System-wide HRO effort yielding good results
UH Clinical Update - July 2018
The PASS reporting system is a crucial component of University Hospitals being a high-reliability organization (HRO). PASS, an acronym for Patient Advocacy and Shared Stories, is the event reporting system used at UH medical and health centers.
This reporting system is so important to the UH system because there are many points of electronic or physical communications - or hand-offs - involved in the care of each patient. Each of these can create the risk of a misunderstanding or a lack of communication. Because humans are fallible, systems and back-ups are necessary to prevent or detect errors.
That is why Patient Safety Events involving adverse patient outcomes and errors should, and are, being reported. Afterward, PASS reports are reviewed for process improvement opportunities by various departments, committees and management teams. Also, all Patient Safety Events in the PASS reporting system are reviewed by a UH Quality Committee.
Since the spring of 2017, more than 22,000 UH employees have been trained about ‘just’ culture. The term refers to a culture in which any and every employee can, and should, speak up if they see something that may be wrong, or a potential error, without fear of retribution. This is what the UH slogan ‘see something, say something’ is all about. (PASS reports can also be entered anonymously, through the Digital Workplace.)
“Good catches,” which as the name implies means the prevention of a possible error, are also entered as PASS reports. They are not used punitively. In recent months, there’s been a system of looking at “good catches” throughout the system, and they are shared in a monthly HRO meeting of UH leaders and clinicians. From all medical and health centers’ reporting of good catches, one is selected as the month’s top Good Catch.
“We have our ‘good catches’ rolling at all of our hospitals,” says Abirammy Sundaramoorthy, MD, Chief Medical Officer at UH Conneaut Medical Center, who also is leading the HRO effort at UH. (She is known throughout the system as Dr. Abi.) “We track reporting and from April 2017 to April 2018, we’ve had a greater than 40 percent increase in reporting of any kind of error.”
A second level of this kind of reporting is gradually getting under way, through a digital Rounding To Influence app.
“Now, senior leaders at all acute care facilities are rounding on staff and employees in all departments and floors, once a month,” adds Dr. Abi. “This new digital tool incorporates HRO rounding for culture and for process-related issues, and it incorporates patient experience rounding as well. We want to make sure there is patient engagement, which helps us creating a zero harm environment.
The rounding tool also features the five categories of risk assessment: clinical operations, patient safety, employee safety, facilities and financial.
“We’ve created a service recovery tool within the app, which allows the leader to click on a tab, describe the current risk. It will allow you to find the person in your hospitals who would mitigate the risk, and click ‘send.’”
Then, as she describes, the ‘risk’ event goes to that person’s inbox, so they can complete the necessary task.
“The senior leader will go back to the floor as a second set of eyes to insure that the task has been completed,” Dr. Abi says.
The pilot is being done at UH Geneva and UH Conneaut health centers so that any technological issues can be smoothed out. Staggered roll-outs will then occur throughout the rest of the UH system.
“At UH, we want people to speak up and speak out,” says Dr. Abi. “Speaking out is not just telling us what is going on, but also knowing that leadership is trickling information back about what has been reported. To develop our speak-out culture, we are encouraging our leaders to sit down in localized work groups, look at the feedback that they as leaders have received, and convey to employees that there is a feedback loop.
“So, for example, if there is an issue on a certain floor, leaders come up with solutions and action plans and convey them to employees. As we all realize, human error is inevitable. Our goal as a high-reliability organization is to put processes in place that prevent error from reaching a patient or employee, creating a zero harm environment.
“To achieve this goal, we need the engagement of every leader, every employee and every patient at UH."