Since the patient safety first program started in 2009, we have had the same safety metric Serious Safety Event (SSE). In this objective metric, our baseline in 2009 was 1.66. Now, in 2012, the rating is 0.44. This is a 73 percent reduction.

What has occurred since my first article?

ADVANCE thanks Stan Holland

• Organizational safety rounds -- On weekdays, for 15 minutes in our boardroom, the topics covered include days since last SSE, Safety Story, organizational occupancy stats, check in with all departments and follow up on problems list. We have learned the power of storytelling and using visual aids.
• Physicians -- All RMH employed physicians have taken a physician safety champion class.
• Hardwired daily departmental safety check-in -- Respiratory Care department has fixed 90 items that were raised, 60 of those since August 2011. As leaders, we work hard to fix issues with 48 hours of them being raised. We post these solutions where all staff have access. The greatest cause of safety issues is not following procedures -- most of these 90 items were related to operational issues that affect procedures.
• Start all meetings with Safety Story -- Senior management took the lead on this initiative. When starting a meeting without asking about safety, they expected to be stopped. They publically thanked staff who brought this to their attention.
• Impure safety claims -- It became obvious that not everyone had pure motives. Sometimes, the "safety card" got played to obtain an unbudgeted item. This was not well received by peers.
• Department safety coaches -- every department has a safety coach. They serve as a resource for peers and complete monthly observations. Our safety coach starts every department meeting.
• Nursing bedside patient report and white boards -- This has been well received by all. At shift change, a report is given at the bedside with the patient and family present. Daily patient care givers and plan of care is written on a white board in their room.
• Staff empowered, leaders have their back -- As staff took the risk to confront unsafe practices sometimes with physicians they were supported by their peers and leaders.

Safety Testimonies

• RC staff last names removed from badges -- Make no mistake, staff safety is equally as important as patient safety. Our emergency department and behavioral health nurses do not have their last names on their badges. Research with the Virginia Board of Medicine validated no state requirement for last names on our badges.
• ET tube pilot balloon floating -- Recently, an ICU ventilated patient had an MRI on the night shift. Before daily safety rounds, the issue came up from both MRI and respiratory care (RC) staff. The RC manager had already alerted material management. Immediate collaboration with the vendor indicated the spring was made of stainless steel. It was MRI safe (safe for magnet) and MRI conditional (safe for device). However, this triggered review of all ET tubes which found three ET tubes used primarily in the operating room on ENT cases that are not MRI safe. These tubes will be marked.
• MRI safety and MRI conditional life support equipment -- ICU RNs and respiratory care practitioners (RCPs) shared that we did not have a vital sign monitor, IV, ventilator for MRI scans. This resulted in an $84,000 unbudgeted purchase. We realized senior leaders really understood.

Internal and External Validation

• Internal: Staff annual member of the team (MOT) Survey -- the last 2 years, 89 percent or 2,154 employees have taken the MOT. There are 10 questions in the Safety Climate Index section. All 10 questions improved ranging from 3.3 percent to 5.3 percent for an average of 4.1 percent.
• External: Patient Satisfaction scores -- In 2009, they were at the 70th percentile, now we are at the 80th percentile. Since August 2011, the roll up score for the five patient safety questions has improved from 88 percent to 92 percent. Patients must feel they are safe before they see good customer and clinical service skills. This becomes even more important because significant reimbursement is tied to these scores.
• External: Testimonies from Community -- more evidence of the culture changes are evident during leaders rounding with patients and families and testimonies coming back from the community. Patients and families take pride in sharing this.
• External: USA Today Safety award -- RMH had the second highest safety score in the State of Virginia for Patient Safety.
• External: Comparing safety culture with other hospitals -- I sit on the Virginia RC Board of Medicine. During a recent informal disciplinary hearing, I realized how far we have come. The RCP from another hospital shared if they asked for help, they would not get it, despite 15 RCPs working that shift.

Next Steps

• SSE root cause investigation process -- Soon, this process will be expanding to include two RCPs, two pharmacy staff and two RNs. Previously, only quality department staff were on these teams. The interdisciplinary focus will enhance the reviews.
• High reliability organizations -- As safety cultures mature, they expect failure, and become obsessed with failure. This means we look critically all the time for what can go wrong, especially before we are in the situation. Resources like Why Hospitals Should Fly, by John Nance, provide best practices from the airline industry.

I started respiratory care school in 1975, 37 years ago. I officially began my leadership role in 1985, 27 years ago. The last 4 years actively participating in our safety journey have truly validated the reasons I entered the healthcare field. This is so rewarding because we are truly helping patients by first doing no harm in a very high risk environment.

Stan Holland is director of pulmonary services, RMH Healthcare, Harrisonburg, VA.