Culture Change Key To Safety, Quality Improvements

Medical checklists are proving to be popular items in hospitals to help promote patient safety and stop medical errors. But at many hospitals, the active ingredient to transform a simple checklist into an effective tool is often missing: an energized work culture that empowers everyone who takes care of patients to speak up.

Peter Pronovost, MD, PhD, who first brought the checklist's potential in the healthcare environment to light nearly a decade ago, is first to admit that checklists will not change anything until the current medical culture changes.

In an interview in this month's HealthLeaders, Pronovost, a professor and medical director for Johns Hopkins' Center for Innovation in Quality Patient Care in Baltimore, says many of these cultures still can "contain a certain degree of arrogance, autonomy, and even fear." To change this, everyone must "evolve to a point where everyone on a medical staff can speak up and look out for the patient," he says

One group likely to agree with Pronovost is the 20-bed pediatric intensive care unit (PICU) at the Steven and Alexandra Cohen Children?s Medical New York in New Hyde Park. Earlier this month, the PICU became the first in New York State to go an entire year without a central-line infection. Key to making that goal was getting everyone on the unit—including 90 nurses and 11 fulltime faculty members—to communicate better with each other.

"Part of what we did is we changed our culture of the way that the ICU works," says Peter Silver, MD, chief of critical care medicine at the medical center. The idea was to move individuals from their "silos"—isolated groups of physicians and nurses who maintained little communication with each other.

And, it meant moving from the often patriarchal or hierarchical type relationship where what a physicians says is absolute gospel—with very little room for communication, Silver says. "We tore down all those walls."

The PICU staff actually had some concurrent assistance from its parent company, the North Shore-Long Island Jewish Health System, which began requiring all employees to participate in TeamSTEPPS—a program from the Agency for Healthcare Research and Quality and the Defense Department designed to improve communication skills among healthcare professionals when it comes to patient safety issues.

With TeamSTEPPS, the point was emphasized that "everybody on the medical team has a voice and everybody has...an obligation to use that voice to speak up in order to what is right for the patient," Silver says.

This training occurred about the same time when the PICU jointed with a nationwide collaborative effort, coordinated by the National Association of Children?s Hospitals and Related Institutions (NACHRI), in 2008 to eliminate pediatric catheter?associated bloodstream infections (CA-BSI). The initial goal was to reduce the infection rate by half, while doubling the time interval between infections.

"There were a lot of parts of the central line initiative that required a culture change," Silver says. Reducing the incidence of CA?BSI in adult patients have been successful mostly by improving insertion techniques. But with pediatric CA?BSI, the insertion of the central line is the cause of only 10% of infections, with the remaining 90% linked to "maintenance procedures" of the line.

The key to combating the infection in pediatric populations meant focusing on those maintenance procedures. The necessities of the catheter itself became a topic for discussion on daily rounds—and part an open conversation among nurses and physicians caring for the patient.

The PICU began using a dedicated nurse observer—with a checklist—who would accompany the physician inserting the catheters. The nurse would observe if safety precautions—such as hand washing or use of caps, gowns, and masks--were being implemented. If there was noncompliance with a checklist item, the nurse could stop the procedure until it was corrected.

Empowering the nurse did take some adjustment, Silver says. "Some of my physician colleagues didn't at first like it much that they would be challenged. But, we changed that culture, and now it's not even an issue.

Now, when a doctor goes in to put in a central line, "they'll go find the nurse—they seek them out," Silver adds. And similarly, nurses can report on how the central line looks--if it's functioning well or if there are concerns that it should come out.

"You have to create a sense of mutual responsibility—where you share the success. I could have talked to the entire group all of the time about how much a central line infection costs and what the mortality risk is, but that has very little impact because we deal with critically ill children," says Silver.

"It's really a matter of working on communication and creating the environment where people realize that everyone is responsible for everything that goes on with a patient—for creating the mindset that a central line infection is not acceptable," Silver says. "It's really letting everybody know that this is really important."