Aligning Culture with the Strategic Plan

September 10, 2015    |   By: Calevir

A success story from SSM Health

Patient safety is a top priority for SSM Health, which owns and operates 20 hospitals, more than 60 outpatient care sites, a pharmacy benefit company, an insurance company, two nursing homes, comprehensive home care and hospice services, a technology company and two Accountable Care Organizations in four states. SSM Health has used the patient safety culture surveys to measure its progress and identify areas for improvement since 2007. While all hospital staff was surveyed in early years, SSM Health limited the survey to caregivers and added home care and long-term care facilities in 2014. Its many medical group practices across all four states were added in 2015 utilizing the medical practice survey tool. All caregivers are now encouraged to share their opinions about patient safety by completing the survey administered by the Center for Patient Safety (CPS).

Download this article in the full Fall 2015 Newsletter.

PARTICIPATION IS UP

Participation in the 2015 survey increased to 62.9%, with some units achieving 100% participation. When asked why participation has steadily increased over the years to such a high level, Debby Vossenkemper, System Director/Patient Safety Officer, credited a consistent senior leader focus with leadership accountability, survey communication process and a strong rollout process. “Our caregivers as well as leaders are serious about improving patient safety,” Vossenkemper said. “Action is taken based on input from the front-line caregivers. In addition, we have a process to systematically communicate within each department details about the surveys, review department specific improvements from prior surveys and distribute the surveys to leaders through the use of a communication tool kit”. “Our System CEO, Bill Thompson, sent a letter in January to all employees setting expectations and explaining that the patient safety survey and employee partnership survey are closely aligned and equally important. Our System Vice President of Patient Safety and Quality, Dr. Kevin Johnson, sent a similar message to all clinicians. System Communications and Human Resources are also very involved in the process, which makes a big difference.” The weekly participation reports by department from CPS were also instrumental in driving up participation, enabling SSM Health to meet its participation goal.

“The Center for Patient Safety has been a pleasure to work with on the safety surveys – this is our second year of doing so. Nothing is too much to ask and it’s always done with a smile! Changes to customize the surveys and reports for SSM Health made a huge difference to our staff’s buy-in.”
– Debby Vossenkemper, System Director/Patient Safety Officer

THE RESULTS

Survey results are aggregated by CPS, who provides reports at the department level. This is helpful, as similar services across the system can compare results with each other. A toolkit including the results, a primer on how to read them and comparisons with previous survey results is distributed to all senior and clinical leaders. Leaders are expected to review, and discuss with their teams, improvements that have been made based on the staff’s input from previous surveys. In addition, the results are shared with senior leaders and System/Regional/Entity Patient Safety Councils to ensure a consistent understanding of the results across the organization and by facility. The top improvement opportunities are identified, and teams of front-line staff develop action plans, which are aligned with the organization’s strategic plan and goals. Each department is expected to have a patient safety goal which is posted on a SharePoint website for transparency across SSM. Each facility’s senior leadership team defines an action plan related to two areas of focus related to the survey results which is reviewed quarterly at the Patient Safety Quality Council. In addition, the action plan addresses both areas of focus related to patient safety and employee partnership.

OPPORTUNITIES FOR IMPROVEMENT AND SUCCESS

While each facility selects areas of improvement based on its specific results, during the prior survey cycle the hand-off process between units, especially between the Emergency Department and nursing floors, was identified as an opportunity in several of the entities. Therefore, CQI teams are working to further study and improve the handoff process. Last year, one hospital identified an opportunity to increase its event reporting rate to better understand where and why events or near-misses were occurring. This year they celebrated a 28% increase! The senior leadership team “owned” the event report goal and made it happen by reinforcing the goal in various ways, including conversations during senior leader rounding, No Harm Team meetings and distribution of talking points, and daily safety briefs.

RECOMMENDATIONS

Vossenkemper shared two learnings from SSM’s survey experiences: First, identify one or two areas that need improvement and drive change, as opposed to trying to improve everything at once. Second, use quality improvement techniques to achieve incremental improvement and set stretch goals to achieve results. Congratulations to SSM Health for their focus and successes in improving patient safety!

FOR MORE INFORMATION

Contact Debby Vossenkemper at [email protected] or 314-989-2197.

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.