How to Improve Patient Safety

WellSpan Health has established an extensive tiered huddle system, revamped patient safety reporting system, and culture of safety.

WellSpan Health has made significant gains in patient safety over the past three years.

Patient safety includes medical errors that impact patients and "near misses" that could have reached patients. Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System.

York, Pennsylvania-based WellSpan Health reassessed the health system's approach to patient safety in 2020, says Michael Seim, MD, senior vice president and chief quality officer.

"We looked at our long-term goal to focus on zero harm to patients and zero harm to team members. As part of our annual plan, our board of directors set a goal to make measurable outcome improvements and reduce safety events that reach patients. We started to focus on our methodology. We understand that most errors that reach a patient are because of system and process design flaws. No one goes into healthcare to harm people—it is about poorly designed systems. So, we spent a lot of time building our management structure and training our leaders in the theory of lean management. Then we spent time getting input from our 20,000 team members to develop a lean management system that connected our frontline team members to our CEO every day," he says.

The results have been impressive.

• WellSpan Chambersburg Hospital: more than 260 days central line-associated bloodstream infection (CLABSI) free
   
• WellSpan Waynesboro Hospital: last CLABSI was prior to 2012
   
• WellSpan Gettysburg Hospital: more than 250 days CLABSI free and more than 100 days catheter-associated urinary tract infection (CAUTI) free
   
• WellSpan Ephrata Community Hospital: more than 980 days CLABSI free
   
• WellSpan Good Samaritan Hospital: more than 830 days CLABSI free
   
• At WellSpan York Hospital, the Open Heart ICU and Surgical ICU have been both CAUTI free for the past year

Safety event reporting

WellSpan has committed to having an extensive tiered-huddle system, where every team member huddles every morning, Seim says. "Every team member is engaged in some type of huddle, where any safety event, harm event, or near miss gets elevated upto our CEO. We trained all 20,000 team members in patient safety and in recognizing risk or harm to patients. We trained all team members in problem solving and root-cause problem solving. The concept is that everyone owns patient safety in our health system."

The frontline huddles are connected to the entire management team, he says. "The second tier of huddles is managers and directors, who elevate concerns from the frontline team members. Then our regional vice presidents huddle; and, ultimately, the vice presidents' huddle reports to our CEO huddle. Every day, we connect any safety concern that a frontline team member identifies all the way up to our CEO."

The health system also has a revamped formal reporting system for patient safety, Seim says. "We rebranded our patient safety process to remove any punitive characteristics for team members—we wanted them to feel psychological safety. We rebranded to putting safety first and called the reporting system "Safety First." We are striving to get the number of events that our team members identify to increase in our Safety First system. We wanted them to not only report errors but also proactively report areas where someone could be potentially harmed."

In 2020, there were 20,000 safety events reported. Over the past year, 42,000 Safety First events have been reported, he says.

Team members can also find out what has happened after they report a safety issue, Seim says. "We created an opportunity for team members to request feedback on how we resolved an issue. A lot of times, team members had felt it was not worth putting in a report because it just went into a black box and disappeared. In the new process, team members can request follow-up from the manager of a unit to find out what we have done to prevent an error from reaching a patient."

Promoting a culture of safety

WellSpan has promoted a culture of safety, with active involvement of the leadership team, Seim says. "Our board sets our annual plan goals, including zero harm to patients and zero harm to team members. We use the lean methodology of sharing data openly. Every two weeks, we have a leadership review of our annual plan goals, which includes patient harm. We have a weekly call every Monday with every manager in the organization where we share information about safety."

The health system has created a culture where patient safety catches are celebrated, he says. "We have what we call a Heads Up, Speak Up Award, where we recognize team members who stop the line for a potential harm event before it reaches a patient. We have had national recalls for products when our team members have stopped the line because there was a safety issue. One was with a fall mat that was slippery when wet. We celebrate the best catches of the year during our annual quality forum. We talk about quality and safety, and we celebrate opportunities to improve patient safety and quality."

Related: Chief Nurse: How to Reduce Serious Safety Events