What's Behind an A? Working Every Day to Improve Patient Care

Tuesday, October 31, 2017

On October 31, The Leapfrog Group, a national nonprofit healthcare ratings organization, released its Leapfrog Hospital Patient Safety Grades for Fall, 2017. The Patient Safety Grade system assigns a letter-grade (A, B, C, D or F) to all hospitals nationwide based on their performance in preventing medical errors, infections and other harms. Augusta Health was one of 832 awarded an "A" for its commitment to keeping patients safe and meeting the highest safety standards in the U.S.

Richard Embrey, MD, is the Chief Medical Officer at Augusta Health, and helps to lead efforts in improving patient safety and quality of care. While he is grateful for the recognition, he believes it's much more important that the community understand the depth of the patient safety initiatives that Augusta Health employees and staff have in place every day to keep patients safe.

"It is a foundational principle in healthcare – first, do no harm. We place the safety and well-being of our patients as the number one priority. To accomplish this goal, we have developed some innovative processes and coupled those with basic common sense, hard work and vigilance to keep our patients safe," he says.

Among the most sophisticated, Automated Surveillance for Sepsis Alerts. Sepsis is a life-threatening complication of an infection. Sepsis is not rare, and is a condition faced daily at hospitals around the country. Augusta Health staff developed an algorithm that analyzes a patient clinical data to determine when a patient's sepsis score is rising, and then uses the internal communication system to notify the patient's care team to intervene. "Because of our Sepsis Alert System, we've been able to reduce death from sepsis significantly. Our rate is now 32% lower than the statewide sepsis mortality rate."

Other key initiatives have reduced CLABSI (Central Line Associated Blood Stream Infections)—it has been more than 500 days since the last CLABSI at Augusta Health. "It's an outstanding number, but we track it and talk about the processes and procedures every day," notes Dr. Embrey.

Some more common sense initiatives? Instituting a standardized process or "bundle" while closing the incision following colon surgery. "Many of these actions, including changing to a different set of instruments to close a wound than those used during the surgery, changing out gowns, gloves before closing —they are common sense. But when situations get complicated and hectic, it's easy to forget the basic stuff. So we've implemented dashboard and checklists to make sure the easy stuff isn't overlooked," Dr. Embrey explains.

Perhaps one of the most important initiatives has been the implementation of a Just Culture program. "As medical professionals, we must have zero tolerance for reckless behavior that endangers patients, " says Dr. Embrey, "but at the same time, we need to realize that care givers are human beings working in a complex, high pressure environment. When mistakes are made, and we need to foster an environment that focuses on learning from a mistake rather than simply assigning blame, which itself can create a culture where errors are more common. To be clear, there is a distinct line that defines unacceptable behavior and everyone on the team understands where that line lies, and our response to crossing that line and engaging in reckless behavior is known and consistent. But it's important to build a culture and an environment of trust so people feel safe to report and learn from errors. It's one of the most important efforts in all of medicine to improve patient safety."

"What our staff does every day is important work," adds Dr. Embrey. "and I am so very proud of their efforts to not just take care of patients, but to improve the way they take care of patients every day.

Augusta Health is an independent, community-owned, not-for-profit hospital whose mission is to promote the health and well-being of its community through access to excellent care. Named one of the 100 Top Hospitals in America by Thomson Reuters/Truven in both 2011 and 2012, Augusta Health has also been nationally recognized by HealthGrades as one of America's 50 Best Hospitals for clinical excellence and patient safety for three consecutive years. For more information about Augusta Health, its programs or its services, please visit the website, https://www.augustahealth.com.