#39
PROJECT NAME: Bridging the Gap: Safety Forums for
Executive Teams and Frontline Staff
Institution: UTHealth Science Center Houston/Children’s Memorial Hermann
Hospital
Primary Author: Caryn Douma MS, RN
Secondary Author: Robert Yetman, MD
Project Category: General Quality Improvement
Purpose/Aim:
Early detection of potential harm and improved communication and teamwork at all levels is
critical to providing safe care. Current adverse event detection methods often fail to capture up
to 90% of adverse and near miss occurrences for timely intervention or prevention. Multiple
organizations have implemented executive rounding processes to improve relationships
between frontline staff and physicians and senior leaders and increase reporting or recognition
of potential safety events. Exposure to front line teams enables leaders to demonstrate their
commitment to building a culture of quality and safety and increase transparency.
A recent increase in the number of patients in the children’s hospital emergently transferred
from the pediatric floors to the ICU led to a series of conversations with frontline staff and
physicians in an attempt to understand potential failures leading to the change. Themes from
the focus groups revealed a failure to recognize deterioration or reluctance to escalate concerns
to appropriate personnel. The feedback was consistent with safety climate survey results from
2011 and 2012 that revealed opportunities for improvement (safety climate score < 80%,
difficulty speaking up to attending physicians<60%, difficulty discussing errors <70%, leadership
rounding impact < 70%).
The purpose of our project was to design and implement an innovative process for frontline staff
and physicians to have regular interaction with the executive team to discuss and resolve
existing and potential patient safety concerns. The overall goal was to create an atmosphere of
transparency to facilitate reporting of identified process and clinical care issues through a series
of communication strategies. A formal process for meeting and closing the loop on identified
concerns did not exist. The executive teams round regularly with frontline staff but many barriers
are currently in place that limit effectiveness, The setting is a quaternary care, academic, fully
integrated, 308-bed women’s and children’s hospital. Key stakeholders are: parents, patients
and families, senior leadership, frontline staff and physicians.
Global aim:
Increase frontline staff and physician safety climate survey scores from a baseline of < 80% to >
80% in the Children’s hospital by March 2014 through the implementation of a communication
bundle.
Specific aim:
Implement a standardized process for frontline staff and physicians to meet with the executive
team to discuss and resolve existing and potential patient safety concerns before October 2013.
Tools and Measurement:






Focus groups with frontline staff and physicians were held
Stakeholder analysis completed
Fishbone exercise with frontline staff, leadership and physicians (see figure 1)
Review of reported events obtained from the hospital event reporting system
Driver Diagram (see figure 2)
Pilot executive rounding
Figure 1
Figure 2
Measures:



Improvement in Safety Culture survey results pre and post intervention.
o Goal: increase overall safety climate score > 80% for CMHH before March 2014,
Increase leadership rounding impact scores to >80% before March 2014
100% of events identified through Leadership Forums will be reported back to staff and
physicians with resolution or follow up plan
Intervention and Improvement:
Following review of pre-intervention data, and a pilot of executive rounding, our team
determined that instead of creating a new process for executive team interaction, we would
utilize existing meetings, interdisciplinary rounds and huddles where safety concerns are
currently discussed but not recorded and resolved. The executive rounding pilot revealed
numerous barriers to success including, difficulty scheduling executive team members, finding
frontline staff and physicians free to interact, and unit geography that only allowed discussion
with 5-10 staff members during each rounding interaction. This approach clearly would not
impact overall culture or yield enough meaningful events to accomplish our aim. Our
intervention included attendance of senior leadership representatives at 12 meetings designated
as safety forums instead of random walk rounds. Team members present during the forums
included frontline physicians, nursing staff, attending physicians, nursing leadership and
supporting services. Each forum served as a PDSA cycle enabling our team to modify the
format for maximum effectiveness. Multiple safety concerns and process issues were collected
and rich discussion within the group enabled the senior leaders to better understand barriers
and process issues interfering with optimal patient care delivery.
Intervention Results:
Twelve safety forums were held with over 200 frontline staff and physicians impacted. The
executive team was able to interact with the groups and create a safe environment to discuss
safety concerns. In total, over 100 issues were identified and resolved or referred to appropriate
personnel for follow up. The graph below demonstrates results from three pediatric end of the
month wrap up meetings. Resolution and action plans were presented back to the groups at
subsequent meetings. Items requiring escalation and follow up were assigned to appropriate
departments. Some issues were able to be resolved immediately by the executive team
member present. Data are currently being collected in Excel and categorized by general
content. A more robust database is in development phase and will enable our team to
categorize, prioritize and build reports. More detailed results with number of categories, events
and outcomes will be available prior to conference presentation. Safety climate survey results
will not be available until March 2014 when the organizational survey results are released.
.
Revenue Enhancement /Cost Avoidance / Generalizability:
Decreasing adverse events, waste and inappropriate use of resources, eliminating delays in
care, improving care coordination, improving flow and eliminating healthcare associated
infections and complications have been demonstrated to decrease cost and patient harm. We
expect to be able to quantify avoidable delays in care, improvement in care coordination through
decreased length of stay and other metrics with full implementation of our project and utilization
of a more efficient database, currently in development. The finance department will assist with
quantifying cost savings in the future.
Conclusions and Next Steps:
This project, when fully implemented, will be a model that can be utilized in other organizations
to facilitate communication between senior leaders and frontline staff and physicians. Next steps
will include assessment of current meetings and huddles to formalize the forum approach and
scheduling senior leaders 6-12 months in advance. The database will assist with improving
metrics and communicating formal reports to staff and leaders.
In conclusion, we recognized that safety concerns are often discussed in many settings but not
reliably recorded or escalated to the appropriate personnel. Executive leaders and frontline
teams benefit from shared knowledge and discussion in Safety Forums and follow up processes
ensure resolution and improved communication.
Objectives:

Identify the role of senior leadership in facilitating effective communication with frontline staff
and physicians to increase event reporting and improve patient outcomes

Demonstrate the impact of the Safety Forum approach to improve recognition and reporting
of identified or potential safety events between senior leaders and frontline teams
References:
Resar RK, Griffin FA, Kabcenell A, Bones C. Hospital Inpatient Waste Identification Tool. IHI
Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare
Improvement; 2011. (Available on www.IHI.org)
'Global Trigger Tool' Shows That Adverse Events In Hospitals May Be…
Classen, David C;Resar, Roger;Griffin, Frances;Federico, Frank;Frankel, Terri;Kimmel,
Nancy;et al. Al. Health Affairs; Apr 2011; 30, 4; ProQuest Nursing & Allied Health Source
pg. 581
Yee PL, Edwards ML, Dixon J, Gleason NS. Implementation of Patient Safety Rounds in a
Children’s Hospital.Nurs.Admin Q; 2009: Vol 33,148-53