Since the 1999 release of the Institute of Medicine report "To Err Is Human," we have been called to reduce the sobering number of preventable injuries and deaths that occur each year in U.S. hospitals. Unlike the airline or nuclear energy industries that have highly automated safety processes, effective health care depends not only on the human connection, but even more so on the interaction of teams and their interface with technology. Coordination and measurement of teamwork is foundational to a culture of safety and high reliability. Most critically, high-performing teams deploy evidence-based measures ina culture where these strategies can be successfully implemented.
In 2009, Main Line Health, a five-hospital, community-based teaching health system in the greater Philadelphia region, began to evaluate its culture of safety and identify risks for preventable patient harm (harm resulting from deviation from generally accepted practice standards). We also looked at all drivers of mortality: We found severe sepsis to be one condition for which deaths were higher than expected.
We knew other leading health care organizations were participating in "surviving sepsis campaigns," and we were committed to learning best practices. Main Line was poised to integrate this clinical improvement work with our cultural transformation to ensure that evidence-based practices were delivered reliably to patients with sepsis at all Main Line sites. By integrating clinical sepsis bundles — a grouping of evidence-based measures proven to ensure best outcomes — with reliably safe behaviors (collectively, our "people" bundle), we were able to reduce the number of deaths from severe sepsis by more than 50 percent at four acute care hospitals.
Creating a Reliable Culture of Safety
Retrospective cause analysis of preventable harm events conducted in 2009 and 2010 highlighted an opportunity to coordinate care across our system. Interprofessional teams often worked in silos, and some staff reported that they were afraid to speak up for safety. Most importantly, we identified opportunities to improve both critical thinking and accountability.
With these factors in mind, we organized culture change work into three strategies: (1) set clear expectations; (2) provide education, training and tools needed to meet expectations; and (3) build and sustain accountability. We adopted leader methods for reliability and specific error-prevention tools (behaviors) assisted by partners from the health care, military and nuclear industry who knew how to build reliability. The most influential leader action was making safety the core value, not to be overshadowed by other important competing priorities. From board meetings to unit or departmental daily huddles, Main Line employees and stakeholders discussed patient safety stories and great catches.
We employed error-prevention tools to counter the reasons people made mistakes: lack of attention to detail, unclear communication, fear of speaking up for safety and working in silos. These tools included actions such as STAR (stop, think, act, review), SBAR (situation, background, assessment and recommendation/request) communication, and addressing escalating problems using ARCC (ask a question, make a request, voice a concern, and then use chain of command if compliance remains an issue).
We trained more than 10,000 staff members and physicians in 2010 and 2011, and we retrain them annually using computer-based modules as well as interactive learning sessions. We manage accountability by setting clear expectations for safety, starting at the point we hire an employee and continuing with annual performance management. The medical staff onboarding process, biannual re-credentialing and peer-review programs include education and evaluation of safety and citizenship behaviors that support Main Line's culture.
Severe Sepsis: Finding and Fixing the Problems
We discovered in late 2012 that our mortality rate in patients who arrived at our emergency departments with severe sepsis was higher than expected. We knew that mandating compliance with evidence-based sepsis bundles alone would not be enough — we also had to work on the cultural aspects of teamwork. It was time to take what we learned over a four-year period about culture and accountability and raise the bar even higher.
Through observations, we found that although our EDs were doing the right things to identify and resuscitate patients with severe sepsis, they were not all following the same steps. We formed a multicampus, multidisciplinary team to evaluate best practices for surviving sepsis. We created standard algorithms and clinical workflows in the information technology systems, standard work checklists, visual cues and reliable handoffs among the ED, hospitalists and critical care units.
One of the most successful initiatives the performance improvement team developed was a nurse-driven protocol that included a sepsis alert. This system informs the intensive care unit and support staff that a severe sepsis patient is being resuscitated and will be handed off soon with responsibility to carry out the maintenance bundle. This model was successful and since has been transitioned to inpatient settings where hospital-acquired sepsis also needs early recognition and treatment. Our technology partner helped to integrate an early sepsis warning system into the electronic health record.
We improved documentation about severity of illness and risk for mortality by engaging clinical documentation improvement specialists to review health records and support physicians. This resulted in an overall reduction in each hospital's mortality index because patients with accurately documented severity of illness and risk for mortality were no longer being categorized as "unexpected" deaths.
While addressing all drivers of mortality, we also recognized the need to support a patient's end of life with expanded palliative care and timely hospice services. We instituted a palliative care internship program for nurses so that, at the end of life, expert caregivers who are focused on the special needs of hospice patients are available.
Where Culture Plays a Role
A reliable culture of safety means that everyone is committed to ensuring that every patient has the same opportunity for the best outcome even in complex, high-risk situations. We promoted the philosophy of "systemness," involving experts from many disciplines to agree on one method of caring for all patients. Setting expectations, our first rule of cultural transformation meant that all teams, regardless of whether they were headed by service chairs, chiefs, nursing directors or managers, would adhere to the accepted protocols in every case.
The process improvement team provided education and tools needed for bundle compliance with simulation and teach-back programs. Leaders held teams accountable by reviewing process and outcomes data, drilling down into process failures, resetting expectations and holding clinicians to one high standard. Leaders keep the drumbeat constant about behavioral expectations, compliance with standards and use of error-preventions tools.
The strategy of integrating clinical process improvement with our culture change was powerful. We realized a 55 percent reduction in observed/expected sepsis-related mortality (p value < 0.001) from January 2012 through December 2013.
To err may be human, but hardwiring a culture of stellar teamwork is the antidote for errors. Practicing timely responses until they became habit, ensuring safe handoffs, and holding each other accountable to the highest standards are what Main Line Health patients have come to expect and deserve.
Denise Murphy is the vice president of patient safety and quality at Main Line Health, a nonprofit health system serving portions of Philadelphia and its western suburbs.