There’s good news for hospitals scrambling to meet The Joint Commission’s culture of safety standard: The government is here to help—and the tools and guidance are free.

Standard LD.3.10 calls on organizations to assess and set up a culture of safety and quality. But if hospitals just stop at assessment and don’t make meaningful changes, they may be doing more harm than good.

“It’s really important for an organization to use the information from the assessment to take action,” says James Battles, PhD, a senior service fellow for patient safety at the Agency for Healthcare Research and Quality’s (AHRQ) Center for Quality Improvement & Patient Safety. “Because if you just do it as an exercise, to check something off, and you’re not going to do anything about it, you may do more damage than if you hadn’t done anything in the first place.”

Simply going through the motions, he adds, will only “frustrate staff and probably make matters worse.”

The AHRQ has a free culture of safety assessment on its Web site, a tool that took years to create. Part of what Battles and the AHRQ looked at when designing the instrument was the questionnaire the Veterans Health Administration (VA) pioneered to assess its culture of safety.

Staff worries about humiliation

The VA began looking at its culture in 1998, one year before the Institute of Medicine’s (IOM) groundbreaking report To Err is Human. The questions unearthed some surprises, as well as some expected news.

“The higher you were in the pecking order, the more you thought communication was great; the further down you were, the more you said it stunk,” says James Bagian, MD, PE, chief patient safety officer for the VA and director of the VA National Center for Patient Safety. “That’s not unique to medicine. Most people thought that was going to be the case.”

What Bagian, a former NASA astronaut who investigated the Challenger and Columbia disasters, didn’t expect were the responses from staff members about the consequences of making a mistake.

“One thing we thought we would find, but didn’t, was that one of the top things people worried about was being punished if they made a mistake,” Bagian says. “That was what we thought. That was the common wisdom. Turned out, that really wasn’t the case.”

Even though several people acknowledged it was an issue, they didn’t rank it very highly on the scale of 1–5. But 49% of the staff ranked humiliation as a 5 when asked about their fears of making a mistake.

“This influenced a lot of what we did,” Bagian says. “You can change your personnel policies to say, ‘If you make a mistake, we won’t downgrade you, we won’t fire you, we won’t suspend you.’ However, that has nothing to do with shame.”

VA focuses on systems, not individual errors

Consequently, the VA decided early on that if a safety investigation found that a clinician had simply made an honest mistake, it wouldn’t reveal his or her identity, but instead look at systems-related solutions. It focused on prevention, not punishment.

Before the VA set out to improve patient safety in the late 1990s, a medication error that caused harm or death typically resulted in some sort of reprimand for the nurse.

Bagian talked to department heads and nurse managers and provided them with tools to do safety investigations that focused not on one person, but on the process that led to it. The investigation might probe aspects such as whether confusion stemming from a look-alike/soundalike drug or possible mislabeling contributed to the medication error.

“Instead of punishing the last person to touch the patient, which typically happened before, now they put a countermeasure in to prevent this from happening again, not just to nurse X, but to anybody,” says Bagian.

When staff members saw that a serious error led to a change that would help all of them make fewer mistakes—instead of a nurse being fired—they not only bought into the program, they became more likely to report events and near misses, he adds.

Clinicians learn from close calls

“You can’t fix what you don’t know about,” Bagian says. “If someone’s not willing to tell you about a problem, there’s no way you can correct it. Secondly, you want to learn from close calls. Wouldn’t you rather learn from something that didn’t happen but could have, rather than wait until you kill somebody?”

If the results of the question on shame caught Bagian off guard, the responses to the query about the importance of safety to patient care absolutely floored him. Again, this predated the IOM’s 1999 report.

The question asked: Do you think patient safety is important to good patient care? Staff members could respond on a 1–5 scale, with 1 being “strongly disagree” and 5 being “strongly agree.”

“We thought that everybody would say 5, strongly agree,” Bagian says. “Well, that wasn’t the case. Twenty-four percent said 1, strongly disagree. We were all flabbergasted about that.”

After talking to the staff, Bagian and his colleagues learned that clinicians didn’t necessarily think patient safety wasn’t important; it just wasn’t a priority to them because they thought they had it all figured out.

“We had to show them that no matter how good they are, given the right set of circumstances, they’re capable of actions that can hurt patients,” he says. “It doesn’t mean they’re bad people; it means they’re human. Mistakes happen and we need to look at what will make it less likely to happen.”

The answer, Bagian says, is to design systems and protocols that make it easy to do the right thing and, when possible, impossible to do the wrong thing.

Effective systems also require built-in redundancies. Bagian uses the airline industry as an example, which has a stellar safety record. Commercial airliners have at least two engines so if one fails, the aircraft doesn’t crash.

Even though engines are built not to fail, if they do, the aircraft doesn’t crash and kill all the passengers on board. “Whereas in medicine, and in many industries, people say, ‘Let’s be perfect, let’s try hard,’ Bagian says. “The metaphor in aviation would be that we’re flying single-engine airplanes. And on a day that the engine does fail, we all just crash.”

AHRQ pushes nonpunitive culture

Like Bagian, Battles stresses that the culture must be nonpunitive if it wants to truly advance patient safety. An AHRQ benchmarking study, Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report, analyzed data from 519 hospitals that conducted a culture of safety survey with 160,000 staff members nationwide. It found the following:

64% worried that the mistakes they made would be kept in their personnel file

49% felt mistakes were held against them

55% felt like the person, rather than the mistake, was being reported

Battles says he hopes the creation of patient safety organizations, mandated by the Patient Safety Act of 2005, will go a long way toward changing those perceptions. Under the legislation, clinicians can sue their hospitals if they are punished or fired for reporting a mistake.

“As part of a framework of culture, the hospital and healthcare environments have been pretty punitive in this respect, and that’s one reason the provision is in the law,” says Battles.

Survey asks about feedback, teamwork

The AHRQ’s survey includes questions in 12 domains that assess everything from communication and openness to teamwork across and within units to feedback and communication about errors. Within each domain, staff members answer questions about their particular unit as well as the hospital overall.

“Depending on your organization, you may have multiple different cultures going on,” Battle says. “There might be different cultures in medicine, surgery, and the ED.”

The literature, he adds, shows that the unit manager has tremendous influence on that unit’s culture. Smaller hospitals tend to have fewer variations in culture in different units.

Hospitals start with early wins

After assessing the organization’s culture of safety, hospitals should tackle the areas where they can most easily see early success.

“Go after the things that are winnable and fixable and get started, because you want to show improvement as quickly as possible,” Battles says. “It’s very difficult to try to fix everything at once.” The AHRQ survey engages everyone who works at the hospital in solving the problem, he adds.

“One of the typical approaches, which is usually a disaster for hospitals, is that we appoint someone to come up with a solution,” Battles says. “It’s now up to the infection control person or the wound care nurse to solve all the problems. And if they don’t fix the problem, we fire that person.”

Instead, hospitals should share the risk so that everybody says: We’ve got a problem, let’s figure out how to solve it together.

“Changing culture takes time,” Battles says. “Culture follows action. To say, ‘I’m going to change the culture and just focus on culture’ is probably not going to help very much.” Instead, hospitals should examine what is causing the culture to be negative.

“There’s the old adage ‘The beatings will stop as soon as morale improves,’ ” Battles says. “You’ve got to begin to take this information and drill down to determine the problems and what you need to fix them. It’s the actions an organization takes that speak much louder than what they say.”

 

Positive strategies to help a hospital create a collaborative, supportive, and ­symbiotic relationship with the medical staff.

This article first appeared in Strategies for Nurse Managers.

In the quest to meet Joint Commission standards, it is very helpful to have a highly engaged medical staff. While usually not employed by the ­hospital, the medical staff is key to the hospital's success in meeting many of the Joint Commission standards. But how does a healthcare facility get physicians to care about the success of a hospital?

There are some strategies that a hospital can utilize to increase the collaboration and level of participation of the medical staff. Some hospitals have tried forcing the issue through requiring attendance at all ­meetings, and making in-services and workshops mandatory. But does this really engage the medical staff? Or does it create resentment?

This article will focus on positive strategies to help a hospital create a collaborative, supportive, and ­symbiotic relationship with the medical staff. As Henry Ford said, "Coming together is the beginning, keeping together is progress, working together is success."

 

Consider the physicians' concerns

One of the most effective strategies for successful physician engagement may also be one of the simplest: Take a step back and listen to what physicians are saying. This helps build trust, which is the foundation for any productive partnership. Avoid focusing your first conversation with a physician on what he or she can do for you. Instead, get the physician's input on where he or she sees opportunities to improve processes and performance, and put yourself in a position to ­deliver something from that conversation.

These early conversations with physicians can also provide insight into the quality of communication within an organization, and whether the goals of physicians and hospital administration are aligned or contentious.

When good interpersonal dynamics exist, it is often easy to determine expectations from both sides as well as predict the level of cooperation expected at the outset. In situations where relationships could be strained, one-on-one meetings with physicians will yield details on the issues that present challenges, the roadblocks to navigate, and the potential solutions.

Cardiologist Mark Hanson, MD, chief of staff at ­Newton Medical Center, says, "Whether or not I'm ­going to agree, I appreciate that I understand what the ­hospital is doing and why. Transparency builds trust and will go a long way toward resolving any conflicts with medical staff."

Once the concerns of the physicians are known, hospitals and physicians can find ways to resolve issues and broker deals that focus attention on the true problems at hand, such as how to decrease the cost of physician preference items while preserving the quality of care, or how to gain physician support in meeting new or particularly challenging standards.

When trust is established and communication issues are resolved, the concept of physician engagement can become a reality. If physicians have an issue regarding one of their areas of practice, it is most beneficial to get their input first and ask for their guidance in how to respond. In turn, a hospital can expect that the physicians will help manage any changes and improvements needed to deal with the issue or standard.

 

Identify physician champions

A critical step in establishing the level of trust necessary for effective collaboration is identifying champions among the medical staff who will serve as liaisons to the hospital and administration and provide leadership, accountability, and clinical oversight for initiatives intended to meet standards or improve processes. Having point-of-contact physicians who can take issues back to other members of the medical staff will ­provide the best framework for ensuring targeted, efficient communication.

Another benefit of physician champions is that they are usually willing to help. Physicians can offer a unique viewpoint that may not have been considered within the organization. "Who else knows the view of the physician, if not the physician?" says hospitalist Josh King, MD.

The process of engaging physician champions can vary. Selecting physicians who are stakeholders in a particular process is a way to respect the preferences of physician leaders and obtain needed insight and support for hospital-led initiatives. An informal process is often effective, with the hospital acknowledging the value and expertise the physician brings to the table in making any changes.

If the process is formal, the expectations of the physician leader and of the hospital must be clearly defined. This helps avoid role confusion and the impression that the physician is "taking the hospital's side" when working through a challenging initiative. Keep in mind that the expectations of both parties are usually higher in a formal process, and the collaborative relationship may be damaged if the initiative is not as successful as either party believes it should be.

 

Watch practice patterns

When it comes to Joint Commission compliance, most ­compliance officers are all too familiar with RC.01.01.01: "The hospital maintains complete and accurate medical records for each individual patient."

The reason this standard is so familiar is that currently, The Joint Commission lists it as the standard with the most compliance issues. Almost all hospitals have had challenges with physicians signing, dating, and timing orders and other documentation in a timely manner.

It is important for documentation and medical ­records compliance to be part of physicians' ongoing professional practice evaluation (OPPE). If a physician has a track record of stellar compliance with documentation standards on OPPE, he or she could easily become your physician champion for changing processes to meet a particular standard. Perhaps this physician has created a personal system that helps him or her remember to ensure documentation compliance with each patient-this best practice can be shared with others.

It is similarly important to identify physicians who consistently fail to comply with standards. You can then utilize the peer influence of your physician champion to change their behavior.

 

Involve physicians in monitoring

When it comes to understanding standards put forth by The Joint Commission, physicians don't have to fall back on "we do this because The Joint Commission says we have to." Instead, they can gain the upper hand. If physicians are part of the process of the hospital adopting processes and policies in alignment with Joint Commission standards, they are more likely to understand the rationale behind the standards.

If physicians are able to attain a better understanding of why certain standards are created, they may become more interested in monitoring other physicians for compliance. In this era of healthcare reform, physicians realize that it is important for hospitals to be successful and preserve high-quality patient care.

If a standard is particularly challenging to a hospital, engaging physicians in creating processes and monitoring the standard can be helpful. Physicians can bring some processes to their own practices, or integrate hospital practices for better continuity of care and a feeling of cooperation.

Newton Medical Center in Covington, Ga., created a strategy to keep all preprinted order sets in a software program accessible throughout the hospital. The order sets could be customized if the physician requested it, and could be printed with patient information included. To bring physicians further into the process of using the order sets, the hospital is setting up a physician portal for admitting physicians, so the same order sets available in the hospital will also be available in offices.

The medical executive committee can help facilitate collaboration between the hospital and medical staff. The committee can go on record in support of policies and processes that comply with Joint Commission standards. Department chairs can work with peers to monitor compliance and cooperation. It is important that a medical staff OPPE program is set up to reflect physicians' individual rate of compliance with standards.

Feedback on compliance and resources for assistance can be provided to physicians as part of their OPPE program. Medical staff leaders, if knowledgeable and engaged about compliance with regulatory agencies, will be valuable champions for hospital processes.

 

Use data to support changes in behavior

Positive results of physician engagement efforts are not earned on the basis of goodwill alone. For physicians, data is a critical component in making decisions that could benefit them and the hospital.

Physicians are not likely to simply accept the word of hospital administration at face value when being asked to make a change. When administration can present physicians with benchmark data, regardless of the clinical indicator, it makes the task easier.

"Most of us are data driven, and do things in response to data and studies," says Hanson. Physicians are scientists, he adds, and will respond to objective data presented along with workable solutions.

Data is an effective tool for driving changes in physician behavior and practices. King notes, "Physicians may initially be resistant to anything that is presented as a critique, but may end up being surprised at what the data shows. It levels the playing field since it is fact, not driven by the goals of the hospital or regulatory agency."

Hanson agrees. "If you showed me that I was the most expensive physician in the hospital, I would reevaluate how I practice," he says.

The same could be said for compliance with regulations. A physician may think he or she is doing well with Joint Commission standards, and may resist any suggestions for improvement. Presentation of data can eliminate opinion and room for disagreement. Physicians are scientists, and they are more receptive to change if detailed information is provided while processes are being constructed. Diligent tracking is also important to keep physicians current on the results of practice changes. Ensuring physicians are up to date on progress made and providing them with feedback will help maintain positive behaviors and compliance.

 

Build momentum for success

Physician engagement strategies require a unique mix of people skills, process maneuvering, technological and clinical expertise, and careful follow-up. Providing physicians with the data they need to make informed decisions is a key component of engaging physicians in improving processes and meeting standards. ­Success ­creates its own momentum, and the more positive ­outcomes are achieved, the more likely physicians will trust the processes and agree to become part of them. The benefit of successful physician engagement can be realized by the hospital, the physicians, and the ­community as a whole.

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