On June 22, 2023, the Health Care Improvement Foundation’s (HCIF) Partnership for Patient Care (PPC) hosted an in-person Safety Forum workshop, “Gun Violence Prevention in the Hospital Setting”. PPC Safety Forums bring together health professionals to collaborate and share knowledge on enhancing safety in healthcare environments. Past forums have covered diverse topics, such as workplace violence, suicide prevention, root cause analysis, and best practices. This year’s focus was gun violence in hospitals, an issue that has escalated, with a rise in violence against healthcare workers since the pandemic. Between 2010 and 2020, 400 healthcare professionals lost their lives due to firearms in the workplace. This statistic emphasizes the urgency of collaboration between health systems to protect their staff and prevent such incidents.
Dr. Stanton B. Miller, Executive Director of the Jefferson Center for Injury Research & Prevention at Jefferson Health, led the keynote talk on the 23rd floor of Independence Blue Cross, overlooking the light rain that fell upon Central Philadelphia. Using a framework from the World Health Organization, he discussed the problem-solving methodology for addressing workplace violence in healthcare. Dr. Miller defined healthcare violence as any form of aggression involving staff, licensed practitioners, patients, or visitors, underscoring its pervasive nature. The magnitude of the problem became evident as he presented statistics, with 75% of 25,000 workplace assaults occurring in healthcare and social service settings. Many incidents remain underreported due to historic attitudes accepting violence as part of the job. Dr. Miller highlighted gun violence as a critical determinant, comparing it to a societal disease that affects American society deeply. “Just as individuals can suffer from PTSD… American society is suffering from PTSD” related to social issues, especially gun violence, claimed Dr. Miller. He dispelled misconceptions about the differences in violence between rural, urban, and suburban areas, urging against discriminatory assumptions.
Leadership emerged as a crucial intervention. “Leadership sets the tone, sets the culture, and needs to clearly define workplace violence,” Dr. Miller said, emphasizing the need for leadership “to be clearly dedicated to placement of systems across an organization that enables staff to report violent instances”. He emphasized the importance of fostering a culture that encourages staff to report violent instances and takes responsibility for addressing workplace violence. Developing screening tools and reporting protocols, along with coordination between databases, were also identified as effective measures. The Haddon Matrix, a tool from Injury Science and Public Health, was introduced as a key element in the implementation process. It helps measure adverse effects and identify effective interventions for specific situations. Dr. Miller highlighted the role, or lack thereof, of legislation in protecting health care workers from violence against them, highlighting the need for such interventions as incidents rise. He ended his keynote by touching on measurements, focusing on the importance of using data informing and evidence based practices.
The roundtable discussion that followed exemplified the need for interdisciplinary conversations between health systems and departments. The audience represented a diverse group of professionals from all parts of the healthcare ecosystem. Representatives from Emergency Services, Patient Quality, Public Safety, Ambulatory Services and Senior Leadership from various Health Systems across Greater Philadelphia shared their expertise, fostering a natural and impactful exchange of ideas. The event concluded with a networking session, where participants continued their discussions. One group decided to get lunch to continue the conversation, embodying the success of this in-person event and demonstrating the power of face-to-face interactions in fostering meaningful connections and promoting positive change. HCIF and PPC remain committed to initiating these essential conversations between health professionals, leading the region in enhancing safety within the health care ecosystem.
The Health Care Improvement Foundation’s (HCIF) Partner Profiles highlight the efforts of valued and innovative health leaders. Our partners’ work supports HCIF’s vision of healthier communities through equitable, accessible, and quality health care.
We are pleased to feature Shannon Davila of ECRI to share more about her reflections on patient safety and quality improvement. Shannon currently serves as the Director of Total Systems Approach to Safety at ECRI and has a clinical background in adult critical care nursing and specializes in infection prevention and healthcare quality improvement. She is certified in infection control, healthcare quality, is a TeamSTEPPS Master Trainer and a High Reliability coach. Shannon is a current member of HCIF’s Clinical Advisory Committee as well as serving as our partner and facilitator for HCIF’s Safe Table program.
How did you first get involved or interested in Patient Safety?
Shortly after completing my enlistment in the United States Air Force, I went to nursing school. As a new graduate nurse, I worked in the ICU and immediately became aware of the safety risks that our patients face. As I have grown professionally, I have been drawn to focusing on how I can help reduce the risk of harm to patients.
ECRI and the Institute for Safe Medication Practices Patient Safety Organization (PSO) and HCIF have been partnering for the Partnership for Patient Care (PPC) Safe Table program for the past seven years. This program offers a framework for Patient Safety Officers to discuss and exchange best practices and solutions for current patient safety issues. Throughout that time, we’ve discussed over fifty different safety topics of concern. Reflecting on the program’s history, what do you see as some of the biggest accomplishments the Safe Table program has achieved?
First, I would say the longevity of the program is impressive! Additionally, the resilience of the participants to stay engaged over those years and through a pandemic demonstrates the power of those relationships. This program creates a safe space for safety leaders to talk, share and learn, and the value of that is evidenced by their continued commitment to the program.
“The Safe Table program serves as a valuable learning system for this region of Pennsylvania…This helps advance the application of safety principles and strategies across health systems, ultimately contributing to making our region safer.”
Shannon Davila
As an innovative model, how do you see the Safe Table program serving the general discipline of patient safety and overall contributing to making our region safer?
The Safe Table program serves as a valuable learning system for this region of Pennsylvania. Under the federal legal protections offered by the PSO, participants are able to share details of safety issues and learn from each other. This learning helps advance the application of safety principles and strategies across health systems, ultimately contributing to making our region safer.
One of the roles of HCIF’s Clinical Advisory Committee is to identify and address Southeastern Pennsylvania’s quality and patient safety priorities. We also know ECRI releases their annual Top 10 Patient Safety Concerns report. As a well-versed patient safety professional, what do you see as some of the biggest challenges ahead or shifts occurring in the field of Patient Safety? Are there any specific regional priorities that you are focusing on?
Issues related to staffing shortages have been something that ECRI has highlighted since the pandemic, and we still see many problems stemming from this issue. This includes problems with transitions of care, managing complex patient populations, and maintaining an adequate level of competent safety and quality improvement professionals. These professionals are critical for healthcare systems to both identify safety and quality issues and bring about transformative change.
As a longstanding partner of HCIF who has participated in several PPC programs over the years, what do you think makes HCIF unique and what have you found most valuable about working with HCIF?
I would say without a doubt, the HCIF team. I work closely with Pam and Liz and their dedication to their members and the program design is always evident.
Reflecting on your own career, what has been one of the proudest moments or greatest accomplishments of your career thus far?
In 2016 I was awarded the Heroes of Infection Prevention Award from Association for Professionals in Infection Control and Epidemiology (APIC), one of my mentors had nominated me and I was honored to have received it.
If you are interested in connecting with our partner, you can connect with Shannon via email at sdavila@ecri.org.
To get to know Shannon a bit more, she shared the following: A quote that she often returns to and inspires her in her work , “You can’t improve what you don’t measure.” Something most people don’t know about her is that she has a green thumb and loves to garden. To reflect back on her gardening hard work, she likes to document her plants as they grow by taking photos of them!
From May 16-18, the American Hospital Association (AHA) hosted their Accelerating Health Equity Conference in Minneapolis, Minnesota. Over 900 professionals gathered in Minneapolis to discuss innovative and strategic ways to accelerate health equity and improve community health.
I, along with my colleague, Liz Owens, had the privilege of traveling to the conference to present on HCIF’s Health Equity Data Strategy Collaborative. Our learning session titled, ”Starting with the Basics: Assembling and Activating REaL and SOGI data” was held during the second day of the conference and we were joined by Dr. Stormee Williams, Children’s Health in Texas, and Morgan Black, The Healthcare Association of New York State (HANYS) (pictured below). Each of our organizations were uniquely poised to share with the audience lessons learned about the collection and use of race, ethnicity, and language (REaL) and sexual orientation and gender identity (SOGI) data. Audience engagement was great, and reinforced that health systems are in very different places with this work – and that through collaboration we can learn so much from one another.
April Reilly, Dr. Stormee Williams, Morgan Black, and Liz Owens
Throughout the three days of the conference, the agenda was layered with noteworthy speakers and breakouts that encouraged attendees to think outside the hospital walls, create cross-sectional partnerships, and overcome challenges to address health inequities (just to name a few!). In total, we heard from 3 distinguished keynote speakers and attended around 10 breakout sessions learning from well over 20 different organizations on topics that ranged from addressing equity in ambulatory settings to creating community support for older adults to the intersection of health care and criminal justice. Day 1 kicked off with Pulitzer Prize winner and bestselling author Isabel Wilkerson who pulled back the curtain on the impact the American caste system has on our society, and on the inequitable medical care Black and Brown patients receive compared to White patients, while offering a path forward for creating a just and equitable future for all. “This is a national health crisis that should move anyone in a position of power to act,” Wilkerson said.
On Day 2, Dr. Ivor Horn, director of health equity and social determinants of health at Google, discussed the landscape of technology in health care – including its promising possibilities and potential perils. Horn also explained how health care and equity leaders can understand and challenge technology to support patients, employees and communities.
The conference concluded with remarks from Brian Smedley, equity scholar at the Urban Institute. He shared lessons learned and offered actionable steps as the U.S. and world move to further address structural racism. Smedley reminded the audience to reframe the conversation to center on “the sources of strength and resilience in the marginalized communities we serve.”
Overall, the themes of collaboration and lifting community voice resonated throughout each of the sessions we attended. We left the conference energized. We re-connected with colleagues. We made new connections. We had meaningful conversations. And we will hold ourselves accountable to take what we learned and turn it into action to inform our work.
Finally, a special thank you to Carol Vianna from AHA for her patience and help in getting our group prepared to present at the conference! We couldn’t have done it without you!
The Health Care Improvement Foundation (HCIF) is proud to have hosted the Excellence in Health Care Awards (previously Delaware Valley Patient Safety & Quality Award) for over 20 years. The Awards program is one of the unique ways in which HCIF promotes and disseminates best practices in health care patient safety, quality, and health equity throughout the region. At HCIF, we are committed to supporting just, equitable, and high quality care. This year, we are inviting improvement teams to submit their most innovative, equitable, and effective initiatives that have advanced patient safety and quality at their organizations. Additionally, we welcome initiatives that promote workforce wellness in the face of staffing shortages and that meaningfully incorporate patients and families.
Organizations that contribute to HCIF’s Partnership for Patient Care (PPC) program – whether freestanding or within a multi-entity system – are eligible to submit up to 4 entries for projects undertaken at each site. In addition, a healthcare system may submit up to 4 entries for system-wide projects that span multiple sites. All entries will be submitted via a web-based platform and will be judged on specific criteria, outlined on page two. Judging will be conducted by administrative, clinical, and community leaders with expertise in quality/safety, health equity, and patient engagement from regional healthcare organizations, who will be reviewing entries in summer 2023.
During recent travels, I was reminded of the jarring statistic from the Institute of Medicine’s (IOM)1999 report, “To Err is Human,” that we lose the equivalent of a jumbo jet full of passengers daily in the US due to patient safety events. It boggles the mind to think that millions of people fly each day and yet they are more likely to die in a car accident on the way to the airport than in a plane crash. The safety record within aviation can mostly be attributed to a culture of safety that permeates the industry.
What makes flying so safe? Importantly, there is a just culture in aviation. This means that anyone – the pilot, a flight attendant, or a mechanic – can report an error, event, or near-miss without fear of retribution. Being able to raise a red flag by any team member ensures that more people are able to surface safety concerns before they become events.
Since the IOM report came out, the lessons learned in the aviation industry have been applied to patient safety. When comparing the two, many features in aviation can be likened to healthcare – the doctor or lead clinician often serves as the “pilot” supported by other critical team members. Team members in healthcare can include not only clinicians, but food and environmental services staff, other non-clinical staff members, and importantly, patients and families. Many healthcare organizations have adopted a just culture to ensure that anyone can surface a safety concern.
The theme of 2023’s National Patient Safety Awareness Week (March 12-18) was “Be a Patient Safety Hero: Anywhere, Anytime – Always.” This theme especially resonates this year as we evaluate the impacts of COVID on patient safety. During the height of the pandemic, fewer family members were able to visit with their loved ones, reducing the number of team members able to surface safety concerns. Additionally, ongoing workforce shortages have stressed the systems that were in place to catch safety concerns before they became events. A recent analysis shows that the gains which were made over the past 25 years in patient safety have been significantly impacted since COVID was first discovered in the US in late 2019, including increases in central line and catheter-associated urinary tract infections and ventilator-associated events.
During this National Patient Safety Awareness Week, HCIF acknowledges and celebrates all of the patient safety heroes who remain committed to the provision of the safest care for our patients. These include members of our Clinical Advisory Committee who steadfastly identify safety concerns in their own institutions and raise these as priorities in the region. We thank and recognize participants in our Partnership for Patient Care programs who take time out of their busy schedules to collaborate and learn together about topics such as medication safety, improving healthcare disparities, and healthcare associated infections. Through the PPC program, we are pleased to provide forums, such as Safe Table, that provide space for patient safety and quality professionals to come together to address serious safety events in a punitive-free and supportive environment.
Similar to the aviation industry – where every member of the team serves an important role in safety – anyone can be a patient safety hero, not just a doctor, nurse, or pharmacist. Even patients themselves and their family members can serve as patient safety heroes. We all have a role to play in regaining the gains made in patient safety prior to COVID.
