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A Case Study: Using Technology to Build a Culture of Safety


Ten years ago, Virginia Commonwealth University Health System (VCUHS) embarked on a safety journey with a vision of becoming America’s safest health system. The goal—zero events of preventable harm to patients, employees, and visitors.

While safety and quality have been an ever-present part of our culture, our focus was on compliance with state, federal, and Joint Commission regulatory standards. We implemented processes to meet core measure requirements, created a falls prevention program, and instituted a rapid response team (RRT). And while we saw each of these succeed, we knew we wanted to achieve more than just regulatory compliance. How could we truly achieve our vision of offering patients the safest health care in the nation?

In 2008, 5 years into our journey, our leadership team determined we needed to accelerate the rate of quality and safety improvement. Instead of thinking vertically, we needed to think horizontally across all existing programs to create a true culture of safety. VCUHS decided to implement behavioral expectations to prevent errors and manage the organization using a high-reliability performance model—one used successfully by nuclear power plants and air-traffic control systems. To bring our culture of safety to life, we needed a mix of behavioral changes and technical approaches. Every member of our organization from the boardroom to the bedside received education on safety, reliability, effective teamwork, communication, and collaboration. We believe that by harnessing the knowledge and skills of our people to design safe processes and use technology appropriately, our organization will become more reliable and safer for our patients, team members, and visitors.

Behavioral changes

VCUHS developed a “Safety First Every Day” behavioral change strategy to challenge all staff to think about safety first—all day, every day. This strategy includes:

  • senior leaders’ commitment to safety through daily rounding on clinical units and discussions with nurses on safety
  • recognition of staff members by the chief executive officer for “everyday” safe behavior and error prevention for preventing harm and reporting near misses. More than 140 employees have been recognized since 2008. Safety star exemplars are displayed on every computer throughout the organization using our screen-saver system, Net Presenter. More than 12,000 employees and physicians have completed training on the principles of safety and how to achieve sustainable improvements. All nurses are specially trained in all aspects of effective teamwork, communication, and relationship management. The nursing professional practice model provides a foundation of shared governance and supports the values of caring, knowledge, leadership, and collaboration.
  • 50 clinical nurses serving voluntarily as safety champions and providing peer coaching on use of safe behavioral and error-prevention strategies
  • an innovative 15-minute daily conference call that reviews the safety status of more than 30 operational areas of the hospital. In a roll-call format, every area reports on such concerns as patients holding in the emergency department, patient falls, patients in restraints, or patients on suicide precautions. Team-member injuries and blood and body fluid exposures also are reviewed. This 15-minute call keeps leaders connected to frontline operations and focused on safety. Concerns are addressed immediately, and follow-up is reported to the entire health system on the next day’s call. Hundreds of staff members participate in this call each day.

Technical approaches

Technology has played a major role in the ability of VCUHS to provide safer patient care. Every day, more than 2.5 million transactions are processed through our electronic health record (EHR), powered by Cerner. VCUHS nurses have documentation available at their fingertips about a patient’s full continuum of care. This saves valuable time and, more important, creates a safer environment because nurses can get timely, accurate patient data from all specialty disciplines across the continuum of care.

Also, recognizing that data must be acted on to achieve better outcomes, we’ve implemented 653 active EHR alerts to provide clinical-decision support. The system can provide a crosscheck for nurses, warn about a negative medication interaction, or offer guidance that could decrease patient complications.

What’s more, VCUHS nurses can view a safety dashboard that identifies high-risk situations or patients’ safety-risk information. Nursing units conduct daily safety huddles and use a safety dashboard as part of their huddles. For all patients on a unit, the dashboard displays on a single screen the key indicators of a patient’s care and health status, such as fall risk; need for physical restraints; presence of I.V. lines, urinary catheters, and surgical drains (all of which increase the risk of infection); and any overdue medical orders. With this ability to quickly assess at-risk patients, nurses can intervene before a problem occurs. The dashboard is accessed more than 300 times daily, and the core indicators displayed have demonstrated measurable improvement. For example, we have reduced the rates of patient falls and falls with injuries by 50%. The dashboard has led to organization-wide additional education in deep vein thrombosis, pressure-ulcer reduction, and use of physical restraints.

Perhaps the most exciting example of effective leveraging of technology to improve care is our Medical Early Warning System and Pediatric Early Warning System (MEWS/PEWS). Inspired by one of our critically ill pediatric patients, we recognized the need for our nurses and RRT to have a real-time monitoring system that continuously measures patient acuity and severity. Using information from the EHR, MEWS/PEWS identifies the most critically ill and decompensating patients and assigns each one a score. Clinicians and the RRT use the information to intervene proactively and escalate care.

The results for the first year are remarkable. The RRT uses the data as its compass to guide prioritization of our sickest patients. The RRT doesn’t wait to be called if a patient is in distress. Instead, the team accesses the MEWS/PEWS score on mobile devices and arrives at the bedside to assess and intervene—at times, ahead of the primary team and nurse. Since launching MEWS/PEWS, there has been a 5% reduction in in-house mortality and a 30% reduction in cardiopulmonary arrests outside the intensive care unit. (See Achievements at the 10-year mark by clicking the PDF icon above.)

At VCUHS, we consider it an honor and a privilege to care for the citizens of our community. It’s up to us to make sure our work is achieving the outcomes that patients deserve and expect. Clinicians have always worked hard. Now, we work smarter as well, partnering with interprofessional colleagues, technology experts and, most important, patients to provide efficient and effective health care and create healthier populations.

Deb Zimmermann is chief nursing officer and vice president of Patient Care Services at Virginia Commonwealth University Health System in Richmond, and chair of the American Nurses Credentialing Center’s Commission on the Magnet Recognition Program®.

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