Inside OhioHealth's High Reliability Journey to Improved Quality

As OhioHealth came out of the coronavirus pandemic, its quality and safety team decided there was a need to do an entire reset across the health system.

OhioHealth has made becoming a high-reliability organization a top priority for the 16-hospital health system.

High reliability was pioneered in the aviation and nuclear energy industries. At health systems, hospitals, and physician practices, it includes focusing on patient safety and limiting medical errors.

OhioHealth launched its high-reliability effort a year ago, says Teresa Caulin-Glaser, MD, senior vice president and chief clinical officer of the health system.

"As we came out of the coronavirus pandemic, our quality and safety team decided that we needed to do an entire reset across the health system," she says. "The goal was to get everybody back into understanding what we needed to be focusing on and working together across the health system to create a high-reliability organization."

At health systems, the foundation of high reliability is safety, but becoming a high-reliability organization generates widespread benefits, Caulin-Glaser says.

"When you focus on safety, you are automatically improving your quality," she says. "You are automatically improving your service to the patient. You are improving the culture of the organization to be safety-first. Financially, you gain a benefit because you do not have unnecessary hospital readmissions, long lengths of stay, or errors that are costly for the organization and the patients."

Teresa Caulin-Glaser, MD, is senior vice president and chief clinical officer of OhioHealth. Photo courtesy of OhioHealth.

Taking the first step

Driving high reliability at a health system starts with education, Caulin-Glaser says.

"The messaging and importance of this initiative came from Steve Markovich, our president and CEO," she says. "His message was: Everybody is training. If you were an executive, you were training. If you were working in accounting, you were training. Everyone in the organization was training on universal skills for high reliability."

OhioHealth has been training employees on several universal skills:

• S.T.A.R.: Employees are encouraged to stop, think, assess, and react.
   
• Make a 50-second connection: Caregivers are encouraged to make a connection with their patients in the beginning of a clinical interaction. For example, a provider can ask how the patient is feeling and about family members. The goal is to know important things about the patient and focus attention on the patient.
   
• Speak up: Staff members have been trained to validate and verify everything they do that touches patients. For example, if a caregiver is administering medication, they are expected to validate and verify that they have the right patient, the right medication, the right timing of administration, and the right dose. In an operating room, if a surgeon asks for an instrument and a nurse is not sure that they heard the request clearly, the nurse is expected to stop and ask a clarifying question to make sure the right instrument is provided.
   
• Communicate clearly: For example, if a patient is in the emergency room, then is transferred to a medical floor in the hospital with direction to receive 325 mg of aspirin, the nurse receiving the patient should ask whether the patient needs 325 mg of aspirin. The nurse is repeating the direction and asking the emergency room staff to verify the prescribed medication.
   
• Practice empathy: Team members should make empathetic statements such as, "I hear you are not feeling well today, and you had a bad night with little sleep." All employees should listen to patients' concerns and acknowledge them.

Caulin-Glaser says the education program is working.

"About 90% of the leaders across OhioHealth have received high-reliability training," she says. "Our goal is to have 70% of our associates—more than 15,000 people—trained by the end of this month. We want to have 100% of our associates trained by the end of September. High reliability is part of our onboarding training."

The value of reporting systems

OhioHealth has established a daily tiered huddle process to report on four kinds of events: patient safety incidents, workplace injuries, workplace violence, and anything that needs to be escalated to senior leadership.

• Tier 1 huddles are conducted with frontline healthcare workers.
   
• Tier 2 huddles feature frontline leaders, who try to resolve issues that arise in the Tier 1 huddles.
   
• Tier 3 huddles address issues that are escalated from Tier 2 huddles, with managers and directors in attendance.
   
• Tier 4 huddles handle issues escalated from Tier 3 huddles, with hospital presidents and their leadership committees in attendance.
   
• Tier 5 huddles are held at noon and address the most serious and repetitive issues reported by the other tiers, and participants include the chief clinical officer, president and CEO, chief operating officer, chief nursing executive, chief information officer, and the vice president of quality and safety.

"Our tiered huddles have helped us to find out what is happening in the health system and to proactively address issues," Caulin-Glaser says. "We are having fewer repetitive issues, and we are getting ahead of issues."

OhioHealth also has an online platform for staff members to report patient safety events. The platform is easy to access and use, Caulin-Glaser says. Over the past year, the health system has experienced a 30% increase in patient safety event reporting.

Safety teams review all safety event reports, and there is a review process for any safety events that are considered serious, Caulin-Glaser says.

"If there are events that we feel need a deep dive, we conduct a root cause analysis that is sent to senior leaders, who determine what we have learned and what actions are going to be put in place," she says.

Expected improvements

OhioHealth has lofty expectations for the impact of its high-reliability initiative.

"Our quality will improve, and we have already seen quality gains," Caulin-Glaser says. "We have been working on high-reliability skills to reduce the mortality rate in our hospitals, and we have seen that number improve. We expect to decrease unnecessary infections such as central line infections and catheter infections. We are expecting to see a reduction in surgical site infections because staff are being more careful."

The health system is expecting to see gains in patient satisfaction, Caulin-Glaser says. They’re hoping that patients will report that they were heard in the hospital and that all members of their team understood the care plan, she says.

In addition to reducing hospital readmissions, length of stay, and costly errors, OhioHealth is expected to reap other financial benefits from its high-reliability initiative, Caulin-Glaser says.

"By establishing high reliability in our outpatient clinics, we hope to be treating patients proactively, so they do not require hospitalization, which should reduce expenses for the patients as well as the organization," she says. "If we become known as a high-reliability organization, it should drive more patient volume to the organization, which will increase revenue."