Building a Culture of Safety Sustaining Clinical Outcomes

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Building a Culture of SafetySustaining Clinical
Outcomes

• Oakwood Hospital and Medical Center
• M. Geheb MD, Division President
• S. Atwell RN MHA Chief Quality and Patient
  Safety Officer

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At Oakwood Patients Come First
2007 Michigan Quality Council Award Winner

• Oakwoods Mission is to Provide excellence in
  care, healing and health to the individuals and
  communities we serve.
• Oakwoods Vision is to Become the recognized
  leader in clinical quality, service and value as
  an independent health care system.
• Each Oakwood employee, physician and volunteer
  lives our C.R.E.D.O. by demonstrating Oakwoods
  Core Values of Compassion, Respect, Excellence,
  Diversity and Ownership.

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About Oakwood Healthcare System

• 4 acute care hospitals
• 1,307 licensed beds
• 41 primary care/specialty care sites
• 35 communities served
• 1.0 million people live in service area
• 1,300 physicians
• 9,200 employees
• 1,700 volunteers
• 2nd largest employer in suburban Wayne County
• 58,137 inpatient discharges
• 203,070 emergency room visits

• 6,146 babies delivered
• 723 open-heart surgeries
• Two rehabilitation skilled nursing centers
  apartments
• 62 assisted living apartments
• 240 independent living 64,737 home care visits
• Adult Day Care program

At Oakwood Patients Come First
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Oakwood Hospital Medical Center (OHMC)

• 632 licensed beds
• 37,000 discharges annually
• 4500 deliveries annually
• 40,000 Surgical procedures (inpatient/outpatient)
  
• 40,000 potential surgical risk events
• 90,000 Emergency visits annually
• 2nd largest Open Heart program in SE MI
• 723 open-heart surgeries

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OHS Quality and Patient Safety Board Lead-Board
SupportedSenior Leaders Accountable

• The OHS Board, Senior Leaders and Management own
  Patient Safety and Quality and have established
  an accountability structure with direct reporting
  to the OHS Board

Medical Executive Committee
Medical Executive Committee
Medical Executive Committee
Medical Executive Committee
Quality Council
Quality Council
Quality Council
Quality Council
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Oakwood Hospital Medical Center 2008 Quality
and Patient Safety Goals

• Culture of Safety
• Implementing Crew Resource Management
• SAQ improvements in teamwork and communication
• CODE of CONDUCT
• AHRQ Patient Safety
• Maintaining regulatory readiness (Joint
  Commission)
• Complying with the national patient safety goals
• Reductions in HAI
• UTI
• MDROs
• BSCI
• VAPs

• Improving Heart Care
• Cardiovascular Best Practices
• CMS Core Measures Top decile CHF and AMI
• Thomson 100 Top Cardiac
• Obstetrics Care Best Practices
• MHA Collaborative
• Improving Surgical Care
• Surgical Safety
• SCIP Measure Performance
• Orthopedic Disease Specific Certification
• NSQIP
• Improving Respiratory Care
• Pneumonia core measures- Top Decile Performance

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Board Driven- Executive Supported -Staff Lead
Three Events (Universal Protocol) Zero
Tolerance
At Oakwood Patients Co me First
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Surgical Patient Safety- Oakwood Leading the
Change

• Background
• In 2007, dealing with events and near misses, OHS
  made the decision to take a new approach to
  building a culture of safety in procedural
  areas
• 40,000 potential risk events
• 5 surgical events in the past year- 4 Sigma
  performance
• OAKWOOD strives to be a 6 SIGMA performer
• Wrong-sided / Wrong patient / Wrong procedure
  surgeries are the 1 reported sentinel events.
• Communication and behavioral gaps are the leading
  causes of these events.
• Goals
• Eliminate Wrong-Sided / Wrong Patient / Wrong
  Procedure
• Eliminate surgical infections
• Reduce surgical complications
• Improve OR efficiency and throughput
• Decrease in delays and observed errors
• Reduce liability
• Create a culture of safety demonstrating
  teamwork, communication thus high employee and
  physician engagement

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Oakwood Hospital and Medical Center Changing the
Rules

• Board Responsibility
• Quarterly review of patient safety and quality
  dashboards
• Quarterly review of all sentinel and serious
  events
• OHMC Medical Executive Committee
• 100 review of all serious and sentinel events
• Revision of the by-laws for behavioral outliers
• Expert Human Resource review of behavioral issues
  for physicians, professional and non-professional
  staff
• Requirement for 100 participation of all
  hospital employees and physician in Crew
  Resource Management ( LifeWings program)
• To roll out over entire OHS over 2 years
• Non-compliant physicians face dismissal from the
  staff
• First infraction suspension of the board 3
  days
• Second infraction 14 day suspension
• Third infraction dismissal reporting to the
  State
• President COS can immediately suspend in the
  case of immediate patient jeopardy

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Oakwood Partners with Life Wings, LLC

• Life Wings is a company that is expert in Crew
  Resource Management (CRM) and has worked with
  over 90 hospitals and health systems nationally.
• Life Wings was formed by a group of pilots,
  astronauts, physicians, nurses and risk managers
  who have a proven success record of implementing
  teamwork training in CRM in healthcare
  organizations.
• Humans are not perfect and make mistakes roughly
  70 of these mistakes are related to team and
  communication issues
• CRM provides a way of using the team to reduce
  inevitable human error, looking to eliminate
  significant, even fatal error.

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Project Organizational Structure
OHS Board
Joint Conference Subcommittee to Board
Quality Committee of the Board
Corporate Quality Council
Med Exec Committee
Dearborn/OHH CRM Steering Committee
CRM Team
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OHMC Project Completion Timeline
LC / LDI
Risk Assessment
Team Skills Workshops
Implementation
Safety Survey
Measurement
OCF
In-Situ Simulation
Continuous Improvement
MD Presentation
Safety Survey
In-Situ Simulation
HST Tools Workshop
Train the Trainer begins
OHMC
OHH
?
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Crew Resource Management
1 Leadership Development
Leadership Action Organizational Support

• Commitment on the part of Oakwood Board,
  Administration and Medical Staff leadership
• 2 Day Leadership Development Retreat to Introduce
  LifeWings CRM Methodology
• 31 physicians champions, including Medical
  Directors, 16 Nurse Managers, Board Member, and
  Senior Leadership
• Willingness to hold executives, directors,
  managers, and supervisors accountable for results
• Recognition that everyone is a member of the team
  and there is the expectation that as a member of
  the team they must voice any concerns
• Formalized training courses for staff and
  physicians with dedicated trainers that lead
  staff development and the tools necessary to
  create change.

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Crew Resource Management
2 Skills Development
Teamwork Skills

• (7) Interdisciplinary, experiential, case study
  based modules customized based on needs analysis
  (CEU/CME approved)

• Mandatory Attendance

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Crew Resource Management
Systems Tools and process Hardwired
3 Tools Development

• Hardwiring Safety Tools Systems
• System Tools Development that ensure effective
  team behaviors, and are used every day.
• Customized site and unit-specific tool
  development to help teams develop the skills to
  detect, trap and correct potential errors moving
  forward

Whiteboard
DeBrief
Timeout
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Crew Resource Management
4 Measure Success
Measurement
Measure Success, Maintain and Sustain

• Surgical Mortalities
• Reduced Complications
• Days between Wrong Surgeries
• Potential Near Misses
• UP Compliance
• Surgical claims
• Employee Engagement

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Next Steps for Oakwood

• Refine and reinforcing our team processes using
  in situ-simulation video
• Train the Trainer- Development Internal skillset
  sustainability
• Widespread deployment throughout OHMC -
• Embed CRM into employee and physician orientation
• Replicate across the Health System-2009
  Implementation
• Oakwood Annapolis Hospital
• Oakwood Heritage Hospital a
• Oakwood Southshore Medical Center
• Patients Come First

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Oakwood HealthCare SystemLeader in Obstetrical
Safety

• OB Forum 2005 -2008
• OHS Obstetrical Safety Improvement project
  2006-2008
• OHS Partners with MHA Keystone OPS 2008-2009

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MHA Keystone Obstetrics and Perinatal Services

• Keystone OPS A collaborative to ensure the
  perinatal team provides a safe and
  patient-focused environment for every patient in
  the labor and delivery unit.
• 13 Hospitals in Michigan-
• Bronson -Munson
• -Covenant -Northern Michigan
• -Crittenton -Oakwood
• -Sparrow -Port Huron
• -Lakeland -Spectrum
• -Mercy Memorial -W A Foote Memorial
• -Mid Michigan

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Why Labor and Birth Care

• Important public health issue pregnancy is most
  common reason for hospital admission in United
  States
• 4 million births annually in the country
• National standards and guidelines promulgated by
  ACOG, AAP, AWHONN, NICHD are available to develop
  standardized evidence based clinical protocols
• New NQF perinatal measures
• Reduce risk of preventable adverse outcomes

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Rigorous science should be the basis for care for
mothers and babies during labor and birth

• Standardized care processes based on national
  standards/guidelines can help clinicians provide
  the best care possible

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Keystone Obstetrical Perinatal Services
Obstetrics Patient Safety Model
Infrastructure/ Enablers
Collaborative Learning
Communication
Ground Rules
Labor Induction
Fetal Assessment
Second Stage Labor
Operational Tactics
Checks Balances
Measurement Momentum
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Obstetrical Performance
Reduction in Sentinel Events
Obstetrical Indemnity/Expense 1998- 2007
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Building a Culture of SafetySustaining Clinical
Outcomes

• Zero Defects
• Just Cultural
• Board Expectations
• Executive Engagement
• Operational/System Support
• Staff Accountability
• Measure- Improve- Measure