Insights

“Encourage Bravery” and Other Advice for Reenergizing Your Safety Work

January 25, 2024

By The Institute for Healthcare Improvement

Why It Matters

For MemorialCare, implementing the National Action Plan led to reductions in harm, advances in equity, and increases in safety culture ratings.

In early 2022, almost two years of COVID-driven illness and death, regulatory changes, financial challenges, and seemingly endless stress were taking their toll on people in health care. Helen Macfie, PharmD, FABC, the past Chief Transformation Officer at MemorialCare Health System (Fountain Valley, California, USA) remembers it well. “People were tired, rethinking their careers, their lives, where they wanted to live,” Macfie said in a recent interview.

At the time, Macfie was part of the IHI Fellowship Program during which she heard IHI Vice President Patricia McGaffigan give a presentation on Safer Together: A National Action Plan to Advance Patient Safety. McGaffigan made a compelling case for using the plan’s recommendations, self-assessment tool, and implementation resource guide to refocus patient and workforce safety amid the pandemic. Rather than see this call to action as an unreasonable demand at a particularly challenging time in health care, “it felt like the perfect thing to get us out of our doldrums,” Macfie said.

Learn about the National Action Plan at the IHI Patient Safety Congress

While MemorialCare still focused on their day-to-day challenges with COVID-19 and running a complex health system, diving into the National Action Plan (NAP) helped them reconnect to their long history of patient safety improvement. For example, before the pandemic, MemorialCare had dropped their inpatient harm rate (a roll-up metric of key harms) by 84 percent, but — as was the case for many health systems — the advent of COVID caused backsliding. Implementing the National Action Plan provided “an opportunity to refocus and get back to basics on our safety goals,” Macfie explained.

Signs of Improvement

MemorialCare has done a range of quality improvement work over the years and accelerated their efforts as members of the IHI Leadership Alliance. Macfie describes implementing the National Action Plan (NAP) as offering a chance “to step back, assess, and rethink what to improve next.” The NAP assessment includes a deeper dive into how an organization is performing in four key domains to support their focus to advance patient safety: Culture, Leadership, and Governance; Patient Engagement; Workforce Safety and Well-Being; and Learning System. Here are some of MemorialCare’s results:

Reductions in harm. The National Action Plan provided an opportunity to change how MemorialCare responded to the challenges posed by the pandemic. Actions included a recommitment to reducing harm, adapting best practice algorithms for COVID care (e.g., sepsis and pressure injury prevention), and retraining all staff on harm prevention bundles, including traveling nurses and bedside staff. As a result, they successfully reduced harm rates down to pre-COVID levels, with a reduction of 84 percent from their historical baseline.
Advances in equity. MemorialCare has been working on advancing diversity, equity, and inclusion as a member of the IHI Leadership Alliance since 2017. In response to the global acknowledgement of racial injustice and health inequities exacerbated by the pandemic, the organization refocused on equity in 2020. MemorialCare developed a comprehensive plan that included incorporating an equity lens in data analysis and stratifying quality and safety data by race, ethnicity, age, and gender identity. For example, after identifying disparities in maternal morbidity and mortality, they increased communication with mothers and their partners before, during, and after delivery to elicit their preferences. They also educated the full care team on unconscious/implicit bias, racism, and tools to support respectful care. These efforts and others reduced gaps in outcomes for C-section delivery rates for NTSV births — nulliparous (first pregnancy), at term (> 37 weeks), singleton (no twins or multiples), and vertex (not breech or transverse) — and led to a revised care team approach for prenatal, intrapartum, and postpartum care.
Increases in safety culture ratings. MemorialCare has been working for many years on cultivating a safe and just culture where staff feel comfortable speaking up and reporting errors. Implementing the National Action Plan helped them make significant improvements in staff safety culture survey ratings, with over four out of five respondents now giving “very good” ratings for both culture and resilience, reflecting increased trust in supervisors and a supportive environment. “The connection between creating a workplace where you can speak up and be part of solutions that improve patient and workforce safety — and how this contributes to reducing burnout, increasing well-being and joy at work, and workforce retention — is very important to this work,” Macfie noted.

Though Macfie is clear there continue to be opportunities for improvement, she is understandably proud of how MemorialCare’s outcomes demonstrate considerable progress and positive impact across multiple domains. She is also eager to share some lessons learned from using the National Action Plan and its self-assessment tool to revitalize patient and workforce safety:

Encourage bravery and ensure psychological safety. Create an environment where colleagues feel comfortable providing honest responses to the self-assessment. Allow anonymity to assuage fear of repercussions or about not necessarily having responses to all the questions. “Do not assume everyone will feel comfortable replying to the survey honestly or admitting they don’t have all the answers,” Macfie advised. “Make it so [respondents] won’t be called out for having an opinion that might be different from somebody in power or somebody who thinks the status quo is great.” For action planning, respond to the findings by fostering collaboration and open discussion. Look at both the range of feedback per question and the open-ended comments. “Try to make it an enjoyable team-building exercise to build shared will to take on the opportunities for improvement,” Macfie recommended.
Keep it simple to support full participation. “I think people look at something like [the National Action Plan self-assessment] and assume it’s going to be big and complicated,” Macfie remarked. She and other colleagues who have used the assessment have focused on getting answers from a smaller number of system and hospital executives, key physician roles, and other leaders most likely to have informed opinions on how to rate each item. In addition to inviting candor, her team asked their busy colleagues to spend no more than 30 to 60 minutes on the entire survey. Macfie credits this advice with helping them attain a 100 percent participation rate.
Avoid “boiling the ocean.” Instead of trying to address everything at once, understand that you will need to prioritize your efforts to make progress. MemorialCare shared their results as both average scores per element and ranges to show any dispersion of responses. Her team was then able to jumpstart the ensuing discussion of solutions and priorities. “You’re going to find something you can work on in every single area, but it’s hard to work effectively on too many things at the same time,” explained Macfie.
Assign responsibility for improvement opportunities. Macfie created a summary report showing the results, recommended actions, and next steps for the review and endorsement of the participating survey team. The report was then shared with their board quality committee and leadership teams. These actions ensured a shared understanding of the opportunities for improvement, the teams’ priorities, and the designation of those responsible for moving the specific improvement plans forward.
Identify where there is energy and focus there. Keep the improvement plan simple and manageable. Concentrate on areas where the team has the most energy and where improvements will have the greatest impact. Macfie and her team repeated the survey in 2023 and saw a significant jump in their ratings. This led to another cycle of action planning to continue “closing the gap.”

For Macfie, the greatest value of implementing the National Action Plan was having a process to better understand her organization and then work with her colleagues to produce shared solutions. She suggested that other organizations could benefit from using the NAP to get their key leaders’ perspectives. Macfie also noted that CMS released their Measures Under Consideration for Patient Safety Structural Measures (PSSM) in December 2023 and suggested that the NAP would be an excellent tool to complement and prepare for the PSSM attestation process.

“It can be easy to assume that either everything is fine, or everything is wrong in safety and quality,” said Macfie. “At the end of the day, it’s about doing the best we can for the patients and families we serve, the workforce of staff and physicians who are on the front lines, and the health care teams that support them.”