Innovative Safety Lessons
Lessons Learned from A Nuclear Power Plant
Sometimes the best advice comes from an unlikely source. Gary Yates, MD, medical director of clinical effectiveness for Sentara Healthcare in Norfolk, Va., discovered the key to improving the safety of his hospital from administrators of nuclear power plants. His innovative approach to safety improvements landed Sentara Norfolk General Hospital the 2004 American Hospital Quest for Quality Prize, awarded by the American Hospital Association.

"The traditional belief is that a high degree of awareness coupled with education will change behavior," says Dr. Yates. "We took the opposite approach by identifying specific behaviors that needed to improve, and found ways to change those behaviors."

To begin the process, Dr. Yates performed a diagnostic test to judge the strengths and weaknesses of his staff. He found the usual suspects: less-than-adequate communication, lapses in attention, breakdowns in following safety policies already in place and a failure to recognize high-risk situations.

Once the problem areas were identified the staff of the hospital were responsible for developing behavior based expectations (BBEs). For instance, the staff at Norfolk General developed the following solutions to the designated problem areas:

• Clear communication. Use clarifying questions and a repeat of orders so, for example, a dosage of 50mg is not mistaken for a 15mg request.
• Lapses in attention. To ensure staff pay attention to details during repetitive tasks, a mnemonic device entitled SAFE (which stands for stop, analyze, focus/perform, evaluate) was developed. "If you have 100 two-second pauses throughout the day, that's only three additional minutes that dramatically decrease attention lapses," says Dr. Yates.
• Red rules. Pick out the most important safety concerns - high-risk situations for instance - and demand 100 percent compliance. For instance, our staff will not pass a scalpel to a surgeon unless a pause takes place (to avoid wrong-site incisions).

Dr. Yates warns the success of BBEs is dependant on monitoring the staff to make sure the guidelines are being followed. He says it's a good idea to assign managers and directors with leadership potential to provide daily oversight of the program; this creates a grassroots feel to the program being rolled out and makes the staff feel it is the employees initiating the changes instead of something coming down from management.

Most importantly, says Dr. Yates, give your staff the tools they need to succeed. "As a leader, you need to be clear as to what needs to be focused on and give the staff tools that help. Without tools, you're just asking them to be more vigilant, and that won't work."

Improving Efficiency
Small Hospital Hands Out Big Bonuses To All After Surgical Volume Increases
Everybody gets a check. That's what happened at Bryan W. Whitfield Memorial Hospital in Demopolis, Ala., when management was able to increase the number of outpatient cases it hosts. Within a year, outpatient cases jumped from 38 percent of overall surgical volume to 52 percent. All full-time employees got a $1,000 bonus, while all part-time employees received $500.

The mastermind behind the lucrative percentage flip and the gain-sharing program is Mike Marshall, CEO of the Tom Bigbee Healthcare Authority. Mr. Marshall came to BWWMH from HealthSouth Corporation with 18 years management experience in not-for-profit and for-profit hospitals. When he moved to Demopolis he found a hospital barely surviving on the blood, sweat and tears of the staff; today the facility is an example of a successful small-town hospital.

A key component of the turnaround involved Mr. Marshall's ability to increase surgical volume - in particular cases that could be done on an outpatient basis. Here are three ways he improved outpatient volume:

• Attract specialists to increase referrals and walk-ins. "When I got here, there was a general practitioner who ran the OR suite. He did good work but was getting older, so we identified a board certified general and orthopedic surgeon who we wanted to practice at our facility. The key to attracting a specialist is simply making it easy for them to operate by adapting the OR schedule to their needs. We also provide our surgeons with new equipment and surround them with staff who understand how to manage an OR proficiently."
• Increase the scheduling of efficient cases. "Increasing surgical volume is strongly tied to performing cases that can be done efficiently. We shifted our focus to endoscopic procedures and created an active eye surgery component. In the future, we plan to start urology and plastics clinics and expand more into those areas."
• Improve staff morale. "Shifting our focus to more outpatient cases also helps the morale of the staff. They enjoy the pace of the procedures, and the schedule is less of a strain on our docs. We also believe in rewarding our staff for working as a team to improve our surgical volume. The checks showed our appreciation for last year. Now the slate is wiped clean, and we'll continue to strive for improvement next year."

	By Daniel Cook Hospitals are the primary work setting for more than one-third (37 percent) of all physician assistants, according to the Academy of Physician Assistants (AAPA) 2004 Annual Physician Assistant Census Report. Twenty-four percent of respondents to the census reported their specialty included surgery/surgical subspecialties ...As reported in October's Hospital OR Monitor, crowded hospitals may look to scheduling elective surgery on weekends to maximize case efficiency. "It's a trend based on demand and surgical volume," says Ron Czajkowski, spokesman for the New Jersey Hospital Association. "A number of our hospitals are looking into night and weekend elective surgery for the sake of patient convenience and also as a means of increasing revenue." Robert Wood Johnson Hospital in New Brunswick, N.J., has realized a 10 percent increase in surgical volume over the past year, says Lorraine Butler, RN, MSA, CNOR, and the hospital's vice president of perioperative services. "Non-high-volume docs who don't have block times during the week are able to schedule their cases on Saturday, and patients don't have to miss work after having a minimally invasive procedure done." ...Merritt, Hawkins & Associates, a Texas-based physician search firm, asked 4,000 hospital CFOs how much revenue physicians generated for their hospitals in 2003. Based on inpatient and outpatient revenue from patient referrals and procedures, orthopedic surgery generated the most revenue for hospitals, with $2,992,022; general surgery ranked fifth at $2,446,987.

Strange But True
One night, a patient and his girlfriend got into a heated argument, resulting in the girlfriend's stabbing him with a steak knife. Luckily for him, it didn't cause any major damage. But the girlfriend waited for us outside the OR because she wanted the knife back to complete her set.

Garnett Irby, RN
Nurse Manager of Surgical Services
Loris Healthcare System
Loris, S.C.

Can you contribute a funny quote or a strange but true tale? If so, please e-mail associate editor Daniel Cook at "[email protected]").

Do You Know What Makes Your Nurses Tick?
Fourteen hospitals in New York are using online surveys called Nurse Engage to improve staff satisfaction and retention. The survey, which takes about 15 minutes to complete, asks nurses questions designed to measure their trust, pride and loyalty in their facilities, nurse managers and peers; the survey doesn't ask questions with respect to salary or benefit satisfaction.

The premise is that by better understanding engagement issues, facilities will have a more satisfied staff, which is a key link to retention.

"We're very excited to participate," says Stephanie Von Bacho, MS, RN, the director of nursing accreditation and advancement for the University of Rochester Medical Center at Strong. Ms. Von Bacho used letters to staff and her hospital's internal Web site to spread word about the survey. "This will help us retain staff during a national nurse shortage, and we also hope it will turn into a recruiting tool."