Perspectives on Safety

Building a Safety Program in a Vast Health Care Network

By Paul E. Phrampus, MD

Perspective

Background

As hospital-based health care in the United States has consolidated, large health care systems have proliferated across the country in the last decade.(1,2) Health care networks involving a variety of care facilities (such as hospitals and physician practices) functioning as a single coordinated entity present unique opportunities and challenges for building patient safety programs.

Large systems often have access to more resources in terms of funding, personnel, and information technology (IT) infrastructure. Many have amassed internal aggregate data that can be used to inform the needs of a patient safety program. Several systems have become fully integrated health delivery networks and have developed their own insurance payers, which further increases access to information on costs and outcomes. Health care networks can communicate across their systems with relative ease, hopefully sharing best practices and lessons learned from within the system itself.

However, large health care systems also present challenges to the building and maintenance of safety programs. Haas and colleagues recently framed some of the risks potentially associated with such systems.(3) Things become even more complex when systems span across state borders. Differing rules, regulations, and state legislation complicate the development of all kinds of programs, including ones focused on patient safety.

While there are advantages to scaling and sharing practices and data across a large network, safety remains a uniquely local phenomenon. The fact that a given practice—whether it's a change in workflow or a computerized reminder—worked in a clinic or hospital that is part of a large integrated system may offer surprisingly little advantage if adopted in a new site, even one that is part of the same system. Trying to legislate or drive safety as a top-down initiative from the corporate towers is a nonstarter.

Beneath the surface of most large health care systems lies a heterogenous set of local entities (often hospitals) of varying size, capacity, and specialization, each having their own culture. Creating a central program that has the flexibility to serve each of the member organizations at a level that they require is crucial for success. Relationships must be actively developed that allow the system-level safety initiatives to interact with the local care–providing entities of the system. This work is challenging but essential.

Vision and Leadership

Setting strategic goals and establishing values and a focus on safety at the highest level of the system are key to enable the member hospitals to start working in a similar direction. It is critical that the executive leaders of the system, as well as the leaders of the member hospitals, be assigned and accept responsibility for safety.(4)

To facilitate such programmatic adaption, the leadership of the system and the individual care entities must understand the goals and future direction. They should be educated in systems thinking associated with modern patient safety best practices and work environments. Leaders must be provided data along with the skills of interpretation and change management that allow them to understand their internal needs so that they can prioritize the resources necessary to carry out the work. Finally, information based on their performance—both as compared to the rest of the system and to external benchmarks—must be available as they are critical components of the ability to demonstrate improvement over time.(5)

While diktats coming from central leadership are of limited use (remembering that safety is local), high-level guiding principles that form the foundations of high reliability organizations (6) as related to quality and safety must be adopted and disseminated throughout the health care network. Such efforts seek to improve safety culture (7) at the front line through promoting more effective communications, increased vigilance of frontline staff to safety issues, and empowering and encouraging staff to intervene or speak up when they feel a patient's safety may be compromised.(8) For example, at University of Pittsburgh Medical Center (UPMC), we adopted a guiding principle of creating a just culture at the local level. After developing a toolkit and workshop series focused on managing within a just culture, more than 1000 mid-level managers were trained in the basic principles. After the initial training, the management and leaders at each hospital localized the incorporation of a just culture into their daily operations. Local implementation across the system ranged from additional training and coordination with Human Resources to substantial changes in the way physician peer review was performed within the hospital.(9)

Middle managers are key to successfully transforming to a systems approach to safety (10), such as embracing and practicing the principles and tenets of a just culture.(11) Examples of other approaches may include publicly celebrating staff members who engage in meaningful safety actions and inserting conversations about safety into annual evaluations as well as all routine staff meetings. Such efforts normalize safety behaviors and actions over time. The net effect is truly engaging frontline staff as partners in patient safety and allowing the organization to disseminate information and actions that otherwise may remain hidden because of fear of punishment or reprisal.

Creating programs in which the central team can assist with or participate in critical safety program activities at the local level (such as root cause analysis [RCA], incident investigations, and mandatory reporting efforts) can help build relationships. At UPMC, our system safety team participates in select local RCAs concerning significant patient harm and in cases involving complex systems issues, as well as on request from the local hospital. This process of collaboration helps to provide an opportunity to understand implementation of the safety programs at the local hospital, and it contributes to consistency across the system. Relevant findings from RCAs are disseminated across the system at our monthly Patient Safety Officer Meeting and various communication pathways, including a system safety blog.

Training

Those managing safety within the health systems member hospitals must have access to training, information on best practices for safety, and interactive forums to further drive alignment of the goals of the larger institution. For example, at UPMC our system team hosts several speakers series on quality and patient safety topics, an annual patient safety awards recognition reception, various workshops, on-demand training sessions, and graduate medical education training on safety. In addition, a number of individual hospitals across our health system hold their own safety conferences and local safety training programs.

Of course, educational efforts cannot be "one and done." In a large complex organization, continual reorganization and employee turnover occur. When the system also includes teaching hospitals, there are the additional challenges of educating trainees, who arrive, stay a few years, and then may leave. All of this makes it important that a system-level safety program provide meaningful education initiatives, and that there is a special emphasis on onboarding of new employees. This onboarding, as well as ongoing educational efforts focused on systems thinking, change management, and human factors, is crucial.(12) It is imperative to recognize that such education must be broad-based and interdisciplinary, involving physicians, nurses, other care providers, managers, and leaders.

Turning Data Into Information

Assisting the network's member organizations in turning safety data into actionable information is another critical part of the central safety initiative. The network has access to data that contains trends and information that may uncover potential system safety issues. While reports alone do not drive necessary change (13), the information serves as the substrate for analysis to identify true safety issues within the organization.

Providing local safety leaders access to such information can help to drive safety priorities. It is also incumbent upon the system safety initiative to develop methods to communicate such findings across the entire system. For example, at UPMC we package the data from our culture of safety surveys to include the local hospital performance as compared to the rest of the UPMC Health System entities and the national AHRQ mean scores. Each hospital receives its own customized report along with the comparative data. We also collaborate with local hospital leadership to suggest areas of focus and assist with improvement planning.

Measuring the culture of safety across a vast health care network can help guide system initiatives, particularly when these measurements are effectively communicated and used to guide the development of action plans.(14) Such efforts also help to encourage collaboration between the member institutions. The net results are more shared learning and institutional growth of a successful safety program.

In summary, while the development of large, integrated health care networks offer major opportunities to improve patient safety, such improvements require careful attention to the respective roles of the central leadership and the local sites. It also requires tremendous attention to information flow in both directions—from the center to the local hospitals and clinics, and from the local entities back to the center. The fact that most safety is local is an important truth to appreciate, but it is no excuse for the central leadership of a large entity to avoid articulating a vision for safety and creating programs and information flow that helps the local entities in their improvement work.

Paul E. Phrampus, MD Director, Peter M. Winter Institute for Simulation, Education and Research (WISER) Professor, Departments of Emergency Medicine and Anesthesiology Medical Director, Patient Safety, and Donald D. Wolff Jr. Center for Quality, Safety & Innovation University of Pittsburgh and UPMC Health System Pittsburgh, PA

References

1. Tsai TC, Jha AK. Hospital consolidation, competition, and quality: is bigger necessarily better? JAMA. 2014;312:29-30. [go to PubMed]

2. Lineen J. Hospital consolidation: "safety in numbers" strategy prevails in preparation for a value-based marketplace. J Healthc Manag. 2014;59:315-317. [go to PubMed]

3. Haas S, Gawande A, Reynolds ME. The risks to patient safety from health system expansions. JAMA. 2018;319:1765-1766. [go to PubMed]

4. Bowen DJ. Leading for Safety. For executives, making healthcare safe is a leadership imperative. Healthc Exec. 2017;32:8-9. [go to PubMed]

5. Clarke JR, Lerner JC, Marella W. The role for leaders of health care organizations in patient safety. Am J Med Qual. 2007;22:311-318. [go to PubMed]

6. Lyndon A, Wachter RM, Hartman EE. Patient Safety Primer: High Reliability. Updated August 2018. [Available at]

7. Ranji S, Wachter RM, Hartman EE. Patient Safety Primer: Culture of Safety. AHRQ Patient Safety Network. Updated August 2018. [Available at]

8. Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. BMJ Qual Saf. 2017;26:869-880. [go to PubMed]

9. Volkar JK, Phrampus P, English D, et al. Institution of just culture physician peer review in an academic medical center. J Patient Saf. 2017 Dec 5; [Epub ahead of print]. [go to PubMed]

10. Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture. BMC Health Serv Res. 2017;17:582. [go to PubMed]

11. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res. 2006;41(4 Pt 2):1690-1709. [go to PubMed]

12. Wachter RM, Gupta K. Understanding Patient Safety, Third Edition. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.

13. Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016;25:71-75. [go to PubMed]

14. Campione J, Famolaro T. Promising practices for improving hospital patient safety culture. Jt Comm J Qual Patient Saf. 2018;44:23-32. [Available at]