Creating a new culture of safety: managing editor Sandra Hoban explores how the stringent safety protocols in high-risk industries work for healthcare, too.

At home, on the job, and even on vacation, safety for ourselves and others is always a concern. When dealing with the elderly, however, safety precautions sometimes fall unintentionally short. Where can we find good safety models for long-term care? Can high-risk industries such as nuclear power, aviation, and power generation, show us the way?

Sentara Healthcare is an integrated, not-for-profit system of hospitals, long-term care facilities, and physicians serving southeastern Virginia and northeastern North Carolina. It continually seeks to improve the quality of the care it provides. "But," says Shannon Sayles, director of Safety and Performance Excellence, "improvement is a slow and incremental process, and we felt ours wasn't happening as fast as it should and decided to pick up the pace, particularly in the area of safety." Sentara began by looking inside the healthcare industry for ideas but felt that there weren't any new approaches to addressing the issue.

In 2002, Sentara learned about Performance Improvement International (PII), an organization that has implemented principles of safety through its experience in improving human performance with nuclear power and other high-risk industries. "PII's approach was intriguing because these industries post superior safety records," says Sayles. "PII helped us to understand and appreciate the important link between behavior accountability and individual responsibility. You can't just tell people to 'be safe'; you have to give them tools and techniques to make safety instinctive."

That fall, Sentara rolled out the Culture of Safety program at its largest hospital facility, Norfolk General in Norfolk, Virginia. "We felt that if the program worked at that location, it could work anywhere within our system," remarks Sayles. By the end of 2003, promising outcomes in safety improvement had been documented and the decision was made to expand the Culture of Safety initiative system-wide including Sentara's 11 long-term care-related sites: seven nursing homes, three assisted living facilities, and one PACE site.

To Move Ahead, Take a Good Look Back

To effectively implement the Culture of Safety, the safety initiative's task force at Life Care (Sentara's long-term care division) had to have an overview of the individual division's safety status. "The task force's first step was to perform a safety assessment at each site," explains Sayles. This assessment included a culture survey that looked beyond the "safety culture" to other aspects of culture, such as interdepartmental integration, self-improvement culture, and understanding of the organizational mission and goals. Then the task force looked at the division's current efforts at safety improvement: What systems are in place for detection, prevention, and correction of problems? What outcomes have resulted from these efforts?

In addition, a common-cause analysis was performed. "We look for common themes in past adverse patient events that have occurred in the Life Care facilities. Some typical causes include inattention to detail and ineffective communication within or across departments, along with noncompliance with policies, or lack of critical thinking (i.e., staff do not follow up on situations that don't make sense to them at first)."

Sentara Life Care BBEs

When the assessment was completed, the task force shared the findings and the recommendations with all staff. The error-prevention strategy is based on establishing specific behavior-based expectations (BBEs), and instructing staff on them to prevent human error. BBEs are simply defined behaviors and related techniques that have proven to enhance safety in high-risk industries. The BBEs for Life Care were developed by a group of on-site staff. In response to the assessment, three BBEs were developed for Sentara facilities:

* Stop and Think. We always think before we do, using STAR--Stop, Think, Act, and Review.

* Communicate Clearly. We respectfully communicate the correct information in a timely and appropriate manner using repeat-backs, clarifying questions, and phonetic and numeric clarification.

* Be a Wingman. We always help others and expect that they will always help us, using techniques of peer checking and peer coaching.

"To make the BBEs work across staff, we kept them simple," explains Alverta Robinson, director of clinical operations at Sentara LifeCare. "Stop and Think is aimed at preventing skill-based errors. In other words, if you're not sure how something is done or it doesn't make sense, ask questions." She adds that Be a Wingman (a term chosen because of a strong Navy influence in the region) encourages teamwork and empowerment. "In essence, it means to check each other and coach each other," she says.

Robinson cites an incident at Sentara's Virginia Beach facility that exemplifies the effectiveness of BBEs. "There was a resident who had a medical emergency. Although there was a DNR order, the family wanted him treated. However, because of the DNR, EMS did not want to transfer the resident. Staff had to explain to the EMS team the DNR does not mean 'Do Not Treat.' They spoke with the EMS supervisor to ensure that the resident received care. In this case, staff achieved the best results by employing the skills and behaviors of Stop and Think and Communicate Clearly."

Sentara Life Care's vision of "Care Without Harm" has had complete buy-in from staff, according to Robinson. After the BBEs were set, staff received training and then began to put that training into practice by sharing safety stories and incorporating the BBEs in everyday work habits. In October 2005, members of the staff trained as safety coaches began to document the results of the training by observing their coworkers using the BBEs.

Red Rules

To support BBEs and to focus staff on actions key to safe outcomes for residents, so-called Red Rules are implemented. Although Red Rules are department-specific, everyone learns about them so that whether the staff member is a caregiver or a dietary or environmental services worker, everyone knows what is expected of them. One of the Red Rules focuses on use of standard lifts. "Because these lift transfers are a high-risk process for us," says Robinson, "the team designed a Red Rule for lift safety": Standard lifts are two-person transfers and should never be attempted alone. "Although this Red Rule is for caregivers, it was presented to all staff. For example, if a dietary worker observes a CNA trying to do a solo lift, she can say, 'Wait. Let me get you some help.' That's observing a Red Rule and Being a Wingman."

Culture of Safety

Sayles advises that creating a culture of safety goes beyond BBEs and Red Rules. "A typical facility has stacks and stacks of procedure manuals. We've learned that sometimes procedures involve too many, often unnecessary, steps that may increase risk," states Sayles. "Consequently we have implemented a process called 'focus and simplify' that involves reviewing processes to remove redundant or unnecessary steps and to document the new procedures in a clearer and simpler format."

This process was begun at the Sentara hospitals and also includes the creation of quick-reference job aids for staff to reference at the point of care. Now, instead of being buried in a 20- to 30-page policy manual, key information is handily available. These improvements save time for staff and maximize care for patients. For example, posters are used to illustrate what IV complication types look like, and directions for using a piece of equipment are attached to the device. This process is now being rolled out to Sentara Life Care.

Conclusion

This approach to creating a culture of safety is so successful and readily accepted by staff across the Sentara system that Mary Blunt, president of Sentara Life Care, has recommended that Virginia long-term care associations encourage their members statewide to take a look at the program. By taking a page from high-risk industries and inserting their safety procedures into long-term care routines, Sentara's Culture of Safety is protecting everyone involved.

Shannon Sayles is Director of Safety and Performance Excellence, and Alverta Robinson is Director of Clinical Operations for Sentara Life Care. For further information, call [phone] or visit www.sentara.com. To send your comments to the author and editors, please e-mail [e-mail].

RELATED ARTICLE: A Campaign for Healthcare's Own Injury-Prevention Icon

Over the past several years, major agencies and organizations have instituted proactive, multifaceted initiatives to educate the healthcare industry and advocate improvements in safe patient-handling policies. The federal Occupational Safety and Health Administration (OSHA) released guidelines for safe patient handling in nursing homes, and the 2005 Safe Patient Handling & Movement Conference in St. Petersburg, Florida, provided further endorsements.

The objective of these initiatives has been to reduce caregiver injuries, improve patient outcomes, and reduce workers' compensation claims. Yet injuries continue to happen, and caregivers continue to be forced out of their chosen profession. Why do intelligent, highly trained nurses and CNAs fall victim daily to the epidemic of injuries caused by lifting or transferring patients when contemporary lifting equipment is readily available?

There is no simple answer, of course, but perhaps we can learn a lesson from an analogous situation, one that each of us encounters daily: the ubiquitous antismoking movement.

The antismoking movement has been in existence for several decades. Its visual icons have become a global phenomenon, designed to ensure instant recognition while encouraging widespread adherence. Gradually, over decades, entire populations have become conditioned to abide by the prohibitions engendered by these icons, which are simple visual cues such as the word "smoking" with a strike-through imposed upon it. Can the medical industry learn from and, more importantly, benefit from the antismoking campaign's successful use of universal visual cues to represent an entire body of knowledge? Can such visual cues be used to signify that an entire facility should be considered a safe-lifting environment? Is it possible that a simple visual cue, posted on the facility Web site or on entrance doors, can signify that injury prevention is a top priority within the entire environment one is about to enter?

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Many individual healthcare facilities have adopted safe-lifting policies in an effort to protect their staff members against musculoskeletal injuries. Unfortunately, most of these efforts have been stand-alone initiatives and are often viewed by individual caregivers as temporary in nature or "just another program."

If we can learn from the success of the antismoking movement, group acceptance and buy-in will only take place when the safe-lifting programs at individual facilities become part of a larger, industry-wide movement with unified efforts and a common goal. It's the next logical step toward accomplishing what we all want to accomplish--namely, caregiver injury prevention through safer patient-handling practices. Constant reinforcement via visual reminders is absolutely key for both no-smoking and no-injury programs.

If your facility currently mandates a safe-lifting environment, or if you are contemplating such a program, it's time to start applying the lessons we've learned from past experience. The Liko "Safe Lifting Environment" campaign can help promote safe lifting in your facility with free educational material, including decals and posters featuring a universal safe-lifting symbol. For more background information on caregiver injury prevention, to order a "Safe Lifting Environment" Starter Kit, or to download a Safe Lifting Environment icon, visit www.safeliftingenvironment.com.

Jim Murphy RN, BSN, COHN-S, is responsible for nursing resources and educational development for safe patient handling at Liko, Inc., a global patient lift manufacturer with North American headquarters in Franklin, Massachusetts.

by Jim Murphy, RN, BSN, GOHN-S