By John Palmer
Editor’s note: Dr. Hoda Asmar is senior vice president and chief clinical officer for Roseville, California–based Adventist Health, a faith-based, nonprofit integrated health system serving more than 75 communities in California, Hawaii, and Oregon.
Q: What do you think are the biggest patient safety issues facing U.S. hospitals at the moment?
Asmar The five biggest patient safety issues, not just in hospitals but across the continuum of care, are care transitions, clarity and transparency around quality data, behavioral health from recognition to access to management and all the steps in between, antibiotic resistance, and hospital-acquired preventable conditions.
Q: Is there any ‘one size fits all’ solution to the patient safety issues in the U.S.? Why or why not?
Asmar: The short answer is no. Now, if you look back at the five issues from your first question, most of the experts in this field would probably agree there are some “one size fits all,” be it principles, standards, or policies that could push the healthcare industry faster in the right direction for the ultimate benefit of the patients.
A prime example would be a non-politicized national effort around access to behavioral healthcare. Another is solving for the clarity of the available quality data to the lay person. What does it matter if the data is available but needs a subject matter expert to be understood?
Otherwise, not all solutions developed at a healthcare organizational level are completely transferable in a copy-and-paste manner to other organizations. The general principles may be transferable but would need to be adjusted to the local culture, teams, and end goals.
Q: What are some of the significant changes and new organizationwide strategies you’ve recently implemented at Adventist?
Asmar: Adventist Health declared care transformation as our true north in keeping the promise to our patients and communities to deliver safe, reliable, best care, best experience. Adventist Health launched projects for the continued development of our physician and clinical leaders. We started a daily systemwide safety huddle focused on our top priorities around patient safety. We are rolling out a new culture of safety survey to the entire organization to include our partners. Since October 2017, we launched 14 care redesign projects around clinical conditions with highest volume and/or highest risk for mortality or complications—such as diabetes, sepsis, hip and knee replacement, stroke, congestive heart failure, etc.—with a goal to reduce variation in care and achieve top-decile outcomes. Our teams are also focused on optimizing our approach to clinical workforce design, deployment, and development. The work is being driven by the frontline teams closest to the patients and is all linked to a master three-year plan that is focused first and foremost on delivering on the promise to our patients and communities.
Q: Adventist Health has realized a 30% reduction thus far on patient safety metrics and is well on track to reach its goal of top-decile performance by or before 2020. What is this decline attributed to?
Asmar: The improvement relates to three key drivers: a culture that lives the mission of “health, wholeness, and hope,” engagement of the entire organization, and clarity of end goals. The focus on achieving top-decile performance in patient safety by or before 2020 is embraced by all stakeholders, from the board to the frontline staff, in all areas—and not just clinical areas. The clinical teams leading the work around patient safety fully understand that patient safety is everyone’s job and not a single discipline can drive the reduction of harm events alone. The clarity around the end goal is the scientific approach of identifying current state, defining the end goal or future state, in this case top-decile performance by 2020. Also, identifying through objective data points specific elements within the patient safety composite score that are driving the performance. Then, committing to a stretch goal reduction in those elements year after year. We then organize the teams, deploy resources and support to match the very specific safety elements targeted for reduction. Additionally, quality monthly close data is shared widely within the organization beyond the traditional quality-focused and clinical venues with the expectation for repeated learning cycles and corrective action plans when results are not on target. We are embedding the attributes of a high-reliability organization in our culture. As a team, we know the pitfalls of quality improvement in healthcare, which are the ability to drive results in a transformational manner and most importantly sustain the improvements, so we are keenly focused on change that is sustainable and scalable. Adventist Health is committed to achieving zero harm.
Q: What can U.S. hospitals (religious affiliated or not) learn from your success in reducing patient errors?
Asmar: Adventist Health is still early in its journey, but three takeaways are critical for this work.
First, there is unwavering commitment from the leadership, Adventist Health CEO Scott Reiner and President Bill Wing. Second, the courage to create a multiyear plan, thus committing to a specific end goal, defining key priorities and saying “no” to every new “shiny project” that could distract the teams. Third, creating a movement for change from the bottom up. The work at Adventist Health is being led by our physicians, nurses, quality staff, operational and analytics teams, and every other discipline and staff person in the frontline. This work is not driven day to day from the top, and we believe this is the key to sustainability.
Q: What are the biggest things holding hospitals back from reducing errors? What makes your strategies different?
Asmar: Many healthcare systems either have been or are on similar journeys. We are not the only ones on this quest to better serve our patients and communities, and some are ahead of us. I cannot speak to others’ strategies, but there are a few principles that most healthcare leaders would agree work: having the right culture, leadership commitment to change, having the right people in the right roles, and focusing on results. Some traps that derail such a big swing are not being able to build a partnership with the teams who are closest to the patient, in particular the physicians; losing focus; and not adjusting the course of action in a timely manner when results are not on target.
Q: Can you tell me about the organization’s five must-have nursing practices that are central to Adventist Health’s commitment to service and patient experience?
Asmar: These are well-known national evidence-based practices and not particular to Adventist Health: AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you), nursing staff hourly rounding, bedside shift report, nurse manager rounding once during hospital stay, post-discharge phone call. We want to achieve 100% compliance with these five practices.
Q: Adventist is “transitioning to multi-disciplinary, collaborative care teams that care for the most common clinical conditions in an evidence-based team approach that is seamless and reduces care variation.” What do these teams look like, and how do they work? What are the results you are seeing?
Asmar: This relates to the care redesign projects I mentioned earlier. Each care redesign project has a physician champion with a multi-professional team of clinicians, other disciplines such as project management, analytics, clinical informatics, and information technology support, to name a few, and all work together on building a step-by-step care process for the clinical condition across the care continuum. In this care redesign work, each clinical discipline workflow is defined using the top-of-license principle, and the final care processes are embedded in the EHR with a focus on the principle of ease of use for the end user. For each care redesign project there are measures of success, for example, readmission rates, complication rates, length of stay, etc. We will also measure the adoption or utilization rate for these care processes. When variations are identified, we will analyze them and repeat the learning cycle of what actions or changes need to follow if the measures of success or adoption rates are not on target.
The initial four projects that were launched in late 2017 are now in the process of being readied for systemwide deployment, with early results from pilot sites showing they are meeting the defined measures of success.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.