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S A F E T Y

Creating a System of Consistent Safety in the Froedtert & Medical College of Wisconsin Health Network

Catherine A. Jacobson, president and CEO, Froedtert Health, Milwaukee, Wisconsin; Susan Huerta, PhD, RN, enterprise vice president, quality and patient safety, Froedtert Health; and Jonathon Truwit, MD, enterprise chief medical officer and senior administrative dean, Froedtert Health and the Medical College of Wisconsin, Milwaukee

In June 2013, Froedtert Health and the Medical College of Wisconsin (MCW), operatingas the Froedtert & MCW health network, developed a joint vision and supporting stra- tegic plan for their combined clinical enterprise and set a goal to achieve top-decile per- formance in demonstrated quality metrics by 2020. Leaders recognized that achieving this goal would involve creating a system of safety across a 550-bed urban academic medical center (AMC), two community hospitals, and two physician practices—one academic and one community based—to ensure the same level of care for patients regardless of their location in the system.

Since that time, we have been on a journey to develop a culture and practice of safety across our clinical enterprise. Our goals are to continually improve in quality and safety and to implement systems and communications that are reliable (through built-in re- dundancies), repeatable, and sustainable.

Clearly, measuring outcomes to demonstrate our performance is important. How- ever, we know that patient safety metrics emphasize the prevention of known or pre- ventable complications and do not consider the nuances of care and services provided every day (Frankel, Federico, & Lenoci-Edwards, 2017; Winters et al., 2016). Reliable clinical and support systems that incorporate safety nets can steer providers to the wise choice and intervene when wise choices are not made. These safety nets can be human; nested in the electronic health record (EHR), such as clinical pathways; or conveyed through devices or cognitive computing. Strong systems have redundancies because fail- ures can occur at any point in a process, particularly failures that involve human decisions or require human response (Joint Commission, 2017).

For more information about the concepts in this column, contact Dr. Huerta at susan.huerta@froedtert.com. The authors declare no conflicts of interest.

mailto:susan.huerta@froedtert.com

SAFETY

STRUCTURE At the Froedtert & MCW health network, our efforts toward patient-centered care, clinical effectiveness, and population health are structured under the systemwide Healthcare Value Council. Clinical effectiveness, as measured by quality and patient safety metrics, is integrated through the health system’s Quality Collaborative. The Quality Collaborative unites the quality programs of the three hospitals and two practice groups and achieves its goals through five committees: inpatient, ambulatory, epidemiology, pharmacy, and therapeutics. Committee members represent all entities of the health network. This design enables us to implement common quality and safety programs and practices across the enterprise, hold each other accountable, and identify best practices. Each year, the com- mittees recommend areas for improvement or sustained performance, accompanied by fiscal year targets for furthering our goal to achieve top-decile performance on existing quality and safety measures. All goals set for the entities throughout the health network cascade from our enterprise goals. Our providers, leaders, and staff are rewarded, finan- cially and through recognition, by means of an aligned incentive system when perfor- mance goals are achieved or exceeded at the end of the fiscal year. Data by entity and subcomponent are transparently available to all committee members, physicians, leaders, and staff, and dissemination of these data fosters our accountability for performance.

CULTURE AND COMMUNICATION We began transforming the culture across the Froedtert & MCW health network by en- couraging all staff to speak up when they believe a patient’s safety is at risk. In addition, we have instituted the Good Catch Award, which rewards the identification of sys- temic problems that could harm patients and that require a process change or rapid fix (Frankel et al., 2017). Good Catch Award winners are featured in quarterly announce- ments on our intranet to highlight the individuals and the program.

Miscommunication and failure to clearly escalate concerns are top reasons adverse events and near misses occur. We have trained staff to speak up using the SBAR (situation, background, assessment, and recommendation) format. We have also instituted an event assessment guide supporting a nonpunitive practice that seeks system solutions for ad- verse events and near misses (Harrison et al., 2015; Joint Commission, 2017). The event assessment guide avoids using the term “investigation.” Instead, it prompts the user to ask questions in a consistent order and make conclusions once the questions have been an- swered. Errors are attributed to the appropriate cause, system or otherwise, and are asso- ciated with interventions to avoid repeating the event. The event assessment guide is available to all staff on the intranet.

Our patient safety emphasis is on preventable events, patient safety indicators, and hospital-acquired infections. On the journey to zero patient harm, we unexpectedly found a culture of “opting out” of components in established care bundles. Both physi- cians and nurses participated in this behavior, despite their agreement to adhere to evidence-based care. To address this issue, we created colorful placards that highlight bundle components, engaged our electronic intensive care unit to observe central line insertions and speak up when breaks in sterility are seen, and provided leaders with pictures of poorly managed central line dressings and ineffective room cleaning. We

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deployed our antibiotic stewardship committee across the health network to reduce un- necessary antibiotic use. Our patient safety and quality officers examined existing indi- cators and metrics and found opportunities to reset our processes, leveraging the EHR to advise and direct human behavior. We also empowered providers and staff, through lo- cally based inpatient and ambulatory teams, to focus on preventable events and take immediate and sustainable action (American College of Healthcare Executives & National Patient Safety Foundation, 2017; Frankel et al., 2017).

EXTENDING BEYOND THE HOSPITAL Improving performance on hospital patient safety metrics toward preventing harm is a start, but we continue to ask whether patients are safe in each of our health network set- tings. Our approach to providing the same standard of care throughout the network uses metrics from both the Centers for Medicare & Medicaid Services (CMS) and the Health- care Effectiveness Data and Information Set and focuses on areas where we recognize opportunity to improve reliability, even those not rewarded by CMS or insurance contracts.

Engaging clinical informatics has accelerated our quality and patient safety programs by enabling us to design care pathways from the perspectives of both the patient and the end user to improve adoption of the EHR’s clinical decision support (CDS) capabilities (Frankel et al., 2017). For instance, our respiratory risk assessment is applied to inpatient and ambulatory surgery patients (Chung et al., 2012), whereby those patients at moder- ate or severe risk trigger suggestions from the EHR for respiratory care consultation and augmented monitoring, such as cardiac telemetry, pulse oximetry, and end-tidal CO2. Alerts also pop up when sedatives or narcotics are ordered, highlighting a risk for sleep apnea and the need to consider correct drugs and dosages for the patient. For ambulatory surgery, we combine the patient’s risk for sleep apnea with a procedural factor score to determine whether outpatient surgery is appropriate and to guide postoperative recovery time. This program has dramatically reduced postoperative events and rapid response team calls related to sedation. A recent review of 300 patients undergoing outpatient surgery found that only one patient required a rapid response team intervention and one patient was admitted from the emergency department within 48 hours of the procedure.

Another CDS tool helps us identify potential hazards for patients. In one case, mag- netic resonance imaging was ordered for a patient who had metal implants, a fact that was unknown to the ordering provider and bedside nurse. The CDS tool, which recognizes risk factors for magnetic resonance imaging, found an earlier note highlighting the im- plant, and the order was stopped.

Our use of technology is not limited to the EHR or electronic intensive care unit. We have implemented teleobservation for patients identified at high risk for falls, which has decreased the need for 1:1 observation by a staff member and improved staffing con- straints. Fall rates did not increase during this transition.

Augmenting our proactive approach to reducing preventable events, readmissions, and mortality using technology and data, we rely on information derived from postevent huddles and reviews. Candid discussions of what did or did not go well guide future improvements, particularly systemwide opportunities involving multiple disciplines in the care team.

SAFETY

CONCLUSION This column describes just a few of our quality and patient safety initiatives, but they are representative of our overall efforts in system design, change management, analysis, and review and our ability to leverage human and digital capital together. These techniques and methods extend beyond the hospital setting and deliver results across our health network. Our attention to both quality outcomes and prevention of harm has helped our AMC rank in the top five for the past three years among participating AMCs in the Vizient annual quality and accountability study. In addition, our two community hospitals achieved top-decile performance in 2017.

Outside the inpatient setting, our ambulatory quality metrics have moved perfor- mance from the bottom quartile to the top quartile in the Wisconsin Collaborative for Healthcare Quality and the Merit-Based Incentive Payment System databases. In 2016, we were one of five organizations nationally recognized by Vizient for excellence in effi- ciently delivering high-quality outpatient care. Now we intend to drive the incidence of preventable harm in our care environments to zero.

Sustaining a culture in which patient safety underpins quality outcomes demands teamwork and reliable, predictable care and service across the health network. We are committed to delivering the right care in the right setting, where every patient, every time, is assured of excellent and safe care.

REFERENCES American College of Healthcare Executives & National Patient Safety Foundation. (2017). Leading a

culture of safety: A blueprint for success. Retrieved from www.npsf.org/cultureofsafety Chung, F., Subramanyam, R., Liao, P., Sasaki, E., Shapiro, C., & Sun, Y. (2012). High STOP-Bang score

indicates a high probability of obstructive sleep apnoea. British Journal of Anaesthesia, 108(5), 768–775. doi:10.1093/bja/aes022

Frankel, A. H. C., Federico, F., & Lenoci-Edwards, J. (2017). A framework for safe, reliable, and effective care. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare.

Harrison, R., Walton, M., Manias, E., Smith-Merry, J., Kelly, P., Iedema, R., & Robinson, L. (2015). The missing evidence: A systematic review of patients' experiences of adverse events in health care. International Journal of Quality in Health Care, 27(6), 424–442. doi:10.1093/intqhc/mzv075

Joint Commission. (2017). Sentinel event alert 57: The essential role of leadership in developing a safety culture. Retrieved from https://www.jointcommission.org/sea_issue_57/

Winters, B., Bharmal, A., Wilson, R., Zhang, A., Engineer, L., Defoe, D., Bass, E., Dy, S., & Pronovost, P. (2016). Validity of the Agency for Health Care Research and Quality patient safety indicators and the Centers for Medicare & Medicaid hospital-acquired conditions: A systematic review and meta-analysis. Medical Care, 54(12), 1105–1111.

http://www.npsf.org/cultureofsafety

https://www.jointcommission.org/sea_issue_57/

Safety Resource Provides Helpful Blueprint for Healthcare Leaders

Leading a Culture of Safety: A Blueprint for Success provides practical and tactical tools for creating a culture that puts safety at its core. The free guide is a collaborative project of the American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation Lucian Leape Institute. Download it at www.npsf.org/cultureofsafety.

JOURNAL OF HEALTHCARE MANAGEMENT 62:6 NOVEMBER/DECEMBER 2017

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