Innovation in patient safety and quality

July 2014
By Angela A. Shippy, M.D., Chief Quality Officer, Memorial Hermann Health System

If you ask any healthcare provider if the care they deliver is safe, they will undoubtedly answer yes! There is never an intention to do harm; however, patients are harmed in healthcare facilities every day.

In 1999 and 2001, the Institute of Medicine provided a call to action and a road map to reduce errors and provide safer care to patients in its widely read reports, To Err Is Human: Building A Safer Health System and Crossing The Quality Chasm: A New Health System For The 21st Century. Over the last 15 years, these two reports have been quoted countless times and improvements throughout the healthcare industry have been made. But, clearly more can be done.

In 2006, Memorial Hermann Health System, the largest not-for-profit hospital system in Southeast Texas with 12 hospitals and 21,000 employees, embarked on a high-reliability journey by applying principles embraced by high-reliability organizations. High-reliability organizations, such as commercial airlines and nuclear aircraft carriers, are able to avoid preventable adverse events in environments where accidents could be expected because of risk and complexity.

By making patient safety a core value, Memorial Hermann underwent a transformation that started with our Board and included every employee - clinical, nutrition, clerical, environmental service, maintenance, and volunteer. This $18 million dollar commitment prepared all staff and employed physicians with safety culture training. In addition, physician alignment strategies including clinical integration and clinical program committees were strengthened to further support this effort.

With an expectation of 100 percent compliance with evidence-based quality measures and a zero percent incidence of patient harm in all aspects of patient care, a uniform approach to performance improvement called Robust Process Improvement™ (RPI) was established. RPI includes Six Sigma, Lean, and change management to solve difficult safety and quality problems, and encourages experts closest to the bedside to lead performance improvement processes in order to promote integration and standardization across the system. This methodology supports transparency of information vertically across the organization; allowing staff to access data and conduct “just-in-time” two-provider (“double”) checks, supporting informed decision making, and enhancing solution design.

This initiative resulted in significant zeroharm milestones and the establishment of a new High Reliability Certified Zero Award to celebrate a hospital’s successful prevention of harmful events and adverse outcomes for 12 or more consecutive months. Since 2011, more than 114 awards have been presented to Memorial Hermann hospitals in the categories of Central Line– Associated Bloodstream Infection, Catheter Associated Urinary Tract Infection, Ventilator-Associated Pneumonia, Retained Foreign Object, Iatrogenic Pneumothorax, Accidental Puncture and Laceration, Pressure Ulcers Stage III & IV, Birth Trauma, Serious Safety Events, and Early Elective Delivery.

The next step for Memorial Hermann in this transformation will be to ensure these better processes are truly hardwired into our system and to translate them to sustained improved outcomes for patients. How do we get there?

Use RPI as our disciplined approach for performance improvement promoting standardization and decreased variation, which results in better outcomes and improved efficiency.

Eliminate failures in basic delivery of care by ensuring timely evaluation, improving direct communication among providers, and rapidly escalating and resolving identified opportunities.

Remain focused on the patient while adopting the principles of high reliability as we continue to be a healthcare system that delivers safe, quality care while avoiding preventable errors.

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” ~ Medal of Honor Recipient William A. Foster

This quote is right on target as it succinctly demonstrates that we must be deliberate in our quest to provide the best healthcare for patients and to ensure we have the best processes and practices in place to eliminate the opportunities for human error.