Covenant Health Transforms Care Delivery with Daily Safety Ops Briefings

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Many white papers have been written on the subject of care delivery and reinventing it for an Affordable Care future.

But it wasn’t a white paper that transformed Lubbock, Texas-based Covenant Health System’s care delivery. It was a white board and 30 minutes every day.

These tools were the game-changers for the system, Dr. Craig Rhyne, chief medical officer, said.

Time, a marker, an eraser, and a room were all that was needed to conduct a Daily Safety Operations Briefing with Covenant Health’s leadership and medical team, and in so doing, communication throughout the system became less siloed and deskbound and more collaborative and interactive.

How to host a daily, no-nonsense briefing

The first thing a Daily Safety Operations Briefing is not like, Rhyne said, is an executive management team briefing, nor is it a two-hour leadership conference.

Rather, department heads, physicians, and medical staff simply walk into an empty room.

There are no chairs. No one sits down. Everyone stands.

As Rhyne explained, this is purposeful.

The Daily Safety Operations Briefing isn’t meant to be comfortable. It’s urgent. Things have happened in the last 24 hours that need to be addressed.

There’s no time to sit down. There’s not even time to chat.

“It’s kind of an interesting concept, but the standing conveys the urgency and the rapid-fire nature of the event,” Rhyne said.

In fact, all conversation dies to a barely audible whisper once the lights flicker and the 30-minute countdowns begins, and during those 30 minutes, Rhyne and his fellow leaders expect a collaborative brainstorm to ensue.

At the center of the room is the whiteboard.

The whiteboard is there to keep the briefing on-track and on-task. It’s also there as a reminder. Nothing is erased from that board until it is tackled and resolved.

Three major buckets, as Rhyne calls them, are discussed at each meeting.

First, there’s the patient experience.

Are there any issues or complaints from the previous 24 hours that need to be explored? Is there any service recovery that needs to take place?

Second, there are the safety concerns.

Has a patient-safety issue been identified that needs to be resolved? Do any of the patients need different IV pumps or different safety needles?

The morning of our conversation, Dr. Rhyne said the safety concern was centered on a patient’s family member who had brought a Taser into the building. This led to a fairly robust discussion, he recounted, about screening and responsiveness and the importance of keeping contraband off the campus.

Third, concerns and complaints from the team are heard.

Are there any conflicts that need to be mediated? Are there staff members who aren’t getting along? Was a physician rude to a nurse or vice versa?

“That to me is one of the biggest benefits of these briefings from a medical staff leadership standpoint,” Rhyne said. “They’ve changed my ability to address issues. It gives me a chance to respond while the issue is still fresh in everybody’s mind.”

In fact, speed is perhaps the greatest benefit of these briefings, he said.

“It has been fairly dramatic in terms of our ability to identify the problems that are occurring in the institution and getting them resolved much faster than they ever used to.”

Using the briefings to prepare and inform

After the three buckets are addressed, a report is given on the census and what the expectations for the day are, especially with regards to post-op bed needs and discharges before 3 p.m.

“We do a two-minute report-out on the census,” Rhyne said. “It’s our state of the union in terms of bed and bed management and that gets everybody on the same page so we know what our challenges for the day are.”

“The daily census used to come in an email that nobody ever opened and read,” he added.

Toward the end of every briefing, a five-minute report is given on a different topic each day in which one member of the group outlines the system’s initiatives within that topic.

Rhyne said they’ll also take time to report out any major decisions from the Physician Quality Review Committee or the Medical Executive Committee.

“If any of those decisions that got made in those two medical staff venues need to be transferred to all of the managing department heads, that gives me an opportunity to let them know about it hot off the press.”

Changing the way communication used to be handled

The idea for the daily briefings came from Covenant’s sister organization, St. Joseph Hospital of Orange (SJO) in Orange County, Calif. Both Covenant and SJO are part of St. Joseph Health.

Rhyne said he and a team from Covenant had journeyed to SJO to observe and share best practices with its clinicians and staff. While there, the Covenant team witnessed a similar daily briefing in which five to seven members of the SJO staff met in a copier room off the administrative suite.

“We thought it was such a unique concept that we would bring it home,” Rhyne said. “And when we brought it home, we decided that by picking a larger venue, copying the standing-only concept, and getting all of the appropriate department heads in the same room every day just for 30 minutes, we could really make an impact.”

Before the daily briefings were implemented, Rhyne said Covenant did what practically every other healthcare system in the United States does.

“If a problem bubbled up to the CNO or the CMO, then it would start a string of either phone calls or emails. You would call or email somebody in the affected department for information, then information would be gathered and sent back by email.

“There would be basically a one- to two-week Ping-Pong match of information exchanged, going back and forth on emails. The other thing we found was, it was really easy to have what felt like a situation, not necessarily a crisis, but a situation that needed to be addressed, and it would sometimes get lost in the next situation that needed to be addressed.”

Under the previous system, institutional memory could be poor and accountability was neglected, he said.

Since problems are now being documented in real time, the daily briefings demand that issues be addressed immediately, usually within a 24-hour timeframe. For a patient or patient-family complaint about services or responsiveness, a member of the team is tagged with the responsibility of addressing it. This person knows they’ll be asked to report back the next day.

“We’re doing very quick service recovery based on this,” Rhyne said. “Everybody knows that if they got tasked with a service recovery item, they’re going to have to report that out the next day. It has changed our accountability tremendously.”

If an issue will take more than 24 to 48 hours to address—such as an EMR issue that requires a software change of six months or more–it goes to a write-on strip that is then entered into a longer-term resolution file.

However, the matter is not removed from the whiteboard until it is resolved, no matter how long it takes.

“This holds the entire leadership team accountable to making sure that we’re not missing things, that we’re not forgetting things,” Rhyne said. “We’re not dropping issues just because they’re remote in our memory.”

A simple concept with far-reaching results

The beauty of these briefings is in the simplicity of the concept, Rhyne said. Little time has been spent modifying them.

Thus, the outcomes have been incredible. Each department is required to give a quarterly report on its metrics, how many units were saved, how many complications were avoided, and the expense that was saved as a result.

Initiatives such as the blood conservation program, which was designed to more appropriately utilize blood and blood products, have been implemented with greater speed and efficiency.

The briefings, Rhyne said, also help to keep everyone on track with budget initiatives.

He highly recommends that each organization consider some form of the Daily Safety Operations Briefing.

Begin by identifying your buckets, Rhyne advised, then determine what the most pressing priority for your institution is. At each briefing, address them in order of importance and keep an ongoing record of the issues that arise, preferably on something as visual as a whiteboard.

And, he stated adamantly, don’t let anybody take any item off the board until it is resolved.

Treating medical directors as physician leaders

The daily briefings have led to other initiatives being implemented throughout the system that are designed to improve communication and raise accountability, Rhyne said.

For example, Covenant used to meet with each of its medical directors annually to review their contracts. Now, Rhyne and his administrative team meet with them quarterly.

The increased frequency of these meetings enables each director to advise the leadership, both in person and through a written report, of what they’re doing. They are required to present a set of nonnegotiable goals, as well as a set of negotiable goals, for every quarter.

“I’m actually starting to treat my medical directors more like physician executives,” Rhyne said. “I’m asking them to give me their goals for their department and what they want to accomplish as a medical director. And I think the message is very clear that I want them to be responsible. We shouldn’t be paying medical directors just to breathe, but to actually produce results and improvements in their area.”

Although it is not possible to accomplish every day, several of the medical directors have been invited to attend the Daily Safety Operations Briefing to witness the administrative mechanics behind event resolution.

Utilized in this manner, it is easy to see how the Daily Safety Operations Briefing is simultaneously solving problems and fostering better relations with the medical staff, Rhyne said.

“It has been eye-opening for many of our physicians to see how many issues are on the table at any one time and to understand how the administrative staff is working diligently to resolve issues in real time.”

-by Pete Fernbaugh

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