Learning from the best
For a decade, leaders at the Betty Ford Center (Rancho Mirage, Calif.) looked on with pride as the National Association for Addiction Treatment Providers (NAATP) recognized addiction treatment organizations for outstanding quality improvements with an award inspired by the Center's first medical director, James W. West, MD.
“When we were approached by NAATP to get involved in creating a quality award, we immediately thought of Jim,” says Michael Netherton, president of the Center's Betty Ford Recovery Hospital. “He is a world-renowned surgeon and was asked by Mrs. Ford to be the first director of the hospital. He has taught us so much about patient care, about clarity and singularity of purpose, and about treating all with dignity and respect.”
“It would take days to tell you what all of us have learned from Dr. West,” says Netherton.
Fortunately, such proof wasn't necessary, since Behavioral Healthcare contacted Netherton, along with Briar Geraci, the Center's vice president and corporate compliance officer, to congratulate them and their colleagues for a patient safety program that earned NAATP's 2010 James W. West, MD, Quality Improvement Award.
“It's a tremendous honor,” says Netherton, who acknowledges that “for some time, we had hesitated to submit our work because of the Center's association with this award. Finally, this year we asked Dr. West if he thought it would be appropriate. We all felt it was time, because, under Briar's direction, the team has accomplished so much.”
Origin of the patient safety program
The roots of this award-winning patient safety program are everywhere at the Center, but they started in its strategic planning process. “We've invested a lot in long-term strategic planning, not only at the board level, but throughout the organization,” says Netherton. One of the board's most significant decisions was to encourage the integration of functions and departments as a way to improve communication throughout the organization. As early as 2002, this led to the goal of creating a single, seamless experience-“one Betty Ford program”-to deliver care to patients and families. This approach reflects Betty Ford's vision of “‘serving patients, saving families,’” says Netherton. “Everything springs from there.”
Around 2005, Center leaders made two other important decisions: They streamlined eight key result areas (KRAs)-Quality of Services, Safety, Patient Satisfaction, Referent Satisfaction, Employee Satisfaction, Financial, and Public Perception and Education-into a structure of just two-“Quality of Services and Safety” and “Financial.” The Center also adopted a single methodology for designing, implementing, and monitoring all process improvement projects: The Plan-Do-Study-Act (PDSA) Cycle.
The Center's ongoing drive to simplify and clarify strategic priorities had implications for the patient safety program as well, Geraci explains: “We've always had a safety program, but we realized that if we merged all of its components under the umbrella of our improving organizational performance program, we could provide greater clarity to staff.”
As that change took place, Center leaders determined that they would revamp the patient safety program around the best and most current organizational strategies available in the current body of knowledge. One key resource was the Institute for Healthcare Improvement (IHI), which explained how systematic application of industrial quality improvement methods could significantly improve clinical processes and healthcare outcomes. From this and many other resources, the Center selected a set of strategies as the foundation for a new patient safety program.
To refine and flesh out these strategies for staff, the Center knew it would need a strong and experienced program leader. Through what Geraci calls “an alignment of the stars,” the Center brought in Jann Robinson, RN, as its new certified patient safety manager in 2008. For about a year, Robinson teamed with Geraci to build out the details of the program, which was ready for launch in early 2009.
The program's first challenge was to evolve the Center's safety culture “to foster the understanding that errors are opportunities for improvement,” says Robinson. “People don't come to work intending to make errors. Often, errors are a signal that a system or process ought to be updated, changed, or risk-mitigated.”
Center leadership shared this understanding, recognizing that its organizational culture had to support continuous improvement in all areas on a long-term basis. Such a culture must, from a staff perspective, enable individual initiative and encourage a willingness to take what Netherton calls “responsible risks.” Yet it must also sustain a sense of safety and trust that enables individuals to feel that they can report errors honestly-an essential element of any quality improvement program.
Such a culture can only “flow from the top, from the board down,” says Netherton. “Making mistakes is something that we all learn from. The attitude must be that if I am acting in the best interest of a patient, it's OK.” He calls it creating “a culture without fear,” where “people can enjoy coming to work. They feel secure, and they feel engaged.”
He asserts that this culture is essential to fostering the emotional honesty and strength that staff members need to deliver effective treatment. “We embrace the depths of this disease. So, we have to be willing to commit to the truth. It's what we offer in treatment and what promotes the desire for change. If we can't model that, how can we expect our patients to embrace it?”
Program launch
In early 2009, the program launched with a range of elements:
Training on a variety of issues including:
Key patient safety strategies;
Basics of high reliability systems, which exposed staff members to the importance of “human factor” analysis in understanding and managing the issues that can result in errors; and
Processes for implementing departmental and organization-wide process improvement programs.
Workplace materials, including:
A patient safety handbook, posted throughout hallways, that uses a highly visual style to minimize the need for reading, while reminding staff of fundamental work and safety processes;
“Patient Safety Tips” fliers published bi-monthly for staff; and
“Just Culture,” an initiative that uses fliers and other reminders to prompt staff use of new strategies, terms, and ideas in their work. The changes must be seen as “just part of the culture.”
Another highly effective strategy is the “leadership walk-around.” At least once per month, a member of the executive leadership team walks around with Robinson throughout the facility, meeting and talking with people.
“When I went with Jann to launch the leadership walk-around, it was a remarkable hour,” says Netherton. “It showed me the importance of experiencing things first-hand, getting real-time data from staff and patients.”
Using a list of questions, developed in advance, the executive informally discusses key performance, satisfaction, and safety issues with patients, families, visitors, and staff. At the same time, Robinson collects and notes findings, harvesting data from the comments received. Later, summaries are presented to the board, leadership, and department directors, who are tasked with implementing solutions.
“These walk-arounds serve many purposes,” says Robinson, noting that they demonstrate leadership is “walking the walk,” listening carefully, and understanding the issues. Perhaps most important, the walk-arounds drive action on day-to-day issues, “the kind of things that many organizations expect staff to work around, rather than resolve.” Results often occur within days, sometimes even faster.
Geraci cites one example: Night shift staff were concerned about practicing earthquake and fire drills. But such drills weren't often available, except at busy shift changes. “We checked it out and made changes.”
When combined with numerical data from employee surveys, experiences like these offer convincing evidence that the patient safety program is working. Post-training testing found a predictable jump in the number of employees who understood best practices for patient safety, relative to pre-test levels. Staff surveys find a rising level of engagement among staff members. And, staff are utilizing the Center's incident reporting system, another critical component of the patient safety program.
“We use the incident reporting system for any kind of out-of-the-ordinary event, or for patients who leave against medical advice,” says Geraci. “First level review of these reports is done by supervisors, who may use them to teach employees or identify trends. Then, I look at the reports for organizational trends, summarize for the board and leadership, and then work with the responsible manager to ensure corrective actions.”
Geraci stresses that the reporting system must make it “safe for an employee to acknowledge a mistake. The consequences of that reported mistake must be fair.” She adds, “Every incident report is an opportunity to review policy: ‘Why did this happen?’ ‘Why wasn't this clear?’”
Employee engagement is also important to reap the benefits of process assessment tools like HFMEA and problem-solving tools like RCA. These tools are used with reported incidents or used to assess high-risk processes, resulting in changes to work systems and work habits, Robinson explains. For example, to reduce reliance on human memory, the Center's electronic medical record (EMR) system was modified to “flag” physician orders for high-risk medications. The flag requires the physician to double-check the order and verify that there's no confusion with a list of “look-alike/sound-alike” medications.
On the departmental or organizational level, process improvement (PI) projects also contribute to the Center's patient safety program. During 2009, for example, the Center's organization-wide PI project involved building a new patient entrance and ensuring the secure passage of every patient through the admissions process.
“The goal was to link nursing and admissions staff while improving the safety of the patient intake flow,” says Robinson. “Because many of our incoming patients are quite ill or under the influence during admission, we cannot leave them alone at any point in the process, which flows through the admissions paperwork, hand-off to nursing staff, medical assessment, search, and other steps.”
A process assessment found that busy nurses were not always available for hand-off of the patient from admissions. So, process leaders brought in “patient ambassadors” to keep patients company until nurses arrived. These friendly observers were there to ensure that no subtle or sudden medical problem could occur without notice and help.
Another area of work involved patient satisfaction surveys. Over the years, the original survey grew lengthy with requests for additional information and questions. The revised survey, says Robinson, contains fewer questions and requests a single answer for each. When the new survey found low satisfaction scores from customers responsible for patient payment arrangements, a process improvement meeting was held with members of the Center's finance staff.
Together, they discovered that a routine of process steps, followed consistently, produced better results. “What we decided was, let's stand up, recognize the customer, shake hands, and then provide the payment information for discussion,” says Robinson. “Then, at the end of that process, let's make sure we've answered all of their questions by asking, ‘Are you certain there's nothing else that I can help you with today?’ That question really makes a difference.”
Betty Ford Center's patient safety program: Key strategies
Culture of patient safety
Healthcare Failure Modes and Effects Analysis (HFMEA) and Root Cause Analysis (RCA)
Incident reporting system
Leadership walk-arounds
Patient satisfaction
Performance improvement survey and outcomes management systems
Each strategy was supported by a written policy, complete with goals, specifications, actions, and outcome measures. The aim was to implement strategies that were:
Specific but not prescriptive, to allow for creativity in implementation;
Measurable;
Realistic; and
Accountable, based on defined ownership and responsibility.
Behavioral Healthcare 2010 April;30(4):22-24
