Can Your Nurses Stop a Surgeon?
With an ‘audacious’ attitude, leaders at Advocate Health Care have set out to create a culture of safety that permeates every level of the organization
Vital Statistics |
Advocate Health Care |
• Headquarted in suburban Chicago |
The patient was prepped. The surgical team was ready. The equipment tray was loaded, the devices cleaned.
The surgeon asked for the scalpel.
“No,” said Clarita Distor, R.N. The team at Advocate Illinois Masonic Medical Center was taking a “time-out”—something they do before every surgery to make sure they are operating on the right patient and the right body part with the right equipment.
The doctor refused to participate. Again he asked for the scalpel. This time, Leonard Arnold, a surgical technician, spoke up. He was Distor’s wingman—a term borrowed from Tom Cruise’s 1986 hit movie “Top Gun” to describe people who watch each other’s backs. Arnold declined to hand over the knife and reiterated that the doctor had to complete the time-out before cutting into the patient.
Visibly—and vociferously—irritated, the doctor reached over and grabbed the knife handle off the surgical tray. To his chagrin, it was empty—Arnold had pre-emptively removed the blade.
“Why can’t I have the [expletive] knife?” the doctor shouted as he threw the handle down and stomped to the door. Distor was already on the phone to the operating room manager explaining the situation. That set off a chain reaction that led all the way up to the chief of medicine, who immediately came down and told the surgeon in no uncertain terms that he couldn’t operate at Illinois Masonic—or any other of Advocate Health Care’s 10 Chicago-area hospitals—unless he abided by the so-called red rule. The physician returned to the OR and hasn’t missed a time-out since that day in June 2006.
“We don’t want to embarrass doctors,” Arnold told an audience of more than 600 managers and senior-level officials at Advocate’s quarterly leadership meeting in June, where he and Distor, along with several other Advocate employees, were honored for their commitment to patient safety. “But patients trust us. We can’t take that trust for granted.”
“Culture of safety” is a popular term, tossed around at health care conferences, medical staff meetings and boardrooms, and championed by the National Quality Forum, the Joint Commission, the Institute for Healthcare Improvement and others. While many hospitals pay lip service to the notion, few have defined exactly what it means in their operations and fewer still have established specific processes to make it a reality. Advocate is among those few.
At Advocate, a culture of safety means all employees have the power to speak up and stop an action that they think may harm a patient or co-worker. More importantly, it means creating a work environment in which critical thinking is as routine as breathing.
And the system has put some real meat on the bones of its safety efforts, launching an ambitious, systemwide training program in 2004 for every employee who walks through the door—from back-office staff to janitors to nonemployed physicians to the chief executive officer. All of Advocate’s acute care hospitals participate; ditto for the 140 outpatient centers, the home health agency and the five ambulatory surgery centers. More than 200 sites, 25,000 employees and 4,500 affiliated physicians are involved. And the system’s health plan will soon join the mix.
Failure to comply is not an option. “This has my 150 percent commitment,” says Advocate CEO Jim Skogsbergh. “The truth is, I love this stuff. If we had any pushback, it wouldn’t have mattered. We were going to do it anyway.”
What is Culture?
A definition of “culture of safety” that satisfies everyone is hard to come by. A lot of people say it’s an error-free environment. That’s wrong, according James Bagian, director of the Department of Veterans Affairs National Center for Patient Safety. The goal isn’t eliminating errors, it’s ensuring that patients are not harmed. There’s a big difference, Bagian says.
A 2001 Agency for Healthcare Research and Quality white paper, Making Health Care Safer, offers a slightly more academic view. Noting that an exact definition does not exist, AHRQ researchers cite four common traits among institutions with a culture of safety:
- Acknowledgement of the high-risk, error-prone nature of an organization’s activities
- Blame-free environment where individuals are able to report errors and close calls without punishment
- Expectation of collaboration across ranks to seek solutions to vulnerabilities
- Willingness on the part of the organization to direct resources to address safety concerns.
Advocate embraces those notions. Key among them is stopping the blame game.
“We learn through a philosophy, unfortunately, of blame and shame,” Donald Aaronson, M.D., medical director for patient safety at Advocate, told 74 residents during a June training session at Illinois Masonic. “When something bad happens, our automatic thinking is we must have messed up, not that we were set up.”
The fact is, errors happen. The objective is to make sure enough checks are in place to prevent the patient from being harmed. At the core, it’s about changing behaviors.
At Advocate, the focus is on five behavior-based expectations, or BBEs: pay attention to detail, communicate clearly, have a questioning attitude, hand off effectively, and be a good wingman. For each one of these, there’s a prescribed code of conduct. For instance, to encourage attention to detail, staff is taught the STAR technique:
Stop: Pause for one or two seconds to focus on what you are about to do.
Think: Is what you are about to do correct?
Act: Concentrate and perform the task.
Review: Check to see if the task was done correctly.
“It gives your brain a chance to catch up with your hands,” Kate Kovich, director of quality and regulatory compliance and patient safety officer at Advocate Christ Medical Center and Advocate Hope Children’s Hospital, told 12 new employees undergoing training in early June. “We do this when we go to the vending machine. We see that the Snickers is B-12. We press B and then wait a few seconds to check and make sure that it’s 12.”
The Journey Begins
By the late 1990s, Advocate’s board of trustees identified patient safety as a systemwide priority. A task force was established to explore ways to improve performance.
Advocate wasn’t alone. A number of other leading systems, as well as external forces such as the Joint Commission, IHI and even Congress, were bringing patient safety to the forefront of the health care agenda.
Then in 1999, the Institute of Medicine published its landmark To Err is Human report, declaring that between 44,000 and 98,000 patients die in hospitals annually from preventable medical errors. The IOM report forced the field as a whole to stop tinkering around the edges.
As Advocate pressed forward with its efforts, leaders shared a feeling that something was missing. “Safety was always a priority,” says Leonard Kosova, M.D., a hematologist and oncologist who has worked at Advocate’s Lutheran General Hospital in Chicago since 1959. “The difficulty has been getting processes in place.”
Lois Elia, R.N., vice president for clinical support services, was more blunt in a talk to the Chicago Patient Safety Forum in March: “We weren’t stopping to think before acting.”
In 2004, Lee Sacks, M.D., Advocate’s executive vice president and chief medical officer, heard a presentation about the safety initiative at Sentara Healthcare, Norfolk, Va. Sentara was that year’s winner of the American Hospital Association’s Quest for Quality Prize, for which Advocate was a runner-up. The presentation, which was given at the AHA–Health Forum Leadership Summit, was an eye-opener.
“We were making some progress,” Sacks says. “But the people at Sentara thought the real key was attacking behaviors.”
Shortly thereafter, Aaronson and Donna Willeumier, administrator of safety and regulatory compliance, visited Sentara. They were impressed. Nurses read orders back to doctors as if it were second nature. Staff members questioned what they thought was a risky behavior.
Upon returning to Chicago, Advocate officials placed a call to Performance Improvement International, the consulting firm that worked with Sentara, and invited then-Chief Operating Officer Craig Clapper to speak at a senior leadership retreat. Clapper, who cut his professional teeth in the nuclear power industry, presented results from his work with Sentara and other health care organizations, as well as with companies in the nuclear, transportation and manufacturing industries. His pitch: To improve safety, you must first change people’s behaviors.
“We realized in nuclear power that over 70 percent of failures or errors were really related to human performance,” says Clapper, now COO of Healthcare Performance Improvement.
He was persuasive. Skogsbergh looked around the room and asked, “Do we want to do this?” Everyone nodded.
The Assessment
Most of Clapper’s early health care clients dipped their toes into the culture of safety experience, trying it at one hospital at a time. Advocate jumped in systemwide all at once. “We tend to be pretty audacious,” Sacks says. “We want our lowest common denominator to be world class.”
The first step was to conduct a cultural assessment. In 2005, staff members were surveyed about their perception of the organization’s commitment to safety. In addition, one-on-one interviews were conducted of 900 employees representing every part of the organization. Finally, Clapper’s team reviewed two years’ worth of root cause analyses, looking for “human factors” that led to the errors.
They found that staff was committed to safety but wanted assurances from leaders that problems would be addressed. They also identified the top five causes of sentinel events: lack of critical thinking, inattention to detail, inadequate knowledge of established procedures, poor communication between caregivers, and noncompliance with policies. PII’s program was then modified to fit Advocate’s needs.
The Rollout
To start, staff had to be selected and trained to lead the effort. There were some challenges. Finding the right leaders was critical, Elia says. If the appropriate person in a division didn’t step up, it was more of a challenge to get line employees to buy into the concept.
Some staff questioned management’s commitment to the effort, wondering if this was just another “flavor of the month” fad that would eventually fade away.
“My initial reaction was skepticism,” admits Kosova. “Not in terms of the goals, but in our ability to really implement the process.”
Nonclinical staff wondered why they needed the training—a question that continues to crop up. During a break at the recent training session for new employees at Christ Medical Center, some attendees, who asked not to be identified, questioned if three hours of training was worthwhile when they don’t care for patients.
Kovich told them about a mix-up at Duke University hospitals in which an elevator maintenance crew stored hydraulic fluid in a canister similar to one for sterilization liquid used in surgery. Spotting the canister in the hall, a housekeeper moved it to the surgical suite. Medical equipment soaked in it for several days before someone noticed. Surgeries had been performed with the equipment that had soaked in it.
“Most people eventually make the tie on how they fit in,” Willeumier says.
Safety in 180 Minutes
Once champions for the initiative were identified they were certified to become trainers, with a goal of one trainer for every five employees. The three-hour training session for nonphysician employees consists of 60 minutes of lecture followed by 120 minutes of role-playing and practice. Physicians attend a one-hour session.
During the initial phase, 150 training sessions were held for nonphysician staff and 62 sessions were held for doctors. Charge nurses and other managers had to juggle staff schedules. At some hospitals, nurses were trained before or after their shifts and were paid overtime or received comp time. In some cases, hospitals had to find ways of filling shifts for nurses during training. Nonclinical employees were trained during their normal workday.
Budgeting for the training also varies from location to location, but it is never a direct line item. Most hospitals use continuing-education money, while others reach into different budget pockets to cover the costs.
All new hires report for training on their second official day and aren’t allowed on patient floors until completing the class. Residents get their hour of training during orientation.
As of late June, 85 percent of employees and 66 percent of physicians had been trained. Among physicians, this includes not just Advocate’s 600-plus employed doctors, but also those with admitting privileges. Two hospitals require doctors to go through training in order to be recredentialed. Other hospitals in the system are exploring similar policies.
“We felt it was the right thing to do,” says Kosova, the Lutheran General physician. “We’ve had little resistance. There have been some people who say they don’t use the hospital much, but there are no exceptions.”
While the training sessions have evolved over time, the basics remain. A major focal point is telling real-life stories. During the session at Christ Medical Center, Kovich cited a half-dozen actual medical errors. Aaronson described several others to the residents at Illinois Masonic.
Some are well-known national examples, but the bulk occurred within the Advocate system, most at the specific facility where the training sessions take place—and that adds a big punch to the message. Aaronson recounts that during one session an incredulous physician stood up and asked, “Do you mean all of those things happened here, at my hospital?”
Red Rules
Once the trainers have everyone’s attention, the sessions turn to brass tacks: the five behavior-based expectations and how they are implemented, and the STAR concept and getting people to stop and reflect before they act.
Another key goal is improving communication. Dozens of studies by groups including the Joint Commission, AHRQ and IHI show that poor communication is one of—if not the—leading causes of medical errors.
Advocate adopted a three-way read-back policy: After a doctor gives an order, the nurse or other clinician must repeat it back to the physician, who then must say, “That’s correct,” before anything can be done to the patient.
The other part of effective communication is known as SBAR: situation, background, assessment and recommendation. It’s a way for nurses or others to suggest that doctors review their orders or to raise concerns about a potential risk—and to do so without fear of retribution.
Getting staff to feel secure enough to use these techniques is one hurdle. Getting physicians on board is another. “Having a physician listen to a read-back at 3 a.m. can be a challenge,” Kosova acknowledges. “First, you have to get the staff to buy in to it and assert the need for it. Then physicians will begin to understand.”
Later this year, Advocate will likely add another red rule to the one mandating a time-out before surgery can begin. It will require staff to match two forms of identification to a patient prior to performing a procedure. Again, no exceptions will be tolerated—multiple violations could lead to disciplinary action, including firing.
No End in Sight
Advocate has made significant strides since embarking on its safety program two years ago. Staff clearly understands the need to report problems and is more comfortable doing so. Reports of sentinel events and near-misses climbed to 336 in 2006, up from 109 in 2005. However, such reports are projected to hit only 174 this year, and Sacks is certain that errors haven’t dropped that steeply. To keep up the momentum, Advocate will roll out a computerized error reporting system later this year.
Between 2005 and April 2007, Advocate saw its complication index improve by 7 percent, the mortality index improve by 13 percent, the rate of ventilator-associated pneumonia drop by 73 percent and central-line infections fall by 8 percent. Since 2004, the system has had a 6 percent decrease in malpractice claims classified as significant on the severity index.
A number of factors contribute to these favorable trends, but there’s no denying that the culture of safety initiative has made an impact. “When you see nurses asking physicians clarifying questions, that’s encouraging,” Sacks says.
Some Advocate hospitals continue to do certain things their own way. Advocate leaders say that’s OK if it improves the process, but not if it’s just a workaround. “We know that some nurses, in the interest of time, have been filling out time-out paperwork in the morning before the procedure,” Aaronson says. “That can’t happen. It needs to take place in the surgical suite, or in the area where the procedure takes place.”
Perhaps the biggest challenge for Advocate and others is making the culture stick for the long haul. Once the initial wave of training is finished, peer pressure and active leadership are critical. The VA’s Bagian says it is in people’s competitive nature to jump on board when they see others following established procedures.
Advocate plans refresher courses for staff, and physicians will be required to read three safety articles and take a test when their credentials are up for renewal.
Skogsbergh firmly believes the endeavor will yield improved patient and staff satisfaction, lower liability premiums and a strong bottom line. “This has made us stronger, healthier and a better service to our community,” he says.