It Starts with Culture: Quality and Safety at Emerson Health

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Tom Haederle
Many hospitals and health systems will attest that building a culture of safety is a foundational mindset. It cannot be an adjunct mission or simply on a list of to do's. Case in point: Emerson Health of Concord, Massachusetts. Adopting an approach it calls equity informed high reliability, Emerson has conducted trainings on driving quality and safety for all stakeholders: board members, organization leaders, front line staff...
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Tom Haederle
really, everyone. One Emerson executive calls it "singing from the same hymnal," and it's made a difference.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this Safety Speaks podcast series hosted by Kristen Preihs, AHA's director of clinical quality, we hear how Emerson Health has achieved increased buy-in and measurable success in building a culture of safety across the organization. A key factor has been building psychological safety for its staff by shifting to thinking about how to improve systems, rather than blaming individuals if something is amiss.

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Kristin Preihs
Hello and welcome to Safety Speaks, brought to you by American Hospital Association's Patient Safety Initiative. I'm your host, Kristen Preihs. And today, like every day, we're dedicated to empowering patients and health care professionals alike. Our goal is to foster engagement in patient safety initiatives, bolster public trust in hospitals and health systems, and promote evidence-based strategies to ensure the highest quality of care.

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Kristin Preihs
Joining us today for Safety Speaks to discuss building a culture of safety is Christi Barney. Thank you, Christi, for being with us today - vice president of quality and patient safety and chief health equity officer at Emerson Health, located in Concord, Massachusetts. Christi, welcome. I'm looking forward to exploring your journey and discussing the impactful work you've been able to achieve in patient safety.

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Christi Barney
Thanks, Kristin.

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Kristin Preihs
Emerson has been on a high reliability journey for several years. What shifts have you seen the greatest impact on patient safety?

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Christi Barney
That is a great question, Kristin. I think some of this is changing a mindset around high reliability. I've worked in other organizations and certainly had a chance to share patient safety work, across the country as well as locally. And I think one of the pitfalls is when we think about high reliability as another project that we're going to graft on top of the work that we're doing in the hospital at any one time. And really changing that mindset and thinking about high reliability as truly the foundation of all the other work that we're going to do, begins to create a different kind of dialog and a different expectation.

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Christi Barney
And that has been very exciting as we sort of embarked on that, embraced it in that way. As a result, we then really dedicated ourselves. Two and a half, three years ago, we began really, truly embarking on what we were calling equity informed, high reliability. So also pulling in the pieces every single time we look at it to think about our own cognitive bias, the bias that we might bring from our experience to also think again about the equity principles of the patients or families that are involved in the care and our own backgrounds that influence the way that we think about things.

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Christi Barney
We rolled all that up, and we did a lot of training, making sure that every single one of our leaders were trained at the same high level about the content that we had. And we train the board and we train the frontline staff and making sure that, again, once we were all, as I like to say, singing from the same hymnal - once we really had the same language, we could then again have this foundational understanding and use that approach then to drive safety and quality throughout the whole organization.

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Kristin Preihs
Wow, I love that and it sounds like your organization has gone through so many changes from training board to bedside. Can you talk a little bit about some of the greatest impacts you've seen in some of the shifts that you've moved forward with?

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Christi Barney
I think some of this really gets down to, again, how we begin to build up psychological safety for the staff. When you begin to really embrace high reliability and the way that we're thinking about it, and in some ways that is different than, say, some of the traditional methodology that we use about, say, root cause analysis. The downside to a root cause analysis is there was often the idea that at the bottom, we're going to quote, get to the root of this, right?

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Christi Barney
And then that often meant that there was a human at the bottom of that that had made an error, either intentional or unintentional. And instead we really begin by thinking about systems. So our work and thinking about systems helps shape the way that we pull apart cases. We certainly look at the human factors as well. But when we start with systems and we really allow ourselves to begin there and work together, what we find in these, these are interdisciplinary, collaborative case reviews.

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Christi Barney
We bring the whole team together. We have on occasion brought in even the patient and family into that analysis, or at the very least reflected the work of having talked to them and getting their perspective, because we really do want a shared understanding again of the systems and what happened during the course of the events.

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Christi Barney
That allows, I think, the team to operate from a different space where instead of feeling blamed for what happened, we really allow them some safety to mull over the impacts. So for example, one of the ways that this has really been enriching is when we find out that, say, the person forgot to do a step that we had assumed was a known safety step, taking it a step back and saying, well, what was our system for training that staff person and having that staff person tell us

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Christi Barney
but then turning to the rest of the crew and saying, did that work the same way for other people? Was everybody present when we did that training? Keep incrementally thinking differently about the way that we intended to communicate the priorities around safety to the frontline staff, and to find what we would call the risk points in there. Because otherwise, the downside is we often got to this point where we decide, well, the human was the risk. And more often it is not.

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Christi Barney
I really, truly believe that the people who choose to work in health care are doing so because they really want to make a difference. They want to provide the very best care every single time to every single patient. So the interesting thing is, where did we not build systems around people so that they're able to do the very best every single day?

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Christi Barney
And where can we equip them differently to make sure that their training, their orientation and that the systems themselves lend themselves for them to cognitively remember the things that they need to do? Certainly a lot of the work then that we do is around system redesign and making things better and safer in the hospital as a result of that.

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Chris DeRienzo, M.D.
Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, the AHA’s chief physician executive and a champion of the AHA Patient Safety Initiative. AHA’s Patient Safety Initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

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Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1500 other hospitals already involved, visit aha.org/patientsafety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA’s Patient Safety Initiative.

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Chris DeRienzo, M.D.
Remember, together we can make health care safer for everyone.

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Kristin Preihs
That's such incredible work. And I want to say too, you went through such a huge transition as you really shifted the mindsets of those you are working with from something that it's much more expectation to be more punitive and how you're looking at things like root cause analysis to really a much more positively focused effort. So could you talk a little bit about how you supported that transition and mindset with those you were working with?

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Christi Barney
Yeah. Great question Kristen. You know, some of this is I think...when we convene these collaborative case reviews, we really start by trying to set that framework to help people. I always give the caution, I want everybody to just stay curious. Often when we're unpacking these situations, people understandably feel passionate about the thing that didn't go to plan. People

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Christi Barney
you know, it really, I think, pains health care workers when a med error is made or again, a patient gets an infection. And so there's a lot of passion in the room and there's a lot of energy. People feel badly sometimes about the role that they may or may not have played in it. And what we want to do is turn down the volume.

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Christi Barney
One of the things that we talk about in the high reliability is, again, that idea of just stay curious. You can't be curious and angry at the same time, right? You don't find a curiously angry person in your life. So really being in that mindset of continuing to feel like you're safe enough to ask yourself questions and ask other people questions, and we mind the emotional temperature of the CCR in that way

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Christi Barney
the collaborative case review. And really try to create an environment where we can keep asking those curious questions. Once we have enough space, then we're like, off to the races, it's really fun. And it often leads to a deeper conversation that I think we were having previously. You know, unfortunately many's the time I've sat in root cause analysis and everybody just struggles over the timeline, the sequence of what was happening.

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Christi Barney
And we can't step away from that to really, again, think big picture, systems thinking. Where were the risks in what we had designed? Where did the things go wrong? This really I think has changed the dialog. The other thing that we've tried to intentionally put into the design is that very naturally, often, near the end of the collaborative case review, we start to talk about an after the event happened or after this came to light, how were people doing?

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Christi Barney
What did we do next? Did we take good care of each other? Was there a debrief at the end of this? If we did a debrief, what was working and not working about it, what would you have liked to do differently? Letting ourselves really think about how we take care of each other, and whether or not that too is highly reliable, that we're making sure that that gets wired in.

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Kristin Preihs
That's such a significant achievement. And again, I just think it's so incredible, that you've changed hearts and minds with this approach and acknowledge that these changes likely took time in many instances. So could you talk a little bit about how you led the staff through kind of this transition, and then what the impact of all of this incredible work was

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Kristin Preihs
as you move from one model to the next?

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Christi Barney
You know, I think it is a journey, right? Every day I think is an opportunity to learn something new and to approach something, from a fresh perspective. Part of the work that we have done is to, again, use that same model to apply to any number of things. I think traditionally, again, sometimes that root cause work would tend to be for a serious reportable event or a sentinel event.

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Christi Barney
And so the only time that people convened in that space and work together and thinking about it in this particular, methodology might be again, those things that again, really you were fighting outcome bias, to a certain extent. Instead we can review anything. So an example, we knew that we had more CAUTIs and CLABSI's than we felt comfortable with because in an ideal world, we would have none.

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Christi Barney
And so what we began to do was, every single time we had a CAUTI or CLABSI, we would have a collaborative case review. And we started out in that case by knowing again, what's the system design, is that first question. We used, some of the ARC framework, some of the best practice documents, and we had a standardized set of questions that we were going to look at ahead of time to help people think through again:

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Christi Barney
did we do the bundle as we truly intended? You know, were there things that fell out of that? But then use that as the beginning of - once we had done that, the springboard of, again, thinking about both the system that the humans... that led to a richness of dialog that over time we began to find certain things that were falling out.

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Christi Barney
So again, this using this concrete example for our CLABSIs, lo and behold, we found out sometimes patients were refusing a CHG back. Again, this interdisciplinary group gathered, it was our patient care technicians, our PCTs who were right at the bedside. They were able to say, well, it's sticky. The patients don't like it. It's really sticky. And that led to this great opportunity to then take that information and think about using, again the quality improvement principles.

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Christi Barney
So now we can take that. We can begin to think of interventions. We can test out those interventions. And in the end we had to build way back. We realized way back before for elective surgeries, we needed to talk to people about why the sticky bath matters and have education going right from the get go. So people had the expectation there is going to be this important bath that helps decrease my risk of infection because I'm going to have a central line

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Christi Barney
so I need to be able to be prepared to do that. Having done that, we've now gone over a year with no CAUTIs and no CLABSIs. And again, it was this standard work of coming together every single time. But we've done collaborative case reviews for when the tissue freezer went out of range in the O.R., and why alerts failed to be signaled in an appropriate time frame.

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Christi Barney
And again, really thinking about again. And that's situation how all of the team fits together. The bio-med people and the again, some of our supply chain folks with staff in the O.R. and how all the systems work together and how we, again, alert and respond. We've had collaborative case reviews where we looked at escalation pathways. When what happens when we have a disagreement?

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Christi Barney
And do we have a standard way that we work through a disagreement and use our escalation process? All of these different things, you can hear could be, very different content wise, but it's that same methodology. And then taking that step back and saying, okay, at the end of the day, how do we do together? How does it feel to be together in the room?

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Christi Barney
How are people feeling? Those kinds of questions, again, mattered a lot. And from that then we began to have, you know, exponential growth. So we had four times as many safety reports as when we started three years ago. We have staff who will seek us out or seek their leaders out and say, I'd like to have one of those collaborative case reviews.

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Christi Barney
This thing happened on the shift last night and it just didn't go right. And I want to understand more about it. so you're really watching people embrace together this spirit of curiosity and a methodology for then, figuring out how to do things better.

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Kristin Preihs
Christi, I think your journey again is just one that we all have so much to learn from. And, you know, just like sticky bath matters, everyone's voice matters when it comes to patient safety. So really appreciate you, being on this podcast today and sharing your valuable insights and experiences in patient safety. I hope we hear from you many, many more times because I think you have a lot to teach us

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Kristin Preihs
really, in your experience. And from, you know, transitioning system wide improvements in quality, improvement in patient safety all the way out to things like burnout and how do you get people to try things that are new, an environment where that can be really difficult to know what to start and how to create that, psychological safety that you mentioned in our current workforce is just so key.

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Kristin Preihs
So I truly applaud you and your efforts. To others that are listening, if you want to have conversations with Christi or learn more about the Patient Safety Initiative, I highly encourage you to join us so we can hear your voice as well. By becoming a member of the Patient Safety Initiative, you gain an access to a wealth of resources, collaborative opportunities and killer expertise

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Kristin Preihs
Just like Chrisi who can support you in your journeys. We're very fortunate to have this initiative and hope others to sign up as well. And Christi , I just want to say thank you again for your time today and look forward to continuing the conversation.

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Christi Barney
Thanks, Kristin.

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Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.