• Article
  • July 7, 2020

Growing A Safety Culture During the COVID-19 Pandemic

Despite the uncertainty the pandemic has created at some health care organizations, children's hospitals can still find opportunities for quality improvement.

By Richard Brant, M.D., FAAP

The predicted shortfall of staff, hospital beds, mechanical ventilators and personal protective equipment at the onset of the COVID-19 pandemic was enough to induce a level of anxiety rarely experienced by most health care professionals during their careers. In the United States, the onslaught continues to be devastating as it has resulted in the death of more than 130,000 people, pushed several health care systems to the brink of collapse under the strain of resource limits, and it derailed a robust national economy.

Nonetheless, through the fog on the front line, there were some giant leaps made in moving health care delivery systems forward. Telemedicine increased access to care, new care models increased throughput within emergency departments and clinics, and the innovation of global pharmaceutical companies and research institutions led to the rapid cycling of therapeutic studies, including vaccine development, that has never been experienced in our contemporary world.

Providers throughout the world became vigilant when protecting themselves and their patients, to the extent that was obvious to even the untrained observer, advancing the culture of safety within their facilities. Working rounds became more patient- and family-centered, relying on a small care team spending more time discussing management plans with patients and their families allowing for longer, clear conversations and shared decision making.

We all recognize these examples, having seen them many times during the pandemic. If we study these changes, we also realize that they are textbook examples of what the Institute of Medicine defined as the six domains of quality health care.

Quality structure

At WVU Medicine Children's Hospital in Morgantown, West Virginia, our pursuit of high reliability and the development of an open culture of safety was more formally set two years before the beginning of the COVID-19 pandemic. We created a multidisciplinary quality structure within the children's hospital that integrated the clinical units.

This framework evolved, culminating in a prescribed mortality review process, a structured cause analysis methodology for reported safety events, and more exposure to quality improvement and patient safety education for physicians, providers and staff.

Many of the structural and process changes resulted in improvement in patient outcomes including the reduction of the hospital's central line associated bloodstream infection rate by 86%, which saved the hospital approximately $700,000. Sharing data such as this has assisted in the engagement of staff throughout the hospital.

The hospital developed a strategic roadmap to further plan for the growth of this work stretching over one, three and five years, but with the onset of the COVID-19 pandemic, the projected time to achieve many of the goals set for quality and safety improvement was compressed. It is the hospital's intent to retain these "temporary" safety motivated activities as we move beyond the COVID-19 crisis and into our "new normal" processes revolving around patient care.

Increased telemedicine used

The increased use of telemedicine has been a strategic goal of our health care delivery system. Our institution's 2020 Strategic Plan targeted a significant increase of being virtual. Due to the pandemic and the exposure risk to physicians, staff and patients, we surpassed our goal within the first four months of the year by increasing the proportion of total visits using telemedicine by 178%.

We are also expanding to allow for inpatient consultation services for our care delivery partners with our sub-specialists. This shift has clearly resulted in improved access for patients, particularly for rural patient referral areas. 

Daily safety huddle

The daily safety briefing is a tool that has been discussed frequently for the last two years but was never successfully instituted due to many factors. Choosing a time, a format and a roster of attendees were but a few of the obstacles. With the onset of the pandemic, it was evident from the beginning that the need for a multidisciplinary conference call at the start of the day was critical to address operational and safety concerns. As an intervention to help fill this gap, the Children's Hospital Daily Safety Briefing was created.

This effort was initially focused on issues related to the pandemic, including isolation precautions, visitation and workflows. However, this has evolved as inpatient volume increases and elective surgeries restart to include operational data, significant safety events from the prior 24 hours and an opportunity for anyone to bring any safety concern to the attention of the hospital leadership to facilitate immediate attention. This daily communication opportunity was immediately embraced and has grown to become a valuable tool that assists with the real-time resolution of issues.

Leader rounds

Leadership rounding has long been an element of safety culture work but has in the past ostensibly felt more like a purposeful act of promoting visibility and approachability. Our leadership rounding has increased in frequency throughout the pandemic and has been used as an opportunity to garner perceived safety concerns and questions from providers. These occasions are now expected by the staff and have provided the chance for them to interact more closely and informally with the hospital's leadership team, promoting spontaneous conversation and resolution of concerns in real time.

Peer support

Second victims work has also been a core component of our quality efforts for over a year. This aspect of peer support has grown over that time, but given the acute onset and fear associated with the COVID-19 pandemic, especially amongst front-line health care workers, the opportunities to provide reassurance and a listening ear have been plentiful. This peer support group has even begun the creation of a regular Almost Daily Distraction newsletter to provide a short but welcomed interruption to their taxing work. In addition, the intensive care unit created an employee relaxation area for lessening anxieties through different physical or mental exercises.

Faster innovation

Throughout the hospital over the last two months, quality improvement projects that historically would take months to prepare and implement have seemingly developed overnight, many of which center on COVID-19 patient care processes. For example, there are projects addressing the effects of isolation on routine patient care, the effect on breastfeeding success in the newborn nursery, the influence on safety event resolution work, and an evaluation of the pandemic response's effect on adherence to best clinical practices.

Spreading the work

As we have evolved over the last two years, this growth has primarily been restricted to our system's flagship children's hospital. This year was to be the one that we planned to begin to spread this structure across the care delivery system, collaborating with other affiliated regional community hospitals that provide pediatric care.

Again, the methodical onboarding strategy for 2020 was accelerated when it became clear early in the pandemic the value that real-time collaboration among these facilities could represent. To that end, an invitation was put forward for a video conference with physician, nursing and administrative leaders of this group of affiliated hospitals to collaborate about current pandemic-related processes and learn from each other.

This "all teach, all learn" method of collaboration has been shown to be successful in the promotion of safety culture work. The initial meeting was so productive and well received, we now hold them weekly with the intention of continuing beyond this current crisis as our focus shifts to other opportunities for enhancing the quality of care for our shared pediatric population.

From turmoil comes transformation

The experience of the COVID-19 pandemic has been unexpected, catastrophic in some places and undeniably traumatic in all due to its effect on the approach to patient care, the operational processes within hospitals and ultimately, the safety of patients and employees. There is evidence this crisis can promote growth and improvement in all quality domains.

It is our intention to promote and facilitate the continued use of the conventions and tools born out of the current chaos as we move further along on our journey to zero harm and continue with our goal of promoting the development of a true safety culture within our institution and among care delivery partners.

Richard Brant, M.D., FAAP, is medical director, Quality and Patient Safety, Section of Pediatric Hospital Medicine, at WVU Medicine Children's Hospital in Morgantown, West Virginia. Send questions or comments.