Session Code C18 Gretchen Ruoff, MPH, CPHRM, CPPS Pat Folcarelli, RN, PhD Margaret Janes, RN, JD
Disclosures Gretchen Ruoff, Pat Folcarelli and Maggie Janes today have no relevant financial or nonfinancial relationship(s) within the services described, reviewed, evaluated, or compared in this presentation. 2
Objectives Articulate how structure and leadership style can impact safety culture and engagement in patient safety efforts. Identify and address problems that minimize the effectiveness of risk management and patient safety improvement strategies. Demonstrate how a hospital leader can leverage risk assessments to minimize gaps between their intentions for patient safety and staff perception. 3
Getting to Know You An Introduction to CRICO and CRICO Strategies CRICO Controlled Risk Insurance Co. Harvard Medical Institutions Insures: 13,400 physicians 23 hospitals 100,000+ employees (Nurses, Advanced Practice Clinicians, Technicians etc.) Includes: Massachusetts General Hospital Brigham & Women s Hospital Boston Children s Hospital Beth Israel Deaconess Medical Center Affiliated Community Hospitals CRICO Strategies A division of CRICO Benchmarking data for comparative analysis and National Community of Learning Risk appraisals for partners and insureds Partners: 180,000 physicians 550 healthcare entities (including 400 hospitals) Includes: University systems (e.g. UCLA) Captive insurers (e.g. Medstar) Commercial Insurers (e.g. TDC) 4
Getting to Know You Who is in the audience today? Show of hands: Hospital leaders? Patient safety executives? Risk managers?
CRICO & BIDMC Unique Perspectives, Shared Goals
The Insurer s Perspective Understanding the Past to Inform the Future How can we leverage 20/20 hindsight of risk experience to impact future care delivery? How can we link quantitative data with qualitative assessments to provide broad perspective on drivers of risk? As our system expands through acquisition, how can we prospectively evaluate and minimize new risks while maximizing patient care benefits? Through regular comprehensive evaluation of insured organizations and new entities 7
Risk Appraisal & Plan (RAP): An Interview-Based Assessment Process Examines safety culture and impact of leadership approach at all levels Evaluates staff appreciation for their role in frontline risk assessment and safety improvement Identifies root causes and provide in-depth insights into safety culture responses Identifies organizational vulnerabilities and barriers that limit engagement in and impact of patient safety programs Empowers local and enterprise leaders with a roadmap to staff engagement and leadership collaboration on patient safety/risk management efforts Prevents culture from eating strategy for lunch! 8
ORGANIZATIONAL VULNERABILITIES CAN THREATEN PATIENT SAFETY EFFORTS Despite significant effort and good implementation, many organizations continue to face the very incidents their patient safety programs are designed to prevent ORGANIZATIONAL VULNERABILITIES CAN THREATEN ACQUISITION INTEGRATION Despite thorough due diligence, many acquiring organizations may struggle to effectively identify more veiled risks that could impact the growing enterprise s risk profile The RAP identifies organizational barriers limiting the effectiveness of patient safety programs understands culture to create successful strategy
The RAP Philosophy Evaluating 3 Key Elements Within & Across Entities Does your: Culture promote learning from near misses and safety events? Structure ensure capture and communication to enable action? Leadership model and empower engagement in patient safety? STRATEGIZE ACQUISITION INTEGRATION What are the GAPS between: Expectation and reality: Where you are versus where you would like to be Intent and perception: The message being sent versus the message being heard Entity and enterprise: Current and future state 10
Safety Culture In a culture of safety, people are not merely encouraged to work toward change; They take action when it is needed. Those engaged in patient safety believe, participate, and willingly contribute to its success. - Institute for Healthcare Improvement 11
Safety Culture Interviewers seek to understand: Is there evidence of a humble, curious, problem-sensing culture? Do staff and providers If I spoke recognize up, I wouldn t the importance be here. of I ve reporting? seen that happen. It s Are there concerns better to about be quiet discussing because things or reporting won t change, errors and or near I don t misses? If want so what to make are the myself barriers vulnerable. to speaking OR up? Staff RN Are there clear processes for recognizing and distinguishing system errors from unsafe, blameworthy actions? Are reporters recognized, rewarded, and responded to? Is there engagement in patient safety efforts at all levels? By staff, as participants in solutions and local champions of patient safety? By the board? 12
Safety Structure A safety culture operates effectively when the hospital fosters a cycle of trust, reporting, and improvement. In the trust-reportimprove cycle, leaders foster trust, which enables staff to report, which enables the hospital to improve. In turn, staff see that their reporting contributes to actual improvement, which bolsters their trust. - Joint Commission 2016 13
Safety Structure Interviewers seek to understand: Are risk and safety leaders structurally aligned for collaboration? Across entities? I feel like entering events is a pain in the butt. I do it for the big ones, but otherwise I don t feel like doing it because we never hear what happens anyways. Staff RN How is information consolidated and shared vertically to promote awareness? Horizontally, to promote peer learning? Is there accountability for communication? Responsiveness to issues drives staff trust. We need to Are there structural barriers to information sharing across departments (or work more quickly and with more transparency and share entities) that limit the organization s understanding of its complete risk profile? more than we do. RN Mgr 14
Leadership A leader who is committed to prioritizing and making patient safety visible through every day actions is a critical part of creating a true culture of safety This commitment is just as critical as the time and resources devoted to revenue and financial stability, system integration, and productivity. -Joint Commission Sentinel Event Alert, March 2017 15
Leadership Interviewers seek to understand: Is patient safety as primary focus of the board? If leadership is perceived as driving the mission and tone of the organization s commitment to patient safety at all levels? Across all entities? Are there They differences speak in numbers in leaders and we patient speak about safety patient concerns safety. and I m down those 10 of FTE s staff (e.g. leadership right now. focus THAT s on an external urgent problem. financial, performance measures vs manager staff focus on internal production pressures, staffing issues)? There s an awful lot of suits around here. Why do we keep hiring VPs and not Is there alignment in strategies and practices for promoting a strong safety culture worker across bees? the leadership staff nurse team? Across entities? I wouldn t know a senior leader by name or face. Why can t they come and say hi? staff nurse 16
Example of RAP Findings (Compilation of findings from multiple organizations) Strengths: Organization has an engaged and visionary senior leadership team focused on growth and emergence as the preeminent provider of healthcare in the region Warm, friendly, and long-tenured staff and providers are a significant asset Increasing collaboration with other sister hospitals is creating bridges for shared learning and improvements Challenges/Opportunities: Staffing changes in the setting of increased volume/acuity over last ~5 years has resulted in significantly increased stress on staff, managers Significant gap between impressions of senior leaders and experience of front-line caregivers: dissonance between workload pressures and leadership s dedication to developing safety culture Communication with front-line staff has not kept pace with vision/growth at top levels; Focus on growth perceived as diminished focus on patient safety Pockets of providers demonstrate behavior incongruent with leadership s vision for its safety culture. Addressing behaviors is critical to closing cultural gaps between vision for a Fair and Just and transparent culture, and its reality. 17
SampleRAP Recommendations Thoughtfully and urgently address operational opportunities to increase safety and efficiency Staffing Continue to evaluate current staffing levels against intensity of clinical needs, to balance credentials, experience, expertise against role responsibilities, ensuring work at top of license/expertise Professional Development Resource educators enabling members ability to work at the top of their license Investigate opportunities for cross-training of nurses, educators/preceptors Clinical Processes Continue focus on establishing standardized, evidence-based care Hand off tools for structured communication (IPASS) Escalation and Chain of Command 18
SampleRAP Recommendations Emphasize clear communication and leadership visibility across the organization Evaluate current communication strategies to broaden exposure and clarify important messages Executive WalkRounds and articulate strategic plan for addressing strategy to manage sustained volume Use IHI framework for Improving Joy in Work Patient safety story telling at ALL meetings, at all levels (near miss, good catch, patient/family stories, stopping the line, successful improvement projects) Consider senior leadership adoption of a clinical unit Distinguished from WalkRounds focused on recognition, personal connections, rewarding YOUR area Coordinate visit to each unit X times/month, and on all shifts Hold office hours / host dinner Responsible for special recognition of their unit 19
SampleEnterprise RAP Recommendations Establish clear vision among senior leaders and develop strategy for collaboration with affiliated and new member entities Method & forum for communication regarding merger/growth plans across all entities With executive and clinical leadership With staff Develop strategic approach to assessments of safety culture, capture of safety event data, and methods for addressing shared challenges Culture leadership team across enterprise to review COS data Develop local and family-wide plan for future surveys Develop enterprise-wide architecture for integrating patient safety efforts Establish regular conference with key leaders (PS, CNO, CMO) Share blueprint for Patient Safety and Quality Enterprise Architecture Share best practices for proactive capture of events, and clinician engagement in practice change Identify mechanisms for cross-exposure and education Create family-wide Touchstone Events to gather, engage, motivate entities in shared vision, and accelerate the benefits of enterprise growth 20
Understanding the Past to Inform the Future: Regular comprehensive evaluation of organizations and new entities Insurer s Perspective: Enables deeper and broader understanding of organizational factors affecting patient safety Ensures awareness of key risk issues and development of pathways for support Prioritizes integration and promotes closer alignment and collaboration with new entities as systems expand Promotes successful patient safety efforts 21
The Hospital Perspective Pat Folcarelli, RN, PhD VP Healthcare Quality, BIDMC
Understanding the Past to Inform the Future: Regular comprehensive evaluation of organizations and new entities Patient Safety and Business Development Leader Perspective: Enables proactive evaluation of culture and safety issues Provides structure for ongoing collaboration and clinical integration within and across organizations Assists in planning for and managing acquisition integration to minimize risks, maximize benefits, and advance quality & safety goals as enterprise grows 23
The Hospital Perspective How does a safety leader objectively evaluate structure and leadership style to understand their impact on staff engagement and safety culture? How can organizational intelligence be leveraged to advance Q&S goals? As our hospital family grows, how do we ensure collaboration between hospital safety leaders and business development leaders? 24
Getting to Know You Beth Israel Deaconess Medical Center 672 beds (77 ICU) $230 million research funding 5,000 births 600,000 outpatient visits 50,000 inpatient discharges Level 1 trauma, heliport 55,000 ED visits >6,000 employees 1,200 nurses 1,250 physicians 3 community hospitals Urgent care Specialty clinics Community health centers Extended care facilities
Getting to Know You Beth Israel Deaconess Medical Center 26
Overview of our RAP Findings System Strengths: Growth perceived as bringing resources, expertise and knowledge to BID entities Each entity contributes unique strengths and approaches to developing and maintaining a culture of safety Collaboration and engagement of senior leaders across the system serves as foundation for spread of best practices System Challenges: Meeting heightened patient expectations across all locations Developing similarly robust patient safety infrastructure and strong cultures of safety across all locations Primary Recommendations for the System: Support continued collaboration, resource sharing, and spread of best practices across the system Address primary structural, cultural and leadership opportunities at each entity 27
RAP Recommendations Academic Hospital: Continue efforts to spread the culture of safety message across the community Feed the patient safety data pipeline and leverage the analytic and business resources to fully realize the role as leading innovator in the field of patient safety Primary Care Practices: Develop a role to support ambulatory risk management/patient safety and a physician champion team to accelerate the progress in education and physician engagement in the patient safety program 28
RAP Recommendations (cont.) Community Hospital A: Invest in cultural transformation with emphasis on staff morale and culture of safety. Develop a more robust infrastructure for patient safety. Community Hospital B: Enhance physician engagement in the patient safety structure with attention to driving accountability for the standards of communication and behavior. in essence, stop culture from eating your strategy for lunch! 29
BID Interventions Infrastructure for Collaboration, Shared Learning, and Improvement Developed Leadership Groups System Quality/Safety Integration Steering Group Comprised of CMO/CQO s; Patient Safety Leaders Leveraged perspectives gleaned from front lines to minimize gaps between leadership & staff goals & concerns Quality and Safety Leadership Committee in Primary Care group Ambulatory Patient Safety Office New Patient Safety/Risk Management Role and CQO role for the primary care network Developed Learning Opportunities from National and Local Leaders Expert Advice: Group Trip to MedStar Leveraged membership in CRICO s AMC PSO 30
BID Interventions Infrastructure for Collaboration, Shared Learning, and Improvement Developed infrastructure for BID-wide Patient safety and Performance Improvement to maximize peer learning and collaboration Created memberships on each others Board Sub Committees for Quality and Safety Consolidated Patient Safety Reporting System where possible Developed shared patient safety curriculum for physicians, experimenting with a spaced learning methodology Identified collaborative performance improvement projects (i.e. peri-procedural anticoagulation management) 31
Insurer s Perspective: Aligning Patient Safety Work Maggie Janes, RN, JD Sr. Program Director, CRICO Patient Safety Services
Understanding the Past to Inform the Future: Regular comprehensive evaluation of organizations and new entities CRICO: Enables deeper and broader understanding of organizational factors affecting patient safety Ensures awareness of key risk issues and development of pathways for support Prioritizes integration and promotes closer alignment and collaboration with new entities as systems expand Promotes successful patient safety efforts Patient safety and business development leaders: Enables proactive evaluation of culture and safety issues Provides structure for ongoing collaboration and clinical integration within and across organizations Assists in planning for and managing acquisition integration to minimize risks, maximize benefits, and advance quality & safety goals as enterprise grows 33
The Insurer Perspective Aligning Patient Safety Opportunities How can we increase collaboration between insured and insurer? Where are there opportunities to leverage relationships to further patient safety work? How can we support our insured to integrate learnings into patient safety work? 34
Strategic Partnership between CRICO and its insured Collaboration DATA Data Analytics Risk Assessments GOVERNANCE CRICO Board and Committees ORGANIZATION CONVENER AMC PSO Chiefs Meetings Task Forces INSURANCE Claims Finance Underwriting CRICO CAPITAL FUNDING RFAs CRICO Directed
External Assessments - Take-aways It is a two way street It takes time Seize on opportunities Measure change over time 36
37 Visit our website for resources! www.rmf.harvard.edu/assessments
Questions & Discussion