Safety

Employee engagement/Culture of Safety Survey

More than 51,000 team members (89 percent response rate) and 2,300 employed physicians (71 percent response rate) completed a combined Press Ganey Employee Engagement and Culture of Safety Survey this year. For employee engagement, both team members and employed physicians ranked above the national and NYS average based on the six engagement items. Team members outperformed the national benchmark across every Culture of Safety domain — Overall, Prevention and Reporting, Pride and Reputation, and Resources and Teamwork as shown.

Favorable ratings for the following statements:

Robotic Surgery

Northwell Health has one of the largest robotic programs in the country with a total of 30 robots in use at nine Northwell Health hospitals. Since 2017, a total of 14,453 robotic procedures were performed.

To improve results, Crowd-Sourced Assessment of Technical Skills (C-SATS) is used to evaluate the technical skill of surgeons who perform robotic surgery through the use of video recordings that are reviewed by certifi ed personnel. These reviews are delivered directly to surgeons as feedback to improve their technical skills. C-SATS technical reviews were performed in 20% of the robotic procedures performed from 2017–2019.

Northwell health is recognized as a Network of Excellence in Advanced Robotic Surgery by the Surgical Review Corporation.

Enhanced recovery after surgery (ERAS®)/Enhanced Recovery Program (ERP)

ERAS/ERP refers to an evidence-based bundle of interventions that, when implemented together, decrease preoperative stress, reduce postoperative pain and complications and accelerate recovery, leading to early discharge. Implementing these interventions requires open communication and collaboration among all health care professionals caring for surgical patients as the recommendations span the patients’ entire surgical experience. Data from one of the pilot sites shows the reduction in excess days achieved due to ERAS/ERP. Excess days may have negative implications on patient safety, clinical outcomes and patient satisfaction, therefore reducing these days is essential.

Optimizing smart pump technology by reducing clinically insignificant alerts

Improving the safety of clinical alarm systems is one of The Joint Commission’s 2020 National Patient Safety Goals.® Currently, most strategies to reduce alert and alarm fatigue are related to physiologic monitors and clinical decision support systems. At baseline (September 2018), infusion pumps at Northwell Health triggered over 750,000 alerts/ alarms, contributing to the total alert and alarm burden in the patient care setting. Infusion pump alerts/alarms are usually characterized as clinical alerts, e.g., dose error reduction software (DERS) or mechanical alarms, e.g., low battery, occlusion and air in the line. The goals of this initiative focused on reducing insignifi cant clinical alerts generated by DERS.

Infusion pump data were obtained through a web-based data source. Snapshot data for the top 10 alerts by drug were obtained for three tertiary and three community hospitals. The medications dexmedetomidine and propofol were among the drugs with the most alerts. Data were then evaluated for frequency of overrides and clinical signifi cance. Dose limits were adjusted if DERS triggered an alert that was deemed clinically insignifi cant. Changes to the DERS were implemented in April 2019. Total number of alerts and frequency of overrides before (September 2018) and after (September 2019) DERS update for dexmedetomidine are shown.

Optimization of dose error reduction software (DERS) for dexmedetomidine and propofol decreased overall infusion alerts by nearly 20 percent without any negative impact on patient outcome.

Limiting computerized tomography (CT) radiation exposure

A CT scan of the lumbar spine is commonly used to evaluate lower back pain in the acute post-traumatic setting in patients with osteoporosis and chronic steroid use when a compression fracture is suspected, and in patients for whom magnetic resonance imaging (MRI) is contraindicated. Due to the frequency of the CT scan lumbar spine order, the Imaging Service Line set out to standardize the CT scan lumbar spine protocol across Northwell Health hospitals and ambulatory sites. The goal was to establish a protocol that would optimize the diagnostic capabilities of the examination while limiting radiation exposure.

During implementation, vendor specific protocols were created, uploaded on each CT scanner and posted on the Imaging Service Line website. Incremental dose reduction was instituted while monitoring diagnostic image quality. Through this process, the mean CT scan lumbar spine dose decreased and variability of individual scanner doses was reduced.

When compared to the national benchmark from the American College of Radiology National Dose Index Registry (NDIR), the Northwell Health mean CT scan lumbar spine dose decreased from above the national median in 2018, to below the national median in the final measured quarter of 2019 as shown. Doses were consistently located in the mid-range of the second quartile for the nation.

Cancer Institute – Medical Oncology: Outpatient weekly safety calls

This collaborative safety initiative aims to establish high-reliability ambulatory cancer centers and enhance the culture of safety. Leadership from the Monter, Imbert and Greenlawn cancer centers participate in a weekly safety call that focuses on improving situational awareness through both prospective and retrospective reporting of concerns related to patient safety. The calls formalize and streamline a structure to identify, measure and resolve safety incidents and near-miss events. In addition to reporting patient occurrences, events such as drug shortages, environmental hazards and equipment failures are also discussed. Input from front-line staff is paramount and is gained through formalized internal reporting structures.

Discrete goals of the initiative include increasing near miss reporting while decreasing the time to resolution of serious safety events. Achieving these goals as well as using the improveNorth safety event reporting application enhances the organization’s safety culture.

Obstetrics and Gynecology (OB/GYN) Service Line: Inpatient weekly safety calls

The Northwell Health OB/GYN Service Line is designed to support high-quality health care in a cost-containing environment as well as provide both patient and clinician satisfaction. OB/GYN system leadership recognized that the hospitals and OB/GYN teams required support to foster transparency and sharing among the sites. Weekly safety calls were initiated to provide a forum for communication among the sites on a regular basis at a predetermined day and time. During the calls, common issues are discussed and best practices are identified and disseminated.

Examples of practice changes discussed and implemented include universal cord blood gas completion, standardization of the second stage of labor guidelines and best practices to support vaginal delivery.

Enhanced root cause analysis

Root cause analysis (RCA) is a structured problem-solving technique that results in the implementation of one or more corrective actions to prevent adverse events. The technique involves an evidence-based understanding of the fundamental causes of errors and events and is a key management function for correcting serious deviations of outcomes from expectations.

To standardize and enhance our organizational approach to RCA, a group of content experts from across the organization convened to build on our internal best practices and introduce well-tested methodologies utilized in high-reliability organizations (HROs). A key intervention was the development of a customized, interactive, case-based learning workshop to support the deployment of a new, standardized system approach to RCA. Content was intertwined with critical components of Just Culture with the goal of improving our overall culture of safety. To foster implementation, an online toolkit containing templates for all standardized RCA tools was disseminated in addition to on-site coaching.

275 interdisciplinary team members were educated on the enhanced RCA process in 2019. A repeat expert consensus study was completed using the NPSF Measures of Ineff ectiveness tool. Results of this study showed 30 percent improvement to date.