Robert Connors, MD, president of Helen DeVos Children's Hospital, a member of Spectrum Health System in Grand Rapids, Mich., recently received the National Patient Safety Foundation's 2011 Chairman's Medal. The medal recognizes emerging leadership in the patient safety field. Dr. Connors spearheaded a patient safety program at the hospital starting in 2007, a program that was picked up by entire Spectrum Health System.
Among the outcomes achieved at the hospital were the following:
- Between 2008 and 2010, safety events were reduced 68 percent.
- Ventilator associated pneumonias in the pediatric critical care unit have been eliminated for 19 consecutive months.
- Hand hygiene has improved from 56 percent to 96 percent for more than a year, helping to reduce hospital acquired infections by 50 percent.
- Catheter-associated blood stream infections in the newborn intensive care unit were reduced by almost 50 percent.
- Asthma core measures at discharge achieved 100 percent compliance.
- Spinal surgery infections were eliminated.
"It's clear from the numbers that Helen DeVos Children's Hospital is on the cutting edge of safety innovation," said Diane C. Pinakiewicz, MBA, president of NPSF, in an NPSF news release about the award.
Dr. Connors discusses the roots of the program, his vision for it and how the hospital achieved such impressive outcomes.
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Q: What led to your starting this program in 2007?
Dr. Robert Connors: Several years ago, we [discovered] there was so much unintentional harm in our hospitals which was very surprising because we're all about helping people. We got very serious about it and decided we were the kind of place that really could and should be the safest children's hospital in the country.
We looked around to find out who was doing this well and who was not. It was quite a search for us. We landed on bringing in a consultant [who focused on] healthcare improvement. Their background was much more scientific about human error management — the analysis of human errors, why they happen and how they happen — and they were from the nuclear regulatory industry where they've really pushed higher liability and pushing error out of their system in ways I don't think healthcare has done.
Q: What were your initial expectations for the program?
RC: I was very intentional about what I was expecting of those people and what I was looking for for our team: behavioral-based changes. I wanted to be able to do things differently and I also wanted to be able to prove we were reducing harm. That's an outcome measure that's very important — looking at these terrible things that happened to people that nobody wished ever happened in hospitals. When we looked at ourselves honestly, [we found] they were happening in every hospital in the country and they were happening in ours, too. We have to be able to talk about that, look at it and then to start to measure it and to prove that you're actually getting a decrease in those unintentional harm events in your hospital. That was a very different way of looking at things and that's why we picked that consultant. I thought they had a methodology for evaluating it best, for teaching us a lot about why we make mistakes as humans and could get at how we can quit making so many mistakes with the ultimate end that we would become the safest children's hospital in the country.
Q: What did you focus on first?
RC: Building a team, and it had to include the entire staff. Not just a couple nurses, doctors, not just a couple specialists. If you're going to change the way you are and if you're going to [strive to] be the safest place, everybody has to help you do that.
We actually did very concentrated instruction of our entire staff. That included everybody that could possibly touch a patient in our hospital. They all were trained in the basics of safety science, some of the behavioral tools we were going to be using to change the way we did things to be safer. That was a big job.
Q: How did you determine what areas to address for improvement?
RC: We examined our environment and made a top 10 list of things where we thought we could make the most progress. To determine the list, we just looked around about where we were making mistakes, such as medication errors. This is where I started to learn that there is a blurring between what people call safety and what they call quality. Some people, when you say the word safety, they think you mean a lot of cops in your lobby. That's not the kind of safety we're talking about. We're really talking about avoiding unintentional harm to your patients. You really have to start looking at standardizing your behavior, standardizing your protocols and you do start looking at a lot of process measures. That's where you can get to a list [that includes those areas we achieved improvements in]. We started working on those and met very frequently about them. We had a core team of people and we included a few specialists that helped facilitate all of this work.
Q: Your hospital improved in so many different areas. Can you choose one you're particularly proud of discuss how you brought about change in it?
RC: We had a major intervention about hand hygiene because we were doing very poorly with it, like every hospital in the country. When you re-talk about it, when you re-preface it, when you re-frame it in terms of safety, in other words saying, 'Look, if you're not washing or cleaning your hands, you just increased the risk of spreading a dangerous infection to somebody,' that doesn't sound like behavior that happens in the safest children's hospital in the country. We had a dramatic increase in compliance in our hand hygiene and have remained highly compliant.
There were several steps to that. You have to have hand sanitizer everywhere; you have to make a big deal of people using that before they go into a room and when they come out of the room. You have to have discussions with some of your leadership and some of your unofficial leadership in the hospital that doesn't quite understand [the importance of that] yet. That was a very specific program we did — it had several steps in it and used all of the different ways we could think of to modify people's behavior.
Q: How did you learn about the patient safety areas you needed the most improvement in?
RC: We set up a leadership safety steering committee and other subcommittees from that, and began working on it. We did a very rapid analysis of safety events. What you find out when you start is you really need to encourage reporting of all events so that you're not just finding out about the most terrible things that happened in your hospital. You really start finding out about more and more things, some things that happen that don't even cause harm because they don't reach the patient, but they might reach the next patient or the one after that if you keep doing things the same way.
We became very interested in not only the serious events but also the less serious events of harm and even what we call "precursor events" where nothing actually happened to the patient except we made a mistake. Some of this has to do with [bringing about a] culture change. Part of that culture change is you have to acknowledge that medicine traditionally has been a hierarchal culture and it's been a pretty intimidating culture, too.
If you're going to do this right, you have to change that. You have to make sure everybody on your team not only has permission but an expectation to raise concerns when they have concerns about whoever it is. I'm a practicing surgeon and if somebody doesn't tell me they have a concern about something I'm doing, that's a problem. I need them to do that, I want them to do that. You want to stop those episodes of harm before they happen. When you do that, then people start reporting more. You can expect your serious safety event rate will actually go up for awhile and then go down over the course of several months.
Q: How can you get your team comfortable raising concerns about their superiors and peers without fear of backlash?
RC: It's absolutely necessary to have this kind of process to change that culture. We're still working at it — this safety cultural transformation is a journey. It's hard work and it continues to be hard work. But you can do it. I think we are doing it and we're seeing the results of that. We tell a lot of success stories here and I think that's a way you get the word out, you tell those stories. Those kinds of stories start to resonate. I think our staff and most medical staffs understand this. Some of the process measures don't resonate with them as much but when you can show them they are avoiding harm, that really does resonate. We've come to believe all of these errors are avoidable and we want to drive toward having absolutely no harm in our hospital.
Q: What would you say was the top challenge you encountered with the program?
RC: One of the challenges that not everybody wants to talk about is it's hard to go to your superiors, to your board or to the press and say we're really getting serious about decreasing the harm we're doing. That's an issue — you have to come forward and talk about it. Evidence shows that the institutions that are talking about harm are actually the safest.
That's a message I think needs to get out. If you're not talking about this, then you're not serious about it because you have to talk about it to get the kind of progress you need. That's a difficult conversation to have within your organization and also as your organization relates to the outside world. It's a process, one that evolves over time. You have to push it pretty early. As soon as people are convinced you need to talk about this to change the culture to make progress, then you do it.
Q: Considering the honor you received from NPSF, what you are most proud of with the program you created?
RC: I'm most proud of the team. I said this when I got this leadership award: You don't get leadership awards unless you're working with a great team. What I've been most gratified with is to see the growth of our team, understanding this work and being dedicated to this work. We're clearly reducing harm in our hospital. But I'm most proud of the groundwork we've laid with the people and the engagement of the champions that we've had on our medical staff, in our nurses, physicians and other support people that give me the confidence we're going to get better and better over time.
Learn more about Helen DeVos Children's Hospital.
Learn more about the National Patient Safety Foundation.
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