. And it's perfect to have you on the show called the handoff to talk about handoffs. I feel like this was meant to be, so thanks for coming on. Before we get into the handoff piece of things, I would love... You created a role for yourself as the Director of Patient Safety that may have never existed before. What was the impetus for that to occur? And how did you jump into creating a new role at an organization that may have not had it before?

Nan:
So I was at the organization in nursing and critical care for around 20 years, and I left for three. And so the role was actually created as they expanded our office of quality and patient care. And they took the typical quality role along with risk management and we divided that up. And so we have quality and then we have patient safety as its own cog in that wheel. And I came in as the first Director of Patient Safety, so I returned after leaving for about three years and came back into this role as the first Director of Patient Safety.

Nan:
And so what we do is we focus on the safety aspects of the patient care overall. We look at safety events, we look at project management, and any process improvement pieces, and we carry that forward. We do all of our failure modes, effect analysis, doing proactive risk assessments. And then we work with our quality partners as we develop these things to carry it forward and develop quality metrics to measure that to make sure that we're seeing the improvement that we thought we would see.

Dan:
I love it. And this is beyond nursing, right? This is across the entire organization and all the interprofessional teams. Is that correct?

Nan:
Yes. I am not in "nursing" at this time. I work for the hospital. So I'm the Patient Safety Director for the hospital. We do have patient safety partners within nursing that are more focused on just that one department and aspect and we work closely together, both quality, regulatory and safety. And so within our office, we have quality, safety, regulatory, infection control, data analytics. And so that's our umbrella. But we are focused overall in the organization to work on patient safety in all areas and not just nursing.

Dan:
I love that. The interdisciplinary approach is so important. What are some of the accomplishments that you've been most proud of in your tenure there?

Nan:
Oh, goodness.

Dan:
I'm sure there's many, right?

Nan:
There's such a long... So when I was the manager over the intensive care unit, we were the first in our organization to do what's called a Beacon Award. It's a mini magnet designation that we acquired for two years, going very early on in the ANCC's designation of that. And so I was very proud of that. And it had a quality and safety focus.

Nan:
So most of what I did within nursing, I always pushed the quality and safety pieces, even when I was in direct leadership in nursing. And so then carrying that over, I'm very proud of our work that we did in conjunction with nursing to get a magnet designation for the organization. We partnered with nursing very closely with a lot of that work. Again, our handoff across the organization, both the traditional with the physicians, has been huge, but then we carried that a step further. And the first with the I-PASS Institute to do that bedside nursing to shift. And then we've carried it across the organization from all care transitions, outpatient to inpatient, procedural areas back to the floors, so we're all speaking that same language. So that was huge.

Nan:
And I guess 2017, we did our first formal strategic plan for the Office of Quality and Patient Care. And we are reviewing that now and all of the successes that we made through that, getting ready for our next three to five year strategic plan. And so that's been huge as well. We have decreased our care failures tremendously, and increased reporting while decreasing anonymous reporting, which was big for us. So we have a very open culture and people are not afraid to speak up, and we've seen an increase in that. And so we're able to catch things very early with our near miss good catch with focusing on process and not individuals. And so we've built a lot of trust and we catch a lot of things very early that could be catastrophic, and we're able to work on processes to improve that.

Dan:
What are some of the steps you took to build that culture of safety, to bring things up? In healthcare, that exists, but it also seems to be an outlier when it does. And so I'm curious what steps you took to make sure people felt comfortable bringing up sometimes really uncomfortable issues, even in the moment with team members that they have to work with every day.

Nan:
So we are very, very clear with my team that we work on processes and not what an individual did. So that doesn't mean that if somebody makes a human error that is competence related, that it doesn't have to be looked at. It just doesn't have to be mean. And so where some of that might have to go back to a manager or through human resources or something like that, our team is solely focused on process improvement, and we've worked to keep our reporting... Our event reporting system is very separate. HR, legal, corporate compliance, none of those people have access directly to the event reporting system. Now, I can pull a report and send it to them, but we don't use it to be punitive in any way. It's all volunteer, non-punitive reporting. And so my team stresses that.

Nan:
We are out and about a lot. We do safety rounds. We do a lot of things to get to know different people. We encourage them. We thank them. We have a huge program for good catch type awards, and we do that on a monthly basis to our quality improvement committee, the board or subcommittee of that. So quality patient safety committee has a monthly winner. Our med safety team also has a winner, so we work closely with the med safety team as well. And we take those things and we incorporate the people at the front line in all of our process improvements. And so not only do we tell them, "You're not going to get in trouble. We're looking for a way to improve the process." We pull them into that unless they were directly involved in a serious safety event. And then we talk to them, get their information, and we allow a team in like roles to work on those things. We have found that that keeps people from feeling like they're being talked about or that it is punitive.

Nan:
And so we work hard around our serious safety events to protect the people that are involved, and to make sure that we're paying attention to the second victim and work with our resilience partners to take care of those people.

Dan:
That's great. You hit on a lot of pieces of the culture, right? One, build the relationships by being present and talking with people, and getting that information and finding out what's going on day to day. And then really digging into and involve them in the process, and then protecting their safety when things go wrong. And it may not be easy to come in and relive those things over and over and talk through why it went wrong over and over, but to really take their input and then continue to design with them and around them. It's such a cool approach. I'm curious, to do all that work, that seems like you need 500 people. So I'm curious how your team is structured and what roles do you have on your team to embed themselves in all this work?

Nan:
So actually, for patient safety, there's my boss, who is the Chief Patient Safety Health Officer for the hospital. And then I have two employees that work under me, and that is patient safety.

Dan:
Oh my gosh, Nan.

Nan:
Now, we partner across our office. We have a five person project management team that is in our office, and so we can tap into those project managers. And then we have an entire data analytics team that we partner with, and then our quality partners. But overall, our organization is not huge anyway, and so my department is not needed to be that big. But every event that is put into our event reporting system, all the way from good catch near miss to a serious safety event, are looked at every single day. And we go through those. I run the daily safety briefing for the hospital, the operational safety briefing, with all the leaders across the hospital Monday through Friday. We do not do ours on the weekend, but we do that Monday through Friday and have lots of conversations there. So we are small but mighty and we use our resources very, very well. And we are very thankful for the partners that we have. So with organization and structure and trust across the organization, you can get a whole lot done.

Dan:
Yeah, 100%. I'm curious, what are the certifications or skillsets of the two patient safety leads on your team?

Nan:
So I have one that her background is in health information systems with a master's in healthcare administration, and I have one that has a master's in nursing with 33 years at our organization. We've followed the same paths. But she was also the Director of Clinical Excellence in nursing and led the organization to the first Magnet designation. She is now on our team as a Clinical Project Manager that runs all of our cause analysis from ACAs to RCAs and manages the daily reporting of the event system. And so we work closely together.

Dan:
That's great. And then from a success standpoint, from a metrics standpoint, how do you measure the success? Obviously, the reduction of errors generally is the goal, but are there daily numbers like the [CALTI 00:11:33] and CLABSI and all that stuff that you're goaled against? What other data points are you looking at to show that you're making an impact there?

Nan:
So we do all of our hospital required conditions, the CALTI the CLABSI, pressure, injury. We've just started a new PAC team around VTE. We have one that's a little, I guess, unique to us. We have what we call a C. diff hack team. We have our patients with the antibiotic use that they have and their immune systems tend to be very susceptible to C. diff, and so we had a very high rate. So we've really pulled a team together and have seen a great reduction in that work, so that's good. We have our quality dashboards that, of course, get reported all the way up to our board. We are very, very transparent in our units with our dashboards that are digitally displayed with all of our metrics on there. And so we're continuously watching those things.

Nan:
We've recently celebrated in our intensive care unit for going over 365 days without an unplanned extubation. We have big celebrations when we do things like that. As an organization, we've gone 365 days without a CALTI a couple of times, and we are headed back up that way. We're over 200 days right now. So we do measure those things on an ongoing basis.

Nan:
The other thing, and this may not belong here, but I'll throw it in there. We partner with our parents. We have a parent on four of our PAC teams, and we also use them in our cause analysis. And so that's been ongoing work over the last three years that really has made a big difference in partnering with our Patient and Family Advisory Council to help us guide some of our work. And we're very transparent with them about the data as well.

Dan:
Well, that leads into my next question, which is you work with the obvious stakeholders, the physicians, some of the clinicians and things. I'm curious if there's teams or team members that have emerged that have had a really unexpected impact on the safety work that you never would have thought were a part of the process. Parents, obviously one of them, but I wonder if there's others.

Nan:
Again, nursing and physicians being the ones that would come to mind. But we've done a lot of work with our microsystems groups in our outpatient setting, which is a multidisciplinary team. Some of our operational people are in that meeting. We've got a triad of somebody from hospital operations, a nurse, and a physician that lead our microsystem teams. And we've done a ton of work in our transfusion center, in our outpatient area, and then our diagnostic imaging area and in our ICU, we've had these triad teams that have done a ton of work. And so it's interesting to see the hospital administration side getting involved in the clinical teams and really driving some of the things that we can accomplish. And so that's been nice.

Nan:
But the biggest thing is our parents. You asked earlier what I was very proud of, and I should have mentioned that. The work that we've done to get our parents involved has been just not only rewarding, but they have a ton of good input of things that we don't think of. We recently, with our CALTI within the last two years, we have gone away from using CHG bath wipes to Theraworx, and we just were not seeing a reduction. But the patients didn't like the CHG. They thought they were sticky, they didn't feel right. And we worked with the parents to find a CHG bath product that was acceptable. And after changing that on one unit, we have gone over 365 days in that one unit without a CLABSI, where they see a lot of our leukemia patients that are long-term patients with central lines that stay in about three years. And they've had great success with this. And so the parent's input was just invaluable in that whole process.

Dan:
Wow. That's such a cool impact. It's that user centered design or user centered problem solving that tends to come up with things you never think about. My son was in the hospital last October for a pretty major surgery, and things like the way the room was set up and the bed he was in just made such an impact to how he was able to stay still and engage and not pull on things. As a nurse myself, you think of those things. Well, we'll tape it down or we'll hide it or we'll do all these things. But getting the parents and the kids involved in what does this look like and how can we make it awesome for you? It's such a no-brainer. That's amazing.

Dan:
So pivoting a little bit, one of the things that you have worked on a lot is this handoff of information at shift change between clinicians. I'm curious how you got interested in that. Talk a little bit more about the I-PASS process.

Nan:
So again, we are participants in the AHRQ Culture of Safety surveys. They used to do them yearly and now they do them every other year. Like many other places, one of the highest areas for improvement was always handoff. And then if you look at the data that is out there, care transition hospital errors can be up to the third leading cause of death in the United States. That's pretty high. That's a lot of opportunity for improvement. And so we started looking at our own care transition events and the things that went wrong with communication when we were handing a patient off from person to person, and we just knew that that was something that we wanted to drive improvement in.

Nan:
So we focused on that within our hospitals starting, I guess, late 2015. We started doing a lot of work and focus groups with our nurses because we knew we wanted to do it. We wanted to start with them for shift to shift handoff. And as that work evolved, we were looking at literature, and we found out more and more about the I-PASS method and the I-PASS Institute, and decided that that was something that we wanted to partner with them to drive improvements and engage them with working with us to do this across the entire organization.

Nan:
We did this in waves, which our plan was to do nurse to nurse shift handoff inpatient, and then move to physicians for their evening shift sign out for overnight care. So we did that and we brought them in, and we organized it to where we would do the standardized handoff with their method and using their bundled approach to implementing that, along with we did a pre and post survey to get data and to show the improvements. But we were going to do bedside reporting, which is something we had tried over and over. And like with many things, Hawthorne effect. As soon as you quit looking, it goes away. And nurses are really good at placating and pleasing people, and then doing what they want to do and doing it the way they want to do it.

Nan:
And so we pulled that together. And with the direct observation that I-PASS puts into their process for implementation, we actually did direct observations for almost 16 months before we stopped observing their handoffs with trained observers on their units. And so we have completely nailed down I-PASS and bedside reporting, and it happens probably 95% of the time we have bedside reporting with the ongoing and offgoing shift, and incorporating the parents in that handoff. There are still some times when that's just not best. Sometimes the parents don't want you in the room. Sometimes it's not beneficial for the child. And so we do take those things into account. But for something that we struggled with for many years of starting and stopping, we have done very well over the last six years with that process now.

Nan:
And then with the I-PASS handoff, and we continue to do safety rounds. We ask for areas for improvement. We make sure that they're doing it. Different areas still do the direct observation at times, just to make sure and capture and do any PTSA that needs to do if that wanes a little bit. But overall, we do very, very well for all five elements of the I-PASS handoff. And we have seen a very, very drastic reduction in care transition and communication failures with that as far as medications shift to shift that were getting missed, sometimes your devices and things like that, we've seen a large reduction in that.

Dan:
That's great. I just remember being involved in lots of bedside handoff initiatives over both my practice career and then different phases of leading education and other things. I remember being an ER nurse and the handoff would be room 26, GI pain, IV in, meds on the way, and just very casual. And then it moved more to the SBAR format and you want to do the SBAR piece with them, and then getting more and more structure around, okay, now we have all these devices and technologies and patient involvement and all these things that were there always, but now we're focused on it. So now how do you do patient involved bedside report? Kaiser used to do one called nurse knowledge exchange, and just really trying to incorporate all these pieces. And it's great to hear that you were able to implement it and sustain it.

Dan:
Because what we found, exactly to what you said, the nurses are great at this. They can put stuff in drawers, they can pull it out when JCAHO's around. There's all kinds of ways we know how to figure out how to make people happy and then not do what they tell us to do. But it's that accountability piece, and ultimately, it's safety. It's part of our professional practice to have to do that. So it's interesting to hear how you had similar experiences with the nurses.

Dan:
So now that it's part of the culture, is it embraced and it's just the normal operating procedure now, or are you still finding some resistance?

Nan:
There's always a little bit of resistance somewhere, but overall, it's pretty much the culture now. Now, that took a little over three years to get there. But for instance, in our diagnostic imaging area, what we did there is we do what's called receiver driven I-PASS. So they are going to receive the patient, but they drive report. And so they have a form that they use that is in the I-PASS structure, and they ask all of their questions of the patient coming.

Nan:
And so instead of calling, and this is what used to happen, they would call up and they would say, "I need Jane Doe to come on down. Can you give me a report?" And they would just say anything and everything about that patient. And now what happens is they call and say, "I'm ready to get report. Are you ready to bring this patient down?" "Yes." "Let me ask my questions." And at the end, they will just do a synthesis and say, "Is there anything else that I need to know that I didn't cover?" And so it decreases the amount of time drastically in the report, and you're sharing the relevant information instead of the entire history of a patient that diagnostic imaging may or may not need to know about at all.

Nan:
And so it can be very tailored area to area. So in intensive care, you may have a little bit more detailed report. But time-wise for nurses shift to shift, we have seen a reduction in the time it takes to handoff an ICU patient from 20 to 30 minutes down to seven to 15 per patient. It was a unintended benefit, but it does shift to shift for nurses, it reduces their time fairly significantly. There's a hospital with I-PASS that has released some data on that, and they reduced their overtime quite impressively. Now, for physicians, it's time neutral, but it still organizes that to where you don't have the opportunity to miss information, but it doesn't take any more time. But we've not found the same reduction of time with the clinical group.

Dan:
I think that's important too. So it's net neutral at its worst, it's positive on getting time back at its best. But I think the other piece is probably the hidden time cost of you get a poor report from somebody, then you have to spend X many hours, potentially, looking through the medical record to find the information you didn't get, or calling somebody because it's not there, or all this other stuff. There's one study that said nurses spend about 36% of their time doing hunting and gathering of information. And if you can reduce that down, that's more time at the bedside, that's more time for safe practices. That's all kinds of different things that are downstream effects just from that one five to 10 minute encounter when you're starting your shift. So I think it's so interesting to hear that impact and the ability to customize it as part of the, probably, success of it too.

Dan:
Everyone thinks they're special. ED thinks they're special, ICU thinks they're special, they all think they're special and have some special way to do it, which in some cases is true. There are some pieces that they need to be customized, like you said, for the diagnostic imaging pieces. So that just sounds like an awesome example of how innovation can be adopted in an organization.

Nan:
Yeah. It really is very flexible, but yet the same, and so you're talking the same language. An example of that is in illness severity, you talk about stable, unstable, or watchers. And now we actually have a watcher list that we discuss every day. We talk about our sepsis watchers, we talk about our early warning system, the watchers from that list. And so everybody knows what that definition is, and it doesn't change unit to unit.

Nan:
Now, in illness severity, what does change, ICU doesn't do early warning because they're already at the highest level of care, right? So on the floors, they do their pew scoring, and they'll use that score to define what their illness severity is. But in ICU, they might talk about their RASS scoring or what is their delirium scoring, and that might be an illness severity. Or that they have a stable airway or an unstable airway. And so those are the things that you adjust.

Nan:
What we used to do is we had to adjust our entire format of handoff thinking, like you said, that ICU is special, and so we need a whole other handoff. And so that's gone. Everybody does it in the same structure and talks the same language, which is very conducive to good communication.

Dan:
No, 100%. You're basically instituting a new language, right? You're helping people translate really complex things into a standardized format to process and make decisions off of. And that's at the core, I think, a patient safety work. So it's just a really interesting story of literally changing a culture to provide better care. So thanks for sharing.

Dan:
As we wrap up, I'd love to hear in your tenure in this work, both with the handoff piece and just patient safety in general, what are some of those nuggets that you'd want nurses and nurse leaders to take away as they listen to this to incorporate in their own practice and help enhance patient safety in their own organizations?

Nan:
I think probably just a couple of things. Standardization and in deference to expertise. Some of the high reliability organization practices are huge. Bring in your front line people always. Let them tell you what will work and what won't. Because if you don't, they're going to teach you what will work and what won't work by hiding things in the drawers and doing workarounds when you're not looking. And so using that expertise of those frontline caregivers is just huge. Knowing that standardization and common language helps everybody across the organization to understand the goal of where they're going. Listen to your parents, listen to your patients, listen to family. Bring them in, allow them to be a part of that process, and then learn from proactive risk. So it's great to learn when a mistake has been made and to drive improvement from that, but it's much more beneficial and a stronger process improvement if you can find out that something's not working and improve it to prevent harm from a patient ever happening.

Dan:
I think the proactive piece, use your data, bring things up early, all of those pieces, as leaders, that's a great responsibility to have. And you need to engage in this work. It's not an extra add-on. This is the practice of care. So thanks for sharing those nuggets. Nan, this has been awesome. If people want to learn more about your work, where's the best place to reach out and find you?

Nan:
You can reach me at Nan364@gmail.com. I am happy to talk with anybody. I love patient safety. I love this work. We've done a lot around this. Even through SPS, Solutions for Patient Safety, if you're in a pediatric institution, it's a great network of people that are looking for patient safety answers. And so we are all about sharing knowledge and each one teach one. And so I would be happy to talk to anybody that had questions or wanted to discuss more.

Dan:
Awesome. We will put that in the show notes, make sure people have a chance to be able to reach out if they need to. And just really appreciate having you on the show.

Nan:
All right. Thank you.

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