Sentara Healthcare’s Continuing Journey to High Reliability
Joel Bundy, M.D., chief quality and safety officer for 12-hospital Sentara Healthcare based in Norfolk, Va., recently described his health system’s journey toward becoming a high-reliability organization (HRO), and how it required a refresh after 15 years of effort and growth of the health system.
Bundy was speaking during a recent webinar put on by the Jefferson College of Population Health in Philadelphia. The webinar organizers noted that despite decades of effort in the field of patient safety, there are as many as 400,000 patient deaths per year from preventable harm. The concept of HROs has been shown to prevent accidents even in areas of operational complexity such as air traffic control and nuclear power stations.
In speaking about how to build an HRO in healthcare, Bundy said first you need to build the infrastructure to capture what is truly happening in the organizations — everything from a safety culture index to leadership rounding, “not just how do you do the rounds, which are important, but rounding with intent to try to find out what's happening in a certain unit, or in a certain part of the hospital about a certain item that you're concerned about using physician peer review, or nursing peer reviews, not as a punitive tool, but as a learning opportunity,” he said.
How does Sentara execute on its HRO principles? One aspect involves leadership. The focus is on making the message about safety the keystone of every single thing that Sentara does, he said. “We need to make sure that we ensure safe operations, potentially by doing daily safety hurdles in the morning,” he said. Accountability also is key. “Giving feedback is something that sometimes we as leaders don't like to do, but we need to do, and for the staff, those people at the bedside really focusing on paying attention to the tasks that they're doing. And communication, communication, communication, whether that be to the medical staff, from the medical staff, to nursing, or to administration, or to the patients and the families. All of these things are incredibly important.”
Sentara began this work in 2002 when it had eight hospitals and 100-plus sites of care, and Bundy said they had very good success in reducing harm under the leadership of Chief Medical Officer Gary Yates, M.D. “Dr. Yates built this on a culture of safety foundation,” Bundy said. “The culture was about safety, and they were focused on technology, processes, and people.”
But by 2015, Sentara had increased in size to 12 acute-care hospitals, more than 300 sites of care, and 28,000 staff, and its medical group was a lot larger. “We had gone through mergers and acquisitions. With each of those, it was a different hospital culture,” Bundy said. “There was senior executive turnover, staff turnover, and churn. What happened? We had increases in in serious safety events. And because of that, we recognized that we needed to do something different.”
“A small group of us met and looked at why we had this worsening performance. We realized that some of the high-reliability tools really weren't being consistently used across the 28,000, clinical and nonclinical FTEs and the 5,000 total providers,” Bundy said. Those HRO concepts were even less well understood within the nonclinical areas.
In 2015, they did a gap analysis and decided they needed to appraise where the opportunities were to improve. That led to several interweaving initiatives. It had been about 12 years since Sentara had looked at its safety habits and tools, and perhaps they needed to refresh those. “We recognized that we needed to improve the safety orientation for our staff and for our leaders,” he said. They also worked to reduce clinical variation.
“In 2016, we trained our senior executives. The next year, we looked at all of the directors and managers, both clinical, and very importantly, nonclinical leaders across the organization.”
“Also, we have to hold ourselves accountable,” Bundy said. “We had to make sure that we held ourselves accountable to get this job done, because this was a large project across the entire enterprise. No. 1 was looking at our safety habits in our toolkit — it had been 12 years. We decided to change from safety habits for error prevention to ‘Safety Starts with Me.’ What does that mean? Well, we wanted to focus on safety, and we really weren't just talking about patient safety. We were also talking about workforce safety, making sure that we elevated safety for our own employees was very important.”
“Every single agenda meeting within Sentara starts with a safety message,” Bundy added. “It doesn't matter if it's at the board of directors, the medical affairs committee, or hospital committee or any committee at all, we all start with a safety message. We are making sure we have safe operations.”
In addition, he said, every division starts every morning with a daily huddle. “What are the things that we were concerned about over the last 24 hours? What are the things we're concerned about today? What about tonight? What about over the next 24 hours?”
Bundy noted that Sentara still does have significant clinical variation across divisions, “but we have made marked improvement. It isn't perfect, but it's much better than it was before.” In terms of timely data, he pointed to a quality and safety dashboard. “As we improve, we continue to change our goals to try to drive further improvement as well,” he said. The dashboard is a living document. “We listen to the people who use this dashboard. We change it based on their feedback, because we want to give the chief medical officers and chief nursing officers what they need. I believe that we're doing incredible work and making our organizations a safer place.”
