Quality and Safety Uninterrupted

The commitment, empathy and heroism of front-line healthcare workers during the coronavirus pandemic have been felt by every American. Less public, but inspiring nonetheless, have been the skill and determination of healthcare professionals working quietly behind the scenes amid the crisis—often in the face of staffing, space, revenue and supply shortages—to uphold quality and safety and keep their organizations on the pre-COVID-19 track to high reliability. 

“We’ve seen firsthand that organizations have stepped up during a time of unprecedented uncertainty,” observes Mark G. Pelletier, RN, COO for Accreditation and Certification Operations for The Joint Commission. “At a time like this, it’s essential that the commitment to quality and safety does not get lost. Considering the amount of information coming at them, I’ve been impressed with how organizations have prepared and responded.” 

Crisis environments of stretched resources, many sick patients and compassion fatigue have not dimmed healthcare workers’ allegiance to zero harm. 

A Time for Innovation
In fact, Richard Brant, MD, CPHQ, medical director for quality and patient safety, Pediatric Hospital Medicine at West Virginia University Medicine Children’s in Morgantown, believes the pandemic has created an environment conducive to the acceleration of innovation on the quality and safety fronts. 

“There is evidence this crisis can promote growth and improvement in all quality domains,” Brant wrote in an article for the Children’s Hospital Association. Citing telemedicine, leadership rounding, peer support, safety huddles and sharing of innovation across health systems as key areas of improvement, Brant believes the heightened activity catalyzed by the pandemic ultimately will help organizations move along the journey to zero harm. 

Of course, even in the best of times, zero harm is a voyage. A commentary regarding data from two hospitals in the American Journal of Infection Control, for example, predicted increases in hospital-acquired infections during the pandemic, noting, among other things, the increased infection-risk potential of innovative care configurations such as the personal protective equipment-conserving batching of tasks by nurses, which can contribute to fatigue and lead to substandard practice.  

However, another AJIC study showed that infection-prevention initiatives by healthcare organizations during the pandemic helped to reduce rates of HAIs involving multidrug resistant organisms, with the pandemic serving as a stark reminder of the importance of basic measures, including hand-washing, equipment cleaning and PPE.

An initiative of the South Carolina Hospital Association and the South Carolina Department of Health & Environmental Control offers further evidence of safety gains in extraordinary times. In September 2020, 59 South Carolina hospitals received certified awards for zero harm for a combined total of 165,997 days free from central line-associated bloodstream infections and 21,552 surgical procedures with no medically caused harm during the pandemic. (Hospitals were required to provide data, which was independently verified, demonstrating elimination or avoidance of specific HAIs over an extended period.)

Engage to See Results
Pelletier points to the best practice, already established in many organizations, of regular huddles with front-line staff as a critical mechanism for executives and their teams to understand staff needs and align resources appropriately (see Huddling on Huddles: Five questions to ask on safety huddles for more on safety huddles). He advises leaders to hold huddles daily and with each shift, and to involve every front-line worker. “It’s the housekeeper or food service worker or radiology technician who may see something that’s not right,” he says. “That person should feel comfortable speaking up.” 

When organizations are struggling with quality and safety, the struggles virtually always can be traced to disengagement at the top, Pelletier notes. Almost without exception, responses to survey questions regarding interactions with senior leaders in quality- and safety-challenged organizations reveal executives who are disconnected from the efforts of front-line staff; hence, the importance of frequent rounds and huddles rooted in a willingness to listen and follow through. 

Healthcare Executive spoke with three leaders—two at major academic medical centers, one at a community hospital of a large health system—to hear how they’re working to sustain quality and safety momentum in demanding times.

UChicago Medicine: A Get-It-Done Mindset
Before the pandemic, “there was never any question that the primary role of clinical and nonclinical senior leadership was to support the work of our bedside clinicians and front-line staff,” says nephrologist Tipu Puri, MD, PhD, associate CMO for clinical operations at UChicago Medicine, which includes the flagship University of Chicago Medical Center. Puri is an ACHE Member.

This underpinning of leadership-clinician cohesiveness, forged over years, carried over organically when the pandemic hit. “Part of the reason we’ve been able to keep safety and quality at the core of our response to the pandemic is that mix of clinical and nonclinical leadership working together to meet the needs of patients and providers,” he says. 

The health system’s existing hospital incident command system for emergency management planning, response and recovery, activated at the onset of the pandemic, provides a framework for communication from the front line to help leaders respond quickly to clinicians’ needs for supplies, equipment and staffing. 

Another safety communication vehicle is a robust event reporting system created as an extension of a just culture. “Fortunately, we’ve created a situation where clinicians are not shy about letting us know when something isn’t working,” Puri says.

The biggest challenge has been managing the daily flood of new information about coronavirus treatment and prevention. “What we tell people one day might change the next. Acknowledging that we’re in an evolving situation in which we’re all learning together has helped build trust and develop our response and practices,” he says. The heightened pace has fostered a get-it-done attitude that has allowed teams to pivot quickly. 

The move toward telehealth visits in the ambulatory setting to control spread of the coronavirus has made it more challenging to monitor blood pressure, A1C and other measures, which may show dips in quality performance, “but it’s not because we’re not continuing to work on these measures,” says Puri. The health system plans to tease out the impact of pandemic-related factors on quality measures versus system-related factors operating independently of the pandemic that need continued attention. 

Quality and safety in the pandemic universe are a natural continuation of practices the organization had been following every day, Puri notes. Quality committee meetings and reviews of dashboards and metrics proceed as before the pandemic. “Are our goals and targets for 2021 as aggressive as they might have been in a nonpandemic world? Perhaps not,” says Puri. “But we’re still working to reduce CLABSI and other measures, and we believe we can make progress. These things have become second nature, which is really what you want when you talk about a safety culture,” he says. 

Mission Hospital McDowell: Keeping Zero Harm Center Stage
Mission Hospital McDowell, Marion, N.C., benefited from its parent organizations’ supply chain strengths and rigorous clinical support in setting up screening protocols for patients, employees and visitors early in the pandemic. The hospital is part of Mission Health, the sixth largest health system in North Carolina, and HCA Healthcare, a for-profit provider that acquired Mission Health in 2019.

Still, despite that extensive clinical and logistical assistance, with the onset of the crisis, local community partnerships became vital for the 30-bed facility serving a population of 46,000 in McDowell County. As a smaller provider, the hospital has an emergency preparedness plan, and, using the Incident Command process, participates in the unified command of the McDowell County Emergency Operations Center, which brings together key stakeholders across McDowell County for planning and response.  The emergency operations center serving McDowell County filled that need for a planning and response partner. 

The emergency services agency essentially functions as an extension of hospital CEO Carol Wolfenbarger, FACHE, and her team, meeting daily to discuss community infection rates, anticipated hospitalizations, bed capacity and other issues. It maintains a COVID-19 dashboard, assisted with the staging of emergency medical tents on the hospital campus in advance preparation for a potential surge in COVID-19 cases, and spearheaded a community awareness and education campaign in collaboration with the hospital to increase compliance with mask-wearing, hand-washing and social distancing.

Mission Hospital McDowell began to focus formally on high reliability and zero harm relatively recently, Wolfenbarger notes, but the staff has demonstrated a powerful commitment to the journey in its attention to quality and safety during the pandemic. Much of the care for COVID-19 patients takes place in the hospital’s new 25-bed universal care unit, designed for intensive care as well as medical-surgical patients. 

The hospital is recruiting additional nurses and has made provisions for changing the model of care to accommodate heightened staffing needs in the event of a surge, notes Wolfenbarger. The top-of-practice model would pair ICU and medical-surgical nurses with nurses who do not necessarily have specialized training but are well-qualified to provide nursing care.  
With the pandemic still raging and the entire staff on overdrive, “we’ve been distracted from the larger conversations and education we need to have around high reliability and zero harm, and yet we’ve had constant opportunities to put the principles into practice,” she says.

Encouraging staff to feel comfortable sharing safety and quality concerns in huddles and hardwiring safety discussions into the first items on the agenda for every staff and physician meeting have been among the hospital’s first steps. So has the focus on assessing the culture of safety across the HCA Enterprise using an Agency for Healthcare Research and Quality tool as well as performing additional surveys of physicians and employees to garner feedback on the hospital’s quality and safety performance during the pandemic. “We’re keeping high reliability in front of us by making safety a part of every huddle about what is happening in the units each day,” she says.  
  
Wolfenbarger learned firsthand when Mission Hospital McDowell opened a new facility in 2018 that safety planning and messages can seemingly disappear into thin air during periods of intense change. “I suspect the same could happen post COVID-19,” she says. “We’ll need to be intentional about how we help our team recover as they come out of this crisis.”

Vanderbilt Health: We’re in This Together
Twelve months ago, in early March 2020, Vanderbilt University Medical Center was thrown into the cyclone of COVID-19 days after a tornado swept through Nashville, Tenn., hitting one of the institution’s supply chain warehouses. Jenny Slayton, RN, senior vice president of quality, safety and risk prevention for Vanderbilt Health, uses the word “steadfast” in describing the system’s approach to quality and safety as it dealt with the dual crises. 

“Our focus was and continues to be keeping a consistent presence on the clinical units,” she says, referring to the system’s corps of quality and safety leaders as well as the executive team, including Deputy CEO and Chief Health System Officer Wright Pinson, MD. These leaders have heightened their presence, sharing responsibility at times for documentation of indicators to lighten the load for bedside clinicians. 

“There may have been a pause in the first month as we were getting our sea legs, but even with surges in COVID-19 cases, we’ve continued to pursue our quality and safety goals,” Slayton says. 

The undeniable and, Slayton believes, underappreciated stress, fatigue and psychological vulnerability among healthcare workers that comes with the demands of caring for patients during a pandemic is viewed by leadership as a call for connection. “We’re being pulled in a thousand directions, but we will bump that meeting if it means going to a unit,” she says. 
Other initiatives that have helped the organization keep quality and safety front and center during the pandemic include:

• Activation of a daily executive leadership COVID-19 command center to discuss the current census across the system and support predictive analytics regarding bed capacity and other concerns. The daily meetings remove siloes and create a “one Vanderbilt” spirit across locations, Slayton says. 
• Development of new clinical decision support tools to track use of HAI reduction strategies, with unit-specific dashboards.
• A reinvigorated hand hygiene program that returned compliance to 97% from 88%, driven by a study that pinpointed glitches in the supply chain. “The importance of reminding people about the basics was a lesson we quickly learned with COVID-19.”
• FLUla-2-Uza, a safety initiative spinoff of the medical center’s annual Flulapalooza employee mass vaccination event. The initiative brought flu shots to staff in multiple locations and served as a test run for the COVID-19 vaccine rollout. 
• A system of colored dots to smooth wrinkles in the prioritization of COVID-19 test samples based on location, patient status and other factors. “Sometimes the simplest low-tech solutions are the most effective,” Slayton says.
• A weekly COVID-19 newsletter and virtual town halls open to all employees and staff. The hallmark of these efforts, “honesty and transparency—saying we don’t know when we don’t know—has allowed us to build trust and support,” she notes.  

COVID-19 has daunted and stretched care teams and healthcare organizations in ways they never could have imagined, but the strength and imagination with which systems and individuals have responded bode well for the future of high reliability in the healthcare field. 

Susan Birk is a Chicago-based freelance writer specializing in healthcare.