Nursing Faculty Matters, February 2012
Preaching Safety from the Ground Up
When Seattle’s Virginia Mason Medical Center wanted to retool its management practices, it looked for inspiration not from another hospital but—of all places— the auto industry. By applying basic elements of Toyota’s management philosophy, it now has the number one safety record of any hospital in America. Following in those footsteps, administrators at Drexel University’s College of Nursing & Health Professions set out to boost patient safety in an even more far-reaching way by adopting some of the same principles into its nursing curriculum. —By Tom Kivett
Drexel’s Dr. Mary Ellen Smith Glasgow was so impressed with the safety practices and outcomes at Virginia Mason that she went to meet with administrators there to learn more. Armed with more understanding about how elements of the Toyota Production System (TPS) were implemented at the hospital, she was convinced that some of those same tenants could be applied to Drexel’s graduate and undergraduate nursing programs.
“What if we could instill safety practices in nursing students earlier in the learning process?” said Mary Ellen Smith Glasgow, Associate Dean for Nursing and Undergraduate Health Professions at Drexel University. “Our thinking was that if we could take some of these proven safety practices and apply them to our curriculum in much the same way that Virginia Mason adopted them to their management model, then we could set a higher educational standard for safety that would stay with our students long after they graduate.”
One of the basic thrusts of TPS is to boost quality by creating a horizontal chain of command. On the Toyota factory floor, every worker is given authority to stop the line if they see a defect or issue that could affect safety. Every time the line is stopped costs money, however workers are never reprimanded for stopping it rather they are applauded.
At face value it might be difficult to see how healthcare can benefit from a system designed for building cars, however, it is easy to appreciate how it could help identify issues and problems that might otherwise be missed because every nurse and doctor has the power—and confidence—to speak up. This aspect of TPS is in full force at Virginia Mason, where even the janitors have responsibility to report safety infractions.
Although Virginia Mason pioneered using TPS in healthcare, it is now being adopted by more widely at other hospitals. Drexel, however, is the first academic institution to introduce it to nursing education. In 2011, the school revised its curriculum to incorporate some of the Toyota principles with a focus on quality and safety. In January 2012, the program was officially rolled out to students and threaded through the curriculum.
“In essence, we’ve established an atmosphere where safety is everyone’s concern,” said Dr. Glasgow, “Students are now beginning to think about safety from macro and micro levels during their educational process. They are learning how to be patient-safety advocates and to view themselves as patient-safety advocates.”
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Helping Nurses Speak Up
One of the first changes Drexel made to the curriculum was to help new nurses with ‘failure-to-rescue.’ These situations occur when a nurse’s inaction results in patient death during a hospital stay. In these cases, the patient required an early intervention, which was not provided.
“One reason failure-to-rescue occurs is that new nurses do not have as finely honed assessment skills as do seasoned nurses so they miss the early warnings signs of a medical issue,” continued Dr. Glasgow. “Conversely, sometimes they recognize a problem but do not trust their intuition and are not comfortable to call the physician because they might be wrong. All those delays can hurt the patient. We have also implemented inter-professional simulation days with our College of Medicine. “
To address this problem, Drexel turned to simulation to create potential failure-to-rescue scenarios. Most nurses will never see these kinds of situations until well after graduation when they actually start working. In these complex patient scenarios, students are asked to detect the signs and symptoms of a complication in a timely manner and to intervene by mobilizing the necessary resources.
“These scenarios are designed to improve students’ assessment skills so they have the data and confidence to notify the physician or rapid response team,” continued Dr. Glasgow. “We then pretend to be a physician on the phone and give a bit of push back to see if they are assertive enough to get their opinion heard.
“We’re not just teaching them what to do but how to do it,” added Dr. Glasgow.
Setting a New Standard Through Standardization
Another aspect of the Toyota philosophy is standardization. Drexel, among other schools, has found that one of keys to improving safety in healthcare is through better standardization.
“It’s difficult and confusing when every teacher teaches a different way to do something,” said Dr. Glasgow. “We try to teach skills the same way to all. For example, if everyone learns to wash their hands the same way then you can really tell when there is a problem with that skill.”
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Limiting Interruptions Reduces Error
Another area Drexel has sought to address is to eliminate interruptions when a nursing student is administering medications. Studies have shown that error rates increase when nurses are interrupted. And, of course, nurses are frequently interrupted. Drexel instituted a policy where instructors never interrupt a student when he or she is administering medications unless required for patient safety.
“Policies like this need to be put in place in more hospitals,” said Dr. Glasgow. “What we’re doing is introducing them on the ground floor while students are still in school so they will be ingrained in their minds by the time they are working in the field.”
Dr. Glasgow also is pioneering some other new ideas to reduce nurse interruptions at some of its partner hospitals and with funding from the Robert Wood Johnson Foundation to replicate practice at Virginia Mason. At Virginia Mason Medical Center, a hospital with medication rooms, when a nurse goes in, a red light goes on signaling that no one should disturb, much like when a pilot is in the cockpit with the door closed.
“We’ve taken that concept one step further in situations where there is no med room,” continued Dr. Glasgow, “We are planning to use arm bands and vests woven with smart fabric allowing them to light up and blink as a way to tell others, ‘do not disturb me, I’m preparing meds.’”
As a way to get new students into the safety groove from Day 1, Why Hospital Should Fly by John Nance will be required reading in all Drexel introductory undergraduate nursing courses. It draws parallels from the aviation industry, which are quite instructive for hospitals and anyone who works in healthcare. Nance suggests that if we managed aviation like we do hospitals, there’d be crashes everyday.
Is the new program working? Drexel is still collecting data but it is quite clear that it is helping build better communication and collaboration.
“Without a doubt, we’re teaching students to be patient advocates, and to communicate clearly and comfortably with physicians and other healthcare providers,” Dr. Glasgow added. “When they complete their studies, they’re going to be more assertive and focused on safety.”
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