Thinking Safe

Joyce Lahue, director of risk management for Baptist Health System in San Antonio, Texas, and president of the South Texas Society for Healthcare Risk Management, has helped drive a reduction in safety events at her hospital system. She tells HRMR how this was accomplished.

Joyce Lahue has a lot to celebrate. As the regional risk management leader for Baptist Health System, a five-hospital health system in San Antonio, Texas, and part of Vanguard Health System, she has helped her organization achieve a greater than 80 percent reduction in serious safety events over the 2010 baseline.
The change correlates primarily to a decided effort by Vanguard Health System partnering with a company, Healthcare Performance Improvement (HPI), to build a high reliability culture that includes a focus on event report information and analysis of every event, from near-misses to precursor safety events to serious safety events.

“As a risk manager I have always felt that reporting is a very important part of what I do. If the staff are telling me what’s going on, I have an opportunity to improve things before an event happens,” she says.

“Reporting is often only the tip of the iceberg, but the more reports you receive the more of the iceberg you can see. If you have a good reporting base you can trend types of events and then fix things or implement safety barriers before you have a major disaster or event.”

Through the information learned by implementing the HPI process Baptist Health has made it possible to identify common trends and to see how those trends might fan out to affect a whole unit, or another hospital.

“Trending can demonstrate indicators that the staff of a unit may be using risky behaviours and not following the rules or policy, or don’t know the policy—you can really pinpoint that,” she says.

The focus on safety is just one of several important changes Lahue has seen in her 15-year career as a risk manager.

“I am very proud of the way in which risk management and healthcare has moved to be more honest and transparent with our patients and families. Bad things do happen—we are all human and until you take the human out of healthcare you can’t fix all the problems.

“When I first came into risk management there was minimal transparency; the focus was on staying away from litigation. Today healthcare is more transparent and I love that because I really do believe that as human beings we’re very resilient, we can handle almost anything, but we need honesty, courtesy, genuine concern and respect. When these things are missing it is very difficult for the patient and for the staff.”

Lahue started her medical career as a registered nurse in oncology, before working in hospice and homecare and then moving into risk management. As with her work in oncology, part of the appeal of risk management lay in helping people through adversity.

“One of the good things I find in risk management is that while I can’t always change what happened to the patient, I can in some way make it better—either by making it safer for the next patient or providing something to the patient and family now to help to smooth things,” she says.

A CULTURE OF SAFETY
Lahue puts much of Baptist Health’s success in risk mitigation down to leadership and daily management meetings, the implementation of safety as a focus and a commitment to staff interaction. The leadership have implemented lean daily management and ‘gemba walks’, whereby members of the management teams visit the hospital floor and have regular conversations with the staff.

“It’s a very open environment for staff to report to leadership and vice versa,” she says. “In undertaking this journey the Baptist Health System has a much more open, transparent relationship with the patient/family and with staff.”

Every Monday at 7:30am Lahue and her colleagues hold a regional meeting where all serious safety events for the previous week are reviewed and discussed.

“We also review precursor events and near-miss events that would be very important to all five hospitals,” she says. “If we catch something on a Tuesday we don’t wait until next Monday to tell everybody; it goes out through our email system and leadership may choose to hold a safety stand-down.

“If, for example, it is determined that staff have diverted from standard practice and have made their own shortcut that has caused or has the potential to cause an adverse event, leadership may have a safety stand-down with staff to point out the shortcut or deviation from performance standards. If something happens in surgery in one facility we’ll take it to the same unit in all five facilities and make sure the same event doesn’t happen at the next hospital.”

Improving staff and physicians’ communication has been pivotal to creating a culture of safety, says Lahue.
“I’ve been a nurse long enough to remember the days when nurses were taught that if a physician came on the floor you gave him your chair,” she says. “Now staff are not as afraid to ask questions and tell the physician if they are not comfortable with something. It’s much more open and the physicians are on board—they like the interaction and respect, for the most part, staff pointing out potential safety concerns. In addition, a physician will say that they’ve come across a safety concern and report it for action or inclusion in trending.”

Despite the air of openness, Lahue is aware that some staff may still feel anxious about speaking out, so to help them there is also an anonymous reporting system that enables staff to raise concerns by telephone or electronically.

Lahue is able to share insights with risk managers outside her health system through her involvement in the South Texas Society for Healthcare Risk Managers. She is currently in her second term as president (her first was 2003–2004), and she enjoys networking with the group as well as ensuring that the very small chapter remains viable so that risk managers from the area have people to network with. She recognises the importance of this, having first joined the society when she began working as a risk manager herself, and knows that networking is important when sometimes what you are dealing with seems to be all negative.

“With a small group of core people as members and officers of the society, we have a commitment to providing new risk managers with a network, somewhere to reach out to, and we will help guide them through whatever they need. This networking is good for all of us, just like the networking done when we attend ASHRM every year. It helps to encourage the risk manager as well as teach them things they may have not yet experienced,” she says.

Asked about the top concerns for her members at present, she pinpoints the shift to electronic medical records, closely followed by the strains on provision of beds and services for psychiatric patients.

“Psychiatric patients and the transient homeless are a huge challenge in our area,” she says. “Psychiatric patients and the deficit in available resources to provide for them are very sad. Patients, due to their illness, may be violent, confused; they can injure staff, they can injure themselves. If a psychiatric patient arrives in an emergency department seeking treatment we must provide care for him or her. If, as often occurs, there is no place that has an open psychiatric bed, patients—for their own safety and treatment needs—must stay in the emergency department until such time as they can be safely transferred or discharged to an appropriate treatment facility.

“With the deficit in resources, the time the patient remains in the Emergency Department can be 24 hours to three days. The challenge of trying to manage the patient with specific psychiatric needs and the risks associated with potential injury to the staff or the patient, plus finding the resources to care for that patient, make it a huge risk issue.”

While issues of this kind are influenced by forces outside her control, Lahue is pleased at the extent to which it has been possible to improve the hospital experience both for patients and staff. Risk management is an ongoing journey and it seems likely that serious safety events will decline still further as Baptist Health System’s hospitals pursue to their commitment to quality, openness and transparency. For Lahue, this is where the job satisfaction lies.

“I love the patient safety aspects of my job and being able to see change that leads to safer and happier patients and staff,” she says. 