As an academic medical center and the safety net for the St. Louis region, Barnes-Jewish Hospital sees any and all kinds of patients and conditions — making its drive for excellence especially tough.

After all, if you specialize in a few things, it’s easier to excel at them because you have a limited focus. Trying to be the best at everything, is a lot more difficult. So the hospital took on one issue at a time.

Step 1

The first step in achieving its goals was to employ “lean management.” This management system was designed to minimize waste, standardize processes and drive continuous improvement.

Standardizing patient care was key. While Barnes-Jewish Hospital standardized its processes for patient care, it allowed tailored intervention per individual patient — when appropriate. This “variation” was allowed because it benefits patients by providing care specific to their needs.

Step 2

The next step involved training the facility’s future providers. The hospital requires residents to have four hours of lean training and then they have to participate in a process improvement project.

One of these projects was for central line-associated blood stream infections (CLABSIs). Previously, the hospital’s seven intensive care units (ICUs) each had its own method for reducing CLABSI. Under the lean system, all ICUs standardized their practices in insertion, maintenance and follow-up.

For example, the clinicians who insert central lines were trained in a simulation to use evidence-based, standard practices, such as being required to wear a gown, gloves and have a sterile field.

The nurses, who maintained the catheters, had a standardized schedule for changing dressings and the hubcaps of the line.

And finally, the clinicians were trained to question the patient’s need for continued use of a central line on a daily basis using a standard checklist.

Thanks to this process improvement project, the hospital experienced a dramatic drop in CLABSIs.

Other projects tackled at the facility included: diabetes medication errors, pressure ulcers and transition of care. To read more about these click here.

Has your facility implemented any quality improvement projects? If so, tell us about them in the space provided below.

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That’s the disturbing takeaway of a recent survey of health care workers by the Agency for Healthcare Research and Quality (AHRQ). The survey looked at data from almost 60,000 staffers at more than 1,100 hospitals to measure how well the organizations had instilled a “culture of safety.” The results aren’t promising.

Most employees reported at least some reluctance to report safety incidents for various reasons. Among the findings :

• 50% of employees said they thought their mistakes are held against them by management
• 54% said that when an adverse event is reported, it appears the person involved is “written up” instead of the actual incident or problem
• More than half of respondents said they don’t feel safe questioning the safety actions of those with more authority, and
• 37% said they are afraid to ask questions about potential safety mistakes.

The findings are troubling: An environment where workers feel safe reporting potential safety issues is vital to any hospital that wants to improve. Even worse: The results of this survey haven’t changed in any significant way since it was first asked in 2007 — which means all the time and energy spent creating a “culture of safety” hasn’t done much to actually make employees feel safe speaking up.

What would it take for hospitals to make staffers feel truly safe in reporting safety issues? Share your thoughts in the comments.

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A typical example is Massena Memorial Hospital in Massena, New York. The hospital’s board of managers recently voted to spend about $20k for equipment including surveillance cameras, lock-down buttons, and pendants staffers can use to summon police.

Massena has experienced a series of violent incidents recently, including a man who committed suicide near the ER entrance and a visitor to the hospital who broke a window.

Massena’s far from the only hospital dealing with the issue of safety. In recent months there have been numerous reports of shootings, attacks on staff and other disturbances at hospitals around the country — a trend that seems to be on the rise.

While no one would argue against improving safety on hospital campuses, health care organizations do have a need to make sure patients and visitors feel not only safe, but welcome. There have been cases of over-reactive security measures that have resulted in violent incidents as well.

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The incident happened at Bronx-Lebanon Hospital Center in New York last Wednesday when a man fired one or more shots in the waiting area. Police arrested a suspect the next day.

Police say the suspect was shooting at a patient who had been in an altercation earlier in the day. The patient saw some of the people from the earlier fight in the waiting area and called his own friends for back-up. One of those friends is believed to have fired the shots.

The nurse and guard who were shot weren’t the targets and were most likely wounded by fragments of the bullet after it ricocheted off a wall. Both the nurse and guard are in stable condition and expected to recover.

The incident is just the latest raising some questions about the security of patients and workers at hospitals. The hospital is located in a dangerous neighborhood according to some staffers. Although there are security guards at each entrance, metal detectors and similar security devices aren’t in place.

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That’s the sad finding of the study, “The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives.”

According to the researchers, although 85% of health care workers said they had been alerted to a potential patient risk by a safety tool, 58% of those who had received a warning admitted they hadn’t mentioned it to other health staff or resolved the problem.

Respondents cited three main reasons that safety issues were difficult to bring up: Other staffers’ dangerous shortcuts, incompetence and disrespect were seen as “undiscussable.”

While safety devices have an important role to play, their usefulness is hampered when health care staff have such difficulty communicating with each other.

The study was a joint project of the American Association of Critical-Care Nurses, the Association of periOperative Registered Nurses and VitalSmarts.

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A 69-year-old repairman was killed while he worked in the elevator shaft at Sts. Mary & Elizabeth Hospital in Louisville, Kentucky. The worker, William L. Motley, an employee of Schindler Elevator Co., was working on a ladder in the shaft when he became pinned by the elevator car. Motley died of multiple blunt force injuries and traumatic asphyxiation.

OSHA is investigating the incident.

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Some nurses get fancy chocolates from grateful patients. This one got goosed.

Joseph Wolf, a patient at Sacred Heart Hospital in Allentown, Pennsylvania, faces indecent assault, harassment and disorderly conduct charges after he twice grabbed the posterior of the emergency room nurse tending to him.

Wolf was in the ER claiming he had been assaulted. Witnesses said he repeatedly demanded pain medication and used vulgar language with the staff.

Finally, when the nurse told him no pain meds were being ordered for him, he grabbed her buttock and said “Well, you’re a nurse, right?” After police were called, Wolf told them he was just trying to thank the nurse for her administrations — and compared it to any other friendly greeting, adding, “In Europe, they kiss.”

Wolf was arrested and held in lieu of $8,500 bail.

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A new study by the Emergency Nurses Association (ENA) reveals startling levels of violence against emergency department nurses.

A nine-month survey of emergency department nurses found that each week 8% to 13% experience some form of physical violence at work. More than half the nurses surveyed said they had experienced verbal or physical abuse at work in the past week.

Among those who experienced physical violence, 15% said they were injured — and in half of those cases, no action was taken against the abuser.

As disturbing as the level of violence is, hospitals’ reactions do little to help. Three-fourths of the nurses who reported violent incidents said they received no response from the hospital. When hospitals did respond, it was most often to give the aggressor a warning.

Who’s at risk — and when

According to the survey, the abusive person was typically either a patient or a patient’s relative in 97% of physical abuse cases, and 91% of incidents of verbal abuse. The most common location for an aggressive act was in a patient room (80% of incidents). About 23% of the abuse took place in common areas, such as elevators, stairwells and hallways; 15% of incidents took place at the nurse’s station. (Some incidents carried into one or more locations.)

Nurses are at most risk when triaging patients (38% of incidents), restraining or subduing patients (34%) or performing an invasive procedure (31%). Male nurses were more likely to be assaulted than female nurses –15% of men reported incidents compared to 10% of women.

Call to action

The ENA has asked the Occupational Safety & Health Administration (OSHA) to change its current guidelines on violence prevention into mandatory standards (downloadable PDF) that hospitals and other health facilities would be required to follow.

The current guidelines recommend hospitals do the following:

• establish a zero-tolerance policy toward both physical violence and verbal abuse
• encourage reporting of all incidents
• ensure employees who report incidents don’t face reprisals, and
• have an ongoing relationship with a liaison in law enforcement to handle incidents as they arise.

The ENA also said hospitals should debrief employees who report incidents to tell them whether the police had been contacted and if the perpetrator was warned, arrested, sent for a psych consult or fled the scene. As for prevention, the ENA encouraged more hospitals to use panic buttons, silent alarms, enclosed nurses’ stations and improved lighting to create an overall safer facility for everyone.

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Columbia University’s Mailman School of Public Health surveyed 1,100 essential workers about their willingness and ability to work during a potentially lethal pandemic. All responses were anonymous.

The researchers found that 80% of workers expected to be able and available to report to work, but only 65% were willing to do so. All told, that left fewer than 50% of key personnel both able and willing to report for work when the risks were highest.

Several factors affected which workers were willing to show up for work under the hypothetical conditions of the survey. Public health workers were most willing (74%) while correctional workers were the least willing (only 56%).

Workers were also more likely to say they were willing to report if their workplace had safety measures in place already, and they had a high degree of trust in the employer’s ability to protect their health. Other factors that led to increased willingness to work during a crisis:

• pandemic vaccine programs
• an established pandemic plan
• employer-provided respirators, and
• prior experience working during a pandemic.

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The OSHA inspection was in response to worker complaints about an unsafe environment. The agency found that the hospital had committed a serious violation of the general duty clause for failing to provide a workplace free of recognized hazards.

Most of the incidents took place in the psychiatric, emergency and general medicine wards.

Among the corrections OSHA suggested:

• Create a written standalone violence prevention program for all hospital staff. The program should include threat assessments, controls and prevention strategies; staff training and incident reporting.
• Provide security staffers trained to deal with violent or aggressive patients. Security should be immediately available.
• Screen all psychiatric patients for potential violent behavior and flag those with a history of violence.
• Ensure that employees aren’t left alone with potentially violent patients in the psychiatric ward.

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