Fresenius Medical Care Sees U.S. Plans for Kidney Disease as Positive
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Fresenius Kidney Care (FKC) recognizes the benefits of a company-wide culture of safety. To set the standard in patient safety by which others in the health care industry are judged, this work cannot simply be delegated to a department. From boardroom to chairside, everyone in FKC has a role to play in the development of a company-wide culture of safety. FKC made a clear commitment to this via its support of the 5-Diamond Patient Safety Program, an ESRD Networks-sponsored program that introduces patient safety principles to frontline staff. FKC can build on that program’s success and take a culture of safety to scale by clarifying team members’ roles and responsibilities across all levels of the organization.
During the 2016 FKC clinical managers’ meeting, executive leadership made a commitment to promote, enhance, and raise awareness across the organization regarding our culture of safety. In keeping with that commitment, FKC launched the 5-Diamond program, consisting of five education modules rolled out throughout 2016. The modules identified attributes of a positive safety culture:
A facility-wide culture of safety enables complete staff and patient engagement, ensuring to assure that everyone is committed to identifying and mitigating any risk to patients. Of the 98 percent of FKC facilities that participated in the 5-Diamond Patient Safety Program, 99 percent achieved 5-Diamond status in 2016, a distinction rate far ahead of any of our competitors. The safety program was a critical strategic investment because it trained our frontline staff to see patient safety and outcomes as the product of systems, and introduced key patient safety concepts at the local clinic level.
Interventions to cultivate a culture of safety must live and thrive within discrete dialysis work areas because safety culture is local. In the hospital setting, patient safety researchers have confirmed that perceptions of safety culture vary from unit to unit, even within the same hospital.7 This variation likely exists because a culture of safety originates in safety climate, or staff members’ shared perceptions of whether their direct leadership truly prioritizes patient safety above other organizational goals.8 Staff perceptions are shaped by what their direct leadership messages, what they devote resources to, and what they hold their team accountable for. Those perceptions guide how frontline staff behave on the job. For example, a patient care technician (PCT) is more likely to wash her hands according to protocol if her clinical manager has demonstrated that patient safety is the clinic’s priority.9
Safety climate becomes safety culture as staff perform behaviors that make patients safer (Figure 1) and the organization learns from their experiences, creating a feedback loop to leadership and staff. The cycle strengthens a culture of safety as the organization gets measurably better and better at keeping safe (Figure 2).10
Because shared perceptions of direct leadership priorities are the origin of safety culture, health care organizations must clarify patient safety goals, roles, and responsibilities across organizational levels. A clinical manager, for example, will have a harder time conveying the importance of patient safety to her staff if her director of operations only talks to her about productivity—and so on up the chain of command. To build on the success of the 5-Diamond Patient Safety Program, FKC can continue to develop the capability within clinic-level teams to do patient safety work and create a chain of accountability for patient safety efforts that connects all levels of the organization (Figure 3).11 As FKC leadership clarifies roles and responsibilities, it must also ensure that staff and leadership have the skills, time, and resources to conduct and lead patient safety work.
One of the most accessible and compelling evidence-based interventions to improve safety culture and make patients safer is the creation of a unit-level process to engage frontline staff in patient safety and quality improvement efforts.12 Clinic-level leadership can drive ongoing employee engagement in patient safety efforts by asking frontline staff to identify defects in the unit-level system and then fixing the defects they identify. Surgeon leaders at the Johns Hopkins Hospital were able to dramatically reduce their surgical site infection (SSI) rates by asking frontline staff, “How will the next patient develop an SSI?” and structuring improvement interventions around staff responses.13 Their experience demonstrated the power of bottom- up, frontline staff-driven quality improvement.
The Johns Hopkins story also demonstrated that although clinicians and patients identify problems at the unit level, they cannot all be solved with unit-level resources.16 Some SSI interventions required leadership engagement at the departmental or hospital level. In dialysis, some clinic-level defects will require support from area and regional leadership to address.
Going up the chain of shared accountability from frontline staff to corporate leadership, each level is accountable for reporting safety concerns that cannot be fixed with available resources. These efforts are supported by an internal transparent reporting process. Going down the chain from corporate leadership to frontline staff, each level is accountable for clarifying patient safety goals, providing resources to enable patient safety efforts, and reviewing performance (e.g., regional leadership routinely reviews all adverse events within its region).14 Interventions to improve a culture of safety must thrive at the unit level, but they require alignment of support and resources across the organization.
Since To Err Is Human was published, the health care industry has become safer but can do more to achieve high reliability.15 FKC—with its people, structure, and access to data—is well- positioned to lead the industry toward safer care. FKC leaders can support a continuously improving, effective safety culture by ensuring that all staff members understand what their safety responsibilities are. This starts with leadership commitment that reflects their beliefs, attitudes, values, and principles about safety in the form of organization-wide policies and practices. FKC has made a commitment to promoting the culture of safety within its facilities with the success of the 2016 5-Diamond program— and a commitment to continue supporting the program on an ongoing basis.
FKC leadership shares the accountability and success of the program by getting employees involved in improving and maintaining the safety culture. The organization must continue to let everyone know that the well-being of patients and the quality of care they receive is the organization’s goal and reason for being. The culture of safety within the dialysis facility should be the first thing staff think about when they come to work and the last thing they think about before going home. It’s a tone continuously supported by corporate and operational leadership, not something that is only talked about occasionally. Employees should embody the FKC mission statement and be committed to delivering superior care that improves the quality of life of every patient, every day, setting the standard by which others in the health care industry are judged.
Kathleen Belmonte, MBA
Vice President of Clinical Services
Fresenius Kidney Care
Kathleen Belmonte brings 20 years of health care experience to her role in leading clinical services for FMCNA’s kidney care division. She is the former Chief Operating Officer for Immediate Care, LLC and served in senior executive roles in the diabetes medical supply and pharmaceutical space. A certified Family Nurse Practitioner and Diabetes Educator, she holds her MBA from Babson College.
Scalable Safety: 5-Diamond
by Kathleen Belmonte & Kathryn Taylor