As part of its approach to instilling a comprehensive patient safety culture through continuing education, MedStar Health, Columbia, Md., has built an extensive internal simulation program over the past two decades with three large simulation labs, a mobile simulation center and vans that bring simulation equipment into its hospital and outpatient environments.
Known as MedStar Health Simulation Training and Education Lab, or SiTEL, and part of the MedStar Institute for Innovation, the team at this facility creates and delivers simulations, interactive online training and continuing professional education products used across the healthcare system and by organizations in more than 40 states.
In that range of settings, the clinician simulates a variety of emergency scenarios to train personnel in team communication and to verify that front-line workers know what they need to do, how and in what order. For example, MedStar Health simulates the first five minutes after a patient goes into cardiac arrest, with a focus on ensuring muscle memory and a second-nature performance of all the key resuscitation steps.
“Simulation allows us to ensure that all the key steps get done correctly, without any impact on actual patients,” says Rollin “Terry” Fairbanks, MD, senior vice president and chief quality and safety officer at MedStar Health and executive director of MedStar Institute for Quality & Safety. “Conducting simulations in the actual patient care environment allows us to optimize sometimes subtle process issues; such as, if someone calls to the service associate and asks for equipment, we learn whether the service associate knows where to find the equipment.”
MedStar Health also trains around childbirth-related emergencies using these techniques and facilities. “This makes sure the team acts in the highest competencies when things are quickly changing, and there needs to be a good team environment,” he says. “One thing we’ll do is, we will have someone artificially introduce a simulated error into the care they’re doing, and we train them in how to respond to that error.” The mantra of MedStar Health SiTEL is, “If you put patients first, don’t try first on patients.”
Establishing and continuously improving upon safety culture is a key vital sign for any healthcare organization, and continuing education plays a critical role in the success of such efforts, both at the 30,000-foot level and in building specific competencies.
Needed expertise includes root cause analysis, human factors engineering, systems and individual approaches to error, and openness to report incidents—and the use of an incident reporting system to do so.
Rigorous evaluations of whether that continuing education is becoming successfully infused at the individual, department and systemwide level is essential to visibility into whether a true safety culture has taken root.
Investment in continuing education pays off exponentially in regard to safety outcomes because safety is a key driver of outcomes in all other domains, says Steve Kreiser, partner, strategic consulting, at Press Ganey, who heads up the safety and liability team and is an ACHE faculty member. “If leaders are focused on keeping patients and employees safe, and keeping the organization safe from harm to their reputation, and harm financially, what you’re doing as a leader is twofold,” he says. “You’re identifying a system problem that needs to be fixed, so everything works better. But you’re also engaging your front line. ... They see the positive outcomes of the leader focusing on addressing problems and issues, which builds trust and makes them feel their voice matters. They get energized when they see problems being corrected.”
Leaders must be aware of the ever-changing science behind safety, and that’s the crux of continuing education, says Steve Mrozowski, FACHE, CPPS, vice president, external peer review and patient safety, Chartis Clinical Quality Solutions. A corollary to that is “recognizing that the old ways of punishing people for making mistakes,” are not effective or constructive, he says. “There are almost always systems contributors, and we need to advance into a fair and just culture.”
Mid-level leaders in quality and safety need to have much more intimate exposure to the “nitty-gritty nuance behind safety culture,” Mrozowski says. “There are always new publications out about that,” he says. “All too often, quality and safety, while a noble effort, are just a few of the things that keep a leader awake at night. The issue is prioritization: How do they keep it on the front burner?”
Mrozowski says education programs need to be constructed comprehensively and at two levels: one for leadership and a second for bedside caregivers. “Whether it’s a nurse or someone who works in food service, it’s incumbent on both leaders and bedside caregivers to have some foundational knowledge of safety science,” he says. “We’ve created safety bundles of expected behaviors for leaders and caregivers. From a prioritization perspective, it’s mandatory for that to work well. And it should be ongoing.”
Safety involves people, teams, processes and technology, and safety design must first anticipate risks and hazards, then ensure that front-line workers are optimally prepared for their roles, Fairbanks says. Continuing education ensures that front-line workers “understand basic safety strategies,” he says.
Tying safety outcomes to educational programs, however, is a difficult task, says Mrozowski, but it’s not impossible.
Typical safety results in reduction of patient harm via a metric such as a serious safety event rate (rolling one-year average of serious safety events for every 10,000 adjusted patient days). Organizations that implement high reliability principles and tools have often demonstrated reductions in serious safety event rates of up to 80% within the first few years of their HRO journey.
MedStar Health has trained all 32,000 associates in high reliability, including nurses, physicians and other caregivers. “Healthcare is so complex,” says Fairbanks. “Empowering our people taking care of patients to recognize, proactively, when there’s a risk or hazard, and ensuring that our operational leaders know basic safety mitigation strategies, is the way to ensure we learn about the hazards before a patient can be harmed.”
MedStar Health uses clinical practice guidelines from internal and external experts to determine best practices and uses leadership communications to ensure everyone knows them, Fairbanks says. For some of the most critical knowledge areas, the healthcare system partners with an e-learning system built on cognitive science principles that fosters rapid learning and long-term retention.
“This system has been a game-changer for us,” he says. “It has a unique approach, which is non-encumbering to those who already have the knowledge, but it detects and corrects the small group who have confidently held misinformation, an issue that often causes barriers in healthcare improvement efforts. Traditional training programs miss that group of people. We call it knowledge engineering.”
Children’s Wisconsin, Milwaukee, has adopted national standards over the past decade around core elements of safety training for leaders and front-line staff, says Chris Spahr, MD, chief quality and safety officer. That’s led to applying a just-culture approach, “ensuring that leaders and front-line staff are approaching safety issues, errors and events within their day-to-day work, with a critical eye for identifying where system issues are. And then having individual accountability for our performance, depending on the issue at hand,” he says.
The underlying theme has been to create an environment of psychological safety through the training and education that Children’s Wisconsin has rolled out, with a focus on promoting a willingness to speak up and report errors when they occur. The reporting of safety issues by front-line staff is critical to identifying the system improvements necessary to provide the safest care, Spahr says.
Scott Turner, Children’s Wisconsin president and COO, and an ACHE Member, says creation of the organization’s “At Our Best” culture has been its North Star, providing a common language and set of concepts that align every provider and employee to the organization’s values, guiding behavior in day-to-day work. Children’s Wisconsin has implemented a provider and staff culture engagement survey that Turner calls probably the single most significant input in terms of driving efforts and methods of engagement.
The hospital also instituted monthly rounds with a dedicated team of vice presidents who share their reactions in real time with the departments that host them, Turner says. “It’s like a box of chocolates from ‘Forrest Gump’: you never know what you’re going to get,” he says. “We react in real time. How you choose to respond is a real element of our culture. We do targeted follow-up as needed.”
Since it initiated its overall safety program 10 years ago, of which leader and broader organizational safety training was a part, Children’s Wisconsin has seen year over year increases in its culture of safety survey results, according to Spahr.
“This is an organizationwide survey of our staff and providers who provide care,” he says. “Example areas of survey assessment include organizational commitment to safety, communication of critical safety information, teamwork and effectiveness of error remediation processes.”
Root Cause Analysis and Human Factors Engineering
The most significant challenge Press Ganey tends to notice with respect to root cause analysis and human factors engineering is that leaders whose work doesn’t focus mostly on safety and quality tend to think those goals are primarily the responsibility of people in those “areas,” Kreiser says. However, senior leaders should feel an obligation to roll up their sleeves, too.“They need to get into the hard work of identifying errors and the causes of those errors,” he says. “When they identify root causes, they need to identify root solutions, and corrective actions, and make sure they’re sustained for the long term. Safety and quality don’t have the manpower and resources to do so. Operational leaders have that capability.”
At Chartis, the concept of root cause analysis has morphed in recent years from simply figuring out why and how a particular incident happened to charging leaders with determining how things go well and putting in place a culture of proactive learning, Mrozowski says. It’s digging deep into the how and why behind safety issues, he adds.
“From an educational standpoint, it’s about recognizing that this is not just the quality department or the safety department at the hospital, but human resources, the medical staff leadership, all of those [departments] need to be aligned,” Mrozowski says. “That exposure at conferences and through continuing education helps to bridge those gaps for organizational leaders.”
Human factors engineering—the design of highly reliable systems that ensure people, process and technology work seamlessly together—is an entire professional training track provided at centers of excellence around the country, Kreiser says.
“If organizations want to dive deeply into that topic, they have to tap recognized experts,” he says. “We’ve worked with a lot of healthcare organizations who have hired human factors engineers in their process improvement or safety and quality departments. They can see gaps in technology, equipment and process integration with people.”
Such engineers can be great resources in coming up with effective corrective actions, but senior leadership needs to be involved to ensure that what is needed to implement effective corrective actions are in the budget, Kreiser says. If they’re not, “we didn’t identify a true root solution,” he says.
MedStar Health also has focused on human factors engineering, a discipline that has been key to safety improvements in other high-risk, complex industries, such as aviation and nuclear power. Within the healthcare context, this minimizes the need for training to some degree because optimal design of computer systems and medical devices makes them intuitive—and thus easier to do the right thing and harder to do the wrong thing, Fairbanks says.
The organization has a large research-funded human factors safety science group that has helped infuse this type of knowledge throughout the health system. “The nice thing about healthcare, compared to many, many professions, is that roles are highly standardized,” he says. “Nursing school, medical school, other healthcare professional training programs have consistent curriculum and training around the country. Board certification is consistent. But there are things about medicine that evolve. ... We take very seriously keeping practitioners up-to-date.”
Children’s Wisconsin has approached training for core safety concepts like root cause analysis and human factors engineering from the standpoint that not every employee has to become an expert, Spahr says. “We focus more on teaching how the principles we apply through a root cause analysis can be used by a local leader or unit and can be applied in their day-to-day work.”
Approaches to Error
Building both systems and individual approaches to error starts with a common cause analysis that determines what types of errors are most frequent, Kreiser says. Look at the last 20 or 30 events of harm and determine what human and system failures are leading to events, lining them up like proverbial pieces of Swiss cheese to see where the holes show up most often.“Every layer represents a human error or a system problem,” he says. “People didn’t have the knowledge or skills, or they’re not paying attention because they’re rushing, distracted or interrupted. Or they’re not communicating, or not using critical thinking or don’t have good situational analysis. Or you don’t have a culture where people are comfortable speaking up. Then there’s compliance errors—are people choosing not to comply? ... Maybe they don’t see the need to comply, don’t have leaders reinforcing expectations, don’t have awareness of potential risk factors, or don’t see other people complying.”
The first step in training around approaches to error is delving into the data to understand why. Then an organization’s top leaders must deliver evidence-based training in a classroom, for two to four hours at a stretch, to groups of 25 to 30 employees across different disciplines, Kreiser says. Ideally, physicians and staff would attend together, and top leaders deliver the training. Training in these kinds of smaller groups, led by leaders, creates the conditions for better discussion, adult learning and trust, he says.
“Leaders need to facilitate this kind of training. Not just the quality and safety crowd, or the folks who work in organizational learning,” he says. “Those folks are well-qualified, but if I see the ICU manager, or the pharmacy director, or chief nursing officer, or chief medical officer, or CEO leading me through evidence-based safety training directly related to our data, I’m all in. I take it to heart. Especially when I hear the examples of the science of how and why we make errors, and how we’re harming patients.”
Efforts to digitize continuing education and gamify, shorten and condense it can work in certain situations, he adds, “but there’s no substitute for human interactions, led by people I work with and for. That’s the secret sauce.”
Building a Reporting Culture
Continuing education is also central to building a “fair and just” reporting culture with a sense of psychological safety in stepping forward to acknowledge safety-related issues and incidents, Kreiser says. “They have to know if they make an unintended error, they’re not going to be punished,” he says. “We want to coach and counsel people not to make those errors in the future.” However, he adds, “if they choose to disregard safety-related policies and procedures recklessly, that demands a fair consequence.”Building trust and consistency in how leaders respond can improve error and event reporting, especially in conjunction with an easy-to-use electronic system to input and then aggregate information, Kreiser says. “You need good data analysis on where individual errors are occurring, and what are the system contributors,” he says. “Rich data can give us insights to identify corrections and system improvements to make.”
Leaders also must understand how to deliver feedback constructively, in a way that will build a culture of open reporting and lead to solutions, Mrozowski says. “All too often, we hear people don’t want to speak up because they don’t know what happens to their report,” he says. “Investing in pure leadership skills in delivering feedback bleeds over into this space, as well.”
Useful incident reporting systems are also foundational, Mrozowski says. One organization for which he formerly worked created a department dedicated to patient safety and harm reduction and during its first year saw about a 295% increase in safety reports. “By redirecting the focus, and a leadership desire for that kind of transparency and learning, we were able to get a threefold increase in the number of people willing to speak up,” he says.
MedStar Health teaches its leaders competencies around psychological safety, such as specific approaches and words that will create an environment that ensures associates feel safe elevating risks they see, Fairbanks says. “We also train our safety leaders in how to conduct effective event reviews, to ensure that we’re learning about all of the factors that might have led to an event, and to ensure that the mitigations put in place are both effective and sustainable,” he says. And then there are the aforementioned simulation trainings.
From safety culture surveys, Children’s Wisconsin learned that for the most part, front-line workers were willing to speak up about incidents, but they weren’t necessarily seeing communication coming back to them to close the loop on how issues were addressed to improve the care, Spahr says. This is the current area of focus for the organization’s safety program and training.
Children’s Wisconsin has trained leaders “to effectively utilize the information the front-line staff is telling them through safety event reports, to address issues as they are able and escalate as necessary to higher levels,” he says. “And most importantly, Children’s has developed better processes to share back with teams that have reported the safety events what they’re doing about them … how their reporting has led to active safety efforts that we’ve been able to prioritize.”
The hospital’s “just culture” emphasis has moved the needle from who’s at fault when an incident occurs, to a focus on what happened, with a formal analysis about both system process issues and individual performance issues, Spahr says.
“The idea is not a blaming culture—but it’s certainly not blame-free, either,” he says. “We go through a thoughtful process for analyzing and reviewing each event, ensuring we aren’t pointing the finger at someone—but understanding why a mistake happened, what was going on in the environment and how the system was designed. That is one of the core components of training for leaders throughout our entire organization. And it’s not an ‘opt-in.’”
Evaluation of Continuing Education Impact
To know whether your continuing education programs are making their desired impact requires leading, real-time and lagging measures of effectiveness, Kreiser says. Leading measures can take the form of surveys that cover perceptions about safety issues and the organization’s commitment to correcting them.“If I feel it’s safe for me to report, speak up and stop the line, six months from now, when I’m in a situation where I see the need to stop, speak up and report on an error, that can stop something from tumbling out of control. That can result in a great catch, saving-the-day moment—that’s one measure,” he says.
Real-time evaluation consists of process measures that revolve around how an organization is training people in the science of safety and measuring human error, Kreiser says. Lagging indicators of safety education success will always be the improvements in safety outcomes such as reductions in patient harm events, employee injuries, infections, pressure injuries and falls.
MedStar Health drives improvement through deep leadership engagement, Fairbanks says. The organization measures outcomes and holds itself accountable, with monthly reports to the leadership team and quarterly reports to the board of directors quality committee. For example, these reports include the organizational key quality performance indicators, such as catheter-associated infections, and the organization holds itself accountable for continuing to reduce those, he says.
Children’s Wisconsin continues to evaluate the performance of its underlying systems, Turner says, ranging from the systemwide harm index to the openness of its reporting culture to whether the shift toward full-circle reporting continues to occur. Spahr says that, ultimately, education, training and system building are all pointing toward safer clinical outcomes.
“We want to build a culture and system that impacts the kids and families we serve,” he says. “We do report transparently, both internally through our board as well as our network [of children’s providers]. We’re not going to compete on safety [with other providers], on a culture or outcomes perspective. We’re all in this together. That’s been so foundational to our work. We don’t want to be doing this alone.”
When Chartis works with organizations to see how they evaluate educational outcomes around safety, they tend to start with, did we eliminate or reduce instances of harm, Mrozowski says. But delving into the component pieces of building a patient safety culture, for example, an evaluation of education around human factors engineering might ask, “Did we actually evaluate how humans are interfacing with their environment?”
One example of a factor to consider in that regard is the geography of work process space, Mrozowski says. When it comes to medication administration, if the medication room isn’t anywhere near the supply room that contains syringes and needles, that requires a redesign, and “you can do pre- and post-intervention assessment,” he says.
Evaluating the impact of education on overall patient safety could be done with an annual or biannual safety culture survey, Mrozowski says. “It addresses a lot of the stuff around openness to reporting and event reporting,” he says. “And also, teamwork. Do I see solutions happening because of escalating concerns? The results of surveys have to cascade and be visible to the front line, but also to the board and C-suite. So we’re framing elements of the education rather than just a rinse-and-repeat of what we’ve done before.”
Mrozowski believes education around safety competencies needs to be expanded and underscored in the healthcare field. “There can always be more, but organizations have to invest,” he says. “The return on investment is always there.”
Ed Finkel is a freelance writer based in Chicago.