If It Ain't Broke, Fix It

Molly Rowe, for HealthLeaders Magazine , December 13, 2007
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Gary Kaplan spends a lot of time looking at clinical processes. On any given day, Kaplan visits units, talks to staff, looks for signs of process breakdown--typical responsibilities for a quality department manager.

But Kaplan is not in the quality department. He is Virginia Mason Medical Center's chief executive officer, and he is one of a handful of CEOs whose jobs as hospital administrators have become intertwined with the roles of quality director, risk manager and patient safety officer. "The days when we spent most of our time hunkered down in our offices with spreadsheets are long gone," Kaplan says.

Although hospital leaders haven't always been involved in the ins and outs of clinical processes, leaders like Kaplan have found that flawed processes are often the root of major medical errors. Rather than evaluating process after a serious event occurs, more leaders are immersing themselves in the details now.

Kaplan, a physician, may have an advantage over other executives when it comes to understanding clinical workings, but as more regulators--and consumers--scrutinize a hospital's performance in quality and patient safety, senior leaders will need to take a more active role in process design and improvement, he says (see Board on the Floor, for more on Virginia Mason's quality efforts).

"Unless the senior leaders in an organization are deeply engaged in achieving the organization's vision, it won't happen," Kaplan says. "Unless we lower the water level, unless we see what is, we'll never be able to make the kinds of breakthrough improvement that we want."

Eliminating shortcuts

Workarounds are a healthcare paradox. Healthcare leaders, like managers in any industry, want employees to be proactive about finding ways to work faster and more efficiently. But in healthcare, workarounds are often early evidence of bigger process issues that can lead to adverse events and hospital liability.

And workarounds are everywhere. According to a nationwide study by VitalSmarts, a Provo, UT-based consulting research firm, 84 percent of physicians and 62 percent of nurses and other clinical-care providers see their coworkers take shortcuts that could be dangerous to patients. "Workers are so consumed with getting their tasks done that they don't see workarounds," says Tami Merryman, chief quality officer at the University of Pittsburgh Medical Center.

That's why UPMC created an independent set of eyes: The Center of Quality Improvement and Innovation. Led by Merryman, the center works with operational leaders at UPMC's 19 hospitals to improve processes before they break. Anyone who sees a potential process problem or workaround can call the center for help. The center is manned by process experts, trained in lean manufacturing, Toyota's production system, and patient flow principles. Working with senior leadership and frontline staff, the center looks at a situation, investigates the processes around it, and offers process improvements.

Until a few years ago, UPMC approached quality the old-fashioned way: A quality department focused on measurement and outcomes and following up when things went wrong. Then, in 2002, Pennsylvania passed the Medical Care Availability and Reduction of Error Act, mandating, among other things, that hospitals immediately report serious events to patients and families. "This rule immediately made senior leaders across the state say, 'Holy cow,'" Merryman says.

UPMC's senior leadership shifted its focus from reacting when processes fail to preventing process failures all together. This doesn't mean Merryman and her team set out to identify and eliminate every workaround; instead, they prioritize and focus on the ones that may affect efficiency or patient safety. For example, although hand delivery isn't the most efficient way to get medications to patients, many hospitals cannot afford alternative, high-tech delivery methods. In this case, Merryman says, the hand-delivery workaround is one to ignore. But if a bed lock is broken and staff has pushed the bed against a wall to keep the patient safe, this is a workaround to fix immediately.

"There are levels of workarounds just like there are levels of everything else. If you don't pick and choose ones that are important to your mission, you'll easily get burned out," Merryman says.

Process hotline

Virginia Mason uses a hotline-type system to identify workarounds and process breakdowns at the 285-staffed-bed hospital. When an employee sees a defect, error or potentially dangerous workaround, she calls a patient safety alert--a telephone and online reporting system that immediately notifies a patient safety specialist and the senior executive responsible for the process or area. The leader will respond and begin the process of identifying the root cause of the patient safety alert and what needs to be done to mistake-proof the process.

Employees are encouraged to use the hotline any time, day or night, if there's even a question of a possible patient safety issue, Kaplan says. "Every staff member can and should be a quality and safety inspector, but [he or she] will only do that if that work is supported 24-7 by the executive leadership," he says.

Since implementing the program in 2002, Virginia Mason has had more than 8,000 patient safety alerts, and that number is growing. There have been approximately 2,000 patient safety alerts between January and September of this year.


Virginia Mason's executive leaders also participate in daily walk rounds. They spend time on the floors in the hospital, clinics and all care delivery areas, working extensively with folks on quality and patient safety. During walk rounds, staff members are asked the following:

  • Has a patient been harmed over the past two weeks that you know of in your work area?
  • Has a near miss occurred in your work area?
  • Are there ideas you have that could improve patient safety?

If a process breakdown is uncovered, the senior leader heads an investigation into what went wrong by conducting a root-cause analysis.

"We commit to evaluating, investigating, and cycling back to give them feedback on what we've done to help prevent that error or defect. We ask them in return to share the visit with at least two other team members who weren't present," Kaplan says.

The senior leader then determines if a system or a person needs to be stopped or removed from the process while the issue is evaluated in order to ensure patient safety. This means nurses, physicians and staff at any level may be removed from a process or unit until the patient safety team confirms that patient care is not compromised.

Assigning responsibility is an important element for process improvement, Kaplan says. "A blame-free culture should not be about lack of accountability or unwillingness to address performance concerns. It's about a culture where people feel safe to report, but people also understand there will be appropriate accountability."

Molly Rowe is leadership editor with HealthLeaders magazine. She can be reached at mrowe@healthleadersmedia.com

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