Main Line Health: Creating a Reliable Culture of Safety
By Jack Lynch, President and CEO
For most people, hospitals are beacons of hope and vital resources in the communities they serve. While the treatments provided may not always achieve desired outcomes, patients and their families expect – assume – that the staff will at least “do no harm.” Those in the health care community know, however, that the complexities of modern health care have not always guaranteed the safety of patients.
At Main Line Health—a not-for-profit health system serving portions of Philadelphia and its western suburbs—we impact the lives of thousands of patients every day. And we can never take their trust for granted.
According to the Centers for Disease Control and Prevention (CDC), an estimated 1.7 million people develop hospital-acquired infections each year, resulting in approximately 90,000 deaths. One in every five Americans report that they or a family member have experienced a medical error of some kind. This is unacceptable. And this is the reason why we developed our Culture of Safety at Main Line Health.
We began to formally evaluate our safety culture and identify risks for preventable harm in 2009. We determined that-- while we had many good practices in place--we needed to commit to high reliability practices across Main Line Health to ensure that every patient had the same opportunity to experience a superior outcome. Foundational to our quest for zero preventable harm, was the creation of our error prevention tools. Two tactics in particular proved most effective in diffusing the power gradient, creating an environment where all staff could raise a safety concern. By using ARCC (Ask a Question, Make a Request, Voice a Concern, Use Chain of Command) and Stop the Line (used to stop any action and reassess the situation so that everyone is on the same page), each and every one of our 10,000 employees is empowered to “speak up for safety.” Since launching our formal safety initiative in 2010, this intensive focus has become deeply embedded in our daily practice and is literally saving lives. In 2014 alone, we had a 55% reduction in incidents of preventable harm.
Given today’s uncertain times in health care, the entire industry is focused on breaking what is referred to as the “normalization of deviance”—the routine acceptance of practices that should be unacceptable. It’s a problem that affects other industries, too. A well-known example of this concept is the Challenger disaster of 1986. After the horrific space shuttle incident, investigators found that the temperature on the morning of the launch was well below the known safe limit. The parts of the shuttle that failed and caused the explosion were not able to function below 59 degrees. Unfortunately, it was discovered that NASA successfully launched the shuttle at lower and lower temperatures over time until eventually, on the morning of the Challenger’s launch, the temperature on the launch pad was 29 degrees. The “norm” became accepting dangerously low temperatures. Some at NASA were concerned. Maybe this event wouldn’t be in today’s history books if just one person had spoken up.
We are all human—mistakes are inevitable when we work alone. But this is why we work together. The definition of culture is “the set of shared attitudes, values, goals and practices that characterizes an institution or organization.” At Main Line Health, our Culture of Safety depends on the support, encouragement and reliability of the entire Main Line Health family. Every day, we have an opportunity to speak up; to help our coworkers; to ensure we are not deviating from delivering a superior patient experience. As our vice president of Safety and Quality says, “Safety, quality and service cannot be divorced.”
Beyond ensuring safety in everything we do, we also recognize best practices and shining examples on an ongoing basis—a constant reminder of the responsibility we have for our patients and to one another. At the beginning of every meeting, it is our standard that we share “safety stories”—both positive and negative—that demonstrate the impact of a staff member in preventing an adverse outcome. An example might be a nurse who Stops the Line following surgery because she is concerned that all of the instruments have not been accounted for, or a food service employee who, upon delivering dinner to a patient, notices the patient seems “off” and goes to find the nurse. In the first instance, the nurse prevented a surgical instrument from being left in the patient; in the latter, the patient was having a stroke and was able to receive timely treatment.
One recent story I heard is that of a patient who was receiving treatment at Main Line Health’s rehabilitation facility—Bryn Mawr Rehab Hospital. During an outpatient therapy session, the patient complained of pain in her calf. Aware of the patient’s history of stroke, the therapist looked for signs, finding discoloration and rigidness in her calf. Despite a negative Homan’s sign—a common indicator of deep vein thrombosis (DVT)—the therapist contacted the patient’s primary care physician and spouse, and immediately sent her to Main Line Health’s Paoli Hospital. An ultrasound revealed DVT, which, left untreated, would have led to a stroke. I hear stories like this often, where keen observation and quick actions have prevented harm and potentially saved lives.
We celebrate such occurrences at our annual managers’ meeting with recognition of our “Great Catch Awards,” honoring staff members who exemplify promoting safety and reducing risks at the individual level. Our Great Catch winners are excellent ambassadors in demonstrating how a reliable culture of safety engages every single person across the health system. Since launching the Great Catch program in 2012, more than 200 of our employees have been recognized as safety award winners.
In 2014, the Health Care Improvement Foundation (HCIF) presented Main Line Health with its Delaware Valley Quality and Patient Safety Award, distinguishing us among 30 competitive entries with the highest scores on evaluation criteria including evidence of significant and sustained improvement in quality or patient safety, innovation, leadership and organizational commitment to improvement, a multidisciplinary approach, and the potential for replication in other health care organizations. Main Line Health has also received national recognition from Truven Health for these efforts, naming us among the top 20 percent of health systems in the nation.
Such recognition would not be possible without the unfailing dedication of our employees, who have wholly embraced our culture of safety and committed themselves every day, in every way, to excellence in patient care.