How two hospitals harnessed EHRs and other tech tools to go from F to A on Leapfrog safety grades

Arrowhead Regional and Daviess Community Hospital. Credit: Google Street View

When Leapfrog Group published its semi-annual list of safety grades last week, there was an interesting twist in the results: Five hospitals that at one point in time had received an F now earned an A.

[Also: See which states earned an 'A' and those that got an 'F' in Leapfrog's new patient safety grades]

We spoke with leaders from two of those organizations -- Arrowhead Regional and Daviess -- to gain an understanding of how they turned their safety grades around so dramatically. Common themes of success include electronic health record optimization, holding employees accountable for their actions, executive-level buy-in that focusing on patient safety is a priority, and investing in new tools to advance those efforts. 

Here's how they made it happen. 

Arrowhead Regional

For Arrowhead Regional Medical Center in San Bernardino County, California there is never a dull moment. The 456-bed hospital is the second busiest emergency department in the state and Katrina Shannon Shelby, Arrowhead's associate hospital administrator for quality and accreditation, said there are always lifeflight helicopters hovering and plenty of action in the ED.

"We serve last resort patients and those that are uninsured," Shelby said. "We serve everyone." 

But helicopters weren't the only thing looming overhead this time last year. April 2017 was the first time Arrowhead participated in the Leapfrog group's patient safety grade scoring. Their start was rocky. That first grade was an F and Shelby and her colleagues got to work making changes and went back to basics.

"I like to integrate the Leapfrog work with my experience as a college professor. If you want a better grade on a test you study harder," Shelby said. 

Shelby, who was an adjunct professor at Webster University's Legal Studies Programs, took a hard look at what the key Leapfrog measures were, where they were, where they wanted to be and who could get them there from all levels of the organization. That meant leveraging input and support from all staff levels, partnering with physicians and functional teams like information technology, performance improvement, nursing, pharmacy and commissioning individual work teams to focus on each of the individual measures that would help to improve scores. Then they put the measures on a strategic dashboard and examined progress daily. And they provided information to the county board of supervisors about their progress.

"We have instituted a great deal of accountability, and with that alignment, making sure everyone has the same agenda and is going in the same direction together," Shelby said.

Beyond the human element, Shelby said they could not have made the improvements they did without the help of their EHR. Arrowhead uses Meditech, and Shelby said the progress was heavily based on the ability to pull meaningful data, reports and trend information that was actionable.

One key focus that the EHR enabled was computerized provider order entry, which allows providers at the point of care to submit patient orders electronically directly to the destination department, especially medication orders which now go straight to the pharmacy, minimizing the opportunity for human error and patient harm.

"This is a really a key issue. From a patient safety and quality standpoint this is huge," Shelby said. "The philosophy of becoming highly reliable organization is being preoccupied with reconciling challenges and don't stop trying to improve. Keep making strides. Leverage stakeholders from all levels of the organization."

From their optimization of the EHR to a daily patient safety huddle where staff gathers for 15-minute meetings to discuss relevant current issues, the difference is night and day. Fast forward to October 2017 and their Leapfrog grade was a B. The most recent Leapfrog scores brought a new benchmark -- in the 2018 Leapfrog Patient Safety scores announced last week, Arrowhead Regional was one of 5 hospitals to score an A for the first time after having once received that F.

Daviess Community Hospital

Daviess Community Hospital in Washington, Indiana is a rural operation with 74 beds, an ICU, ED, Medical Surgical unit, geriatric behavioral health unit and a "very robust" obstetrics unit.

"We delivered 500 babies last year," Daviess CEO Tracy Conroy said. 

Daviess has also had a rocky relationship with Leapfrog, having started with an F years ago then climbing to a C, a year off and then coming back with a B. But the high honors had proven elusive. Until the 2018 report, that is. 

"One of the biggest reasons we scored an A is we really are trying to change the culture," Conroy explained. "And when I say that, it's a great culture here but we've now become proactive instead of being reactive. That's what's made the biggest difference."

Conroy said they are much more vigilant and do frequent risk assessments, not for regulatory agencies but as a means of monitoring the "vital signs" of their hospitals. When something is wrong they know sooner and can fix it faster. 

Conroy continued that they had noticed an increase in falls in the geriatric unit. Clinicians looked into the situation and found that the doors opened in an awkward way that was difficult for patients to maneuver around. They re-attached the doors so that they functioned better, making patients safer and reducing falls.

Daviess is also taking a regulatory tool meant for use after an adverse event and making it a template for looking into any hospital issue. Conroy said that when you have an adverse outcome you do a root cause analysis, or RCA, to prevent further occurrence. Daviess has taken this a step further and now uses that report format for every incident, even ones where there was no harm or patient risk. Anything that happens that didn't go as planned is looked at through that lens to identify ways to change and improve.

The hospital has also added additional staff to its quality department so that big RCA undertaking gets spread out.

Much the way Arrowhead leveraged its EHR to advance patient safety, Daviess is optimizing it's so that in the future all orders will be electronic and clinicians will not even have the option of issuing a written order. 

What's more, Daviess deployed a new more user-friendly incident reporting system, enable staff to more effectively report issues, which Conroy said contributed to the hospital's success as well.  

But Conroy also said that the most important of Daviess improved patient safety grade hinges on the human element. 

"This A, all the credit goes to staff and our providers. They give their input. They take responsibility for their actions and hospital operations. We listen to each other. They aren't afraid to speak out," Conroy added. "When something happens it's not punitive it's how can we make this better. We don't take a punitive approach, it's 'let's get together and discuss this so it doesn't happen again.' We need their input to do that. They are on the front lines."

Twitter: @BethJSanborn
Email the writer: beth.sanborn@himssmedia.com