This article describes the journey of integrating patient safety and risk management and reports a 62% overall reduction in hospital professional liability premiums over 10 years that has occurred as a result of the integration and a dramatic increase in the reporting culture.
By Jamie Leviton MHA, CPHQ, and Jackie Valentine MHA, Rph
Engaging health care professionals and staff around reporting errors to reduce risk and improving the safety culture is a crucial but difficult task for many organizations. Unless staff members are engaged, feel safe to speak up, and are enabled to learn from the occurrence of preventable medical errors, poor patient outcomes will likely continue to occur. How organizational leaders respond to safety events and communicate to staff, patients, and family members following such events is key to building high reliability organizations and enhancing safety cultures.
A report published by the NPSF Lucian Leape Institute, Shining a Light: Safer Health Care Through Transparency, describes transparency as the most important element among the Institute’s recommendations necessary to transform the health care industry. In most organizations, the risk management and patient safety departments are separated in goals, scope, and leadership. In 2006 Virginia Mason chose to integrate the risk management function into the patient safety department and since then have utilized the Virginia Mason Production System (VMPS) management methods, to continuously improve the patient safety system by enhancing transparency in reporting, disclosing, mitigating risk, and improving patient safety.
This article shares the journey of integrating patient safety and risk management and reports a 62% overall reduction in hospital professional liability premiums over 10 years that has occurred as a result of the integration and a dramatic increase in the reporting culture.
The Patient Safety Alert System (PSA system) is the cornerstone of safety and quality for staff and patients at Virginia Mason. The PSA system began in 2002 and has been the focus of an on-going initiative to:
- Encourage reporting and a culture of safety
- Produce a rapid and standardized response to identified concerns
- Empower managers to address issues close to the source
- Promote greater transparency
The PSA system requires any employee who encounters a situation that has harmed or has the potential to cause harm to a patient to report a PSA and take actions to “stop the line.” Approximately 800-1000 PSAs are submitted per month via the online incident reporting system. Each PSA is reviewed by a patient safety specialist, who makes an assessment of the severity of the PSA based on whether there was harm or potential harm to a patient. The assessment by the patient safety specialist determines whether the PSA will be handled by the manager of the operational area or by a higher level administrator. For those PSAs that require a more intensive review, the patient safety specialist partners with the accountable executive and a multidisciplinary team to facilitate a root cause analysis and corrective action plan. At Virginia Mason, risk management and patient safety are not separate, they are one in the same. We believe our patient safety program is our most effective risk management tool and have structured our department to focus on identifying safety risks and mitigating them quickly which allows for improvements to safety for patients while reducing risk to the organization at the same time.
There are 3 key strategies for how patient safety work is leveraged to reduce risk:
- Culture of safety that encourages reporting of events
- Leadership training and engagement
- Early notification and collaboration with risk management (disclosure, support, etc)
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Culture of Safety
The first strategy is the culture of safety. While Virginia Mason has a relatively good degree of reporting, there are opportunities to improve communication around patient safety events and develop a culture where staff feel safe to speak up. The safety system should not be perceived as punitive, and staff members should be engaged in the solutions to identified safety issues. Armed with the VMPS management method and the support of dedicated team members, Virginia Mason has explored new and innovative ways to approach safety. The first step was to create a shared vision of patient safety at VM. A group of staff and leaders was brought together to come up with a vision statement: “To be inspired and prepared to take the right action, at the right time, with the right resources.” In addition to developing the vision statement, the team developed a future-state model and a three-year Kaizen plan, or work plan that has provided the roadmap for accomplishing the vision.
Critical concepts of the vision include:
- Safety is deliberate.
- Safety work utilizes VMPS and is aligned organizationally.
- Safety starts and ends on the front line.
- Engaging in safety is simple, fast and intuitive.
Five strategies are used to accomplish these goals: prevent, detect, respond, analyze, and learn/teach.
Communicating with staff about safety and celebrating success is critical to maintaining the culture, encouraging reporting, and normalizing the behaviors of speaking up and taking actions to improve safety.
All leaders at VM are expected to discuss safety issues with their staff regularly at huddles and staff meetings and ask for their ideas on how to improve systems and processes. Engaging the teams in discussing the problems and developing solutions gives them ownership and pride in improving safety every day. Safety is communicated at not only the local level, but also the organizational level, through a communication plan developed to raise awareness of patient safety and publicize some of the successes resulting from safety work.
The Good Catch Award is a celebration of a staff member who reported a PSA that had a compelling story which led to system improvements. The winner is presented with a certificate and a logo baseball signed by members of the quality oversight committee and is recognized on the website and at several leadership meetings. This award helps to stimulate conversation about safety and encourages staff to report safety issues. It is also used to publicize some of the great improvements that have been initiated as a result of those reports.
Reaching out to physicians and engaging them in safety and reporting is a critical element to building and maintaining a culture of safety. One strategy used at VM to engage physicians is PSA Pointers, a series of succinct educational presentations designed for the busy practitioner. Each PSA Pointer is created by the Continuing Medical Education office and is based on an actual Patient Safety Alert involving a gap in knowledge. The story of the PSA and the educational lesson is highlighted in fewer than 5 minutes through a video presentation. Each time a new PSA Pointer video is created, clinical staff receive an email notice with links to the video site.
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Leadership Training and Engagement
In order to ensure that the leadership across the organization shares the same mental model of patient safety, a patient safety orientation for all new leaders was developed. The training covers the history of patient safety at Virginia Mason, the expectations for leaders around communication with their staff related to safety, and the commitment to a non-punitive environment that provides tools and resources they can use to investigate and resolve safety concerns. Each leader is partnered with a patient safety specialist to mentor them through their safety journey and serve as a resource and team member.
Integration of Risk Management Function
At Virginia Mason, we do not have a risk management department. The function of managing claims is done within the patient safety department by claims specialists, but our philosophy is that the patient safety work is our strongest risk management tool.
All of the work related to improving culture and engaging leaders and staff in patient safety is key to the success of our risk management function. The patient safety department works closely with the claims team to ensure that they are notified early of any potential risk-related events. The claims team is able to evaluate potential risk events early, support providers and teams through disclosure, and work proactively to resolve patient complaints. Learning about potential risk events early allows the claims team to act sooner to mitigate that risk and not only protect future patients, but improve on the experience of the patient affected. In addition, the patient safety staff has worked closely with the patient relations team to develop a program for synchronized ongoing support (SOS) to respond to unexpected incidents such as reportable events and unanticipated deaths. We created a process available 24/7 that leverages our current resources including patient relations as well as spiritual care for staff and patients, patient safety, and leadership. This program serves to provide immediate and ongoing support for our patients, families, and team members and to initiate the investigation for process improvement.
To evaluate the impact of the safety initiatives, the number of PSAs reported per month was measured. At baseline, there were 430 PSAs reported each month; recently the numbers have increased to the goal of 1000 PSAs per month. More PSAs are not an indication that we are less safe, but that our teams feel safer to report—which is the ultimate goal. In addition to incident reports, culture metrics are measured. Each year staff at VM take a safety culture survey. The survey includes questions assessing the degree to which staff feel they are informed about errors on their unit, receive feedback about changes put into place based on incident reports, and participate in discussions to prevent errors from happening. Spot checks of the safety survey results have been favorable.
Finally, reported malpractice claims have fallen by approximately 50% at the same time PSA reporting significantly increased. There has been a 62% overall reduction in hospital professional liability premiums since 2006. The results show that the investment in a culture of safety and process improvement related to staff-identified safety concerns, coupled with robust communication and leadership training, can really impact the bottom line—which is good for patients and for the organization.
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Do risk managers and patient safety staff collaborate at your organization? Comment on this post below.
Jamie Leviton is manager, patient safety, at Virginia Mason Medical Center. Contact her at Jamie.firstname.lastname@example.org. Jackie Valentine is director, patient safety, at Seattle Children’s Hospital. Contact her at Jacqueline.email@example.com.