Selected Podcast
Ep. 5: WellSpan's Journey to High Reliability
Roxanna Gapstur and her guest MaryEllen Pfeiffer discuss WellSpan's high reliability initiative.
Featuring:
MaryEllen Pfeiffer, DO
As Corporate Director of Patient Safety, MaryEllen is leading the teams with a spirit of continuous learning to investigate all safety breeches in a timely and thorough fashion. We are working as one with clinical departments across our system to become a highly reliable organization. MaryEllen is the leader of WellSpan's 'just culture' educational programs. She collaborates with the Patient Safety teams at all WellSpan locations, in York, Gettysburg, Ephrata and Good Samaritan Hospitals, as well as the WellSpan Medical Group, Pharmacy, Surgical centers and VNA. Transcription:
Michael Carrese (Host): Welcome to Inspiring Health, a series of conversations with Roxanna Gapstur and other WellSpan leaders about WellSpan 2025. I’m Michael Carrese and Roxanna, it’s good to be with you again.
Roxanna Gapstur (Guest): It’s great to be with you Michael.
Host: What are we going to be talking about today?
Roxanna: Today, we’re going to be talking about WellSpan’s journey to being a high reliability organization and also our work on quality and safety excellence.
Host: And you have a special guest with you.
Roxanna: I do. Dr. MaryEllen Pfeiffer is our Director of Patient Safety across the WellSpan System.
Host: Welcome MaryEllen.
MaryEllen Pfeiffer, DO (Guest): Thank you.
Host: Roxanna let’s start by defining reliability. What does it mean to you?
Roxanna: Reliability to me is standardizing our care consistently to best practices and highest quality outcomes. So, one of the things we like to say is standardizing to the science and customizing that science to the individual to make care safer and higher quality for patients and families. So, they know what to expect from us each and every time they get care.
Host: And why is high reliability something WellSpan should be striving for?
Roxanna: Well there are a lot of reasons why high reliability is a very good thing for patients and for our communities. One reason is it builds trust between us and those that we are serving. So, to be a trusted partner and attract loyal patients; which is our new vision for 2025; we need to have high reliability so we can build that trust. In addition, we want the best patient outcomes. We want healthy communities here at WellSpan. And to have healthy communities, we need the best care. And so having reliably consistently great care at all times will build those great quality outcomes.
Host: So, MaryEllen Pfeiffer, how does an organization improve quality and safety?
Dr. Pfeiffer: I think what separates the best organizations from everyone else is a strong culture. And strong culture really depends on a concept that we call psychological safety where you feel safe to share your mistakes and problems with one another and I think that’s exactly the kind of culture we’re trying to cultivate here at WellSpan. A high reliability culture also has this kind of constant vigilance. Always looking for risks or hazards in the environment and trying to develop situational awareness and going to where the work is done to figure out how to fix the problems and find a better way to deliver that high quality care.
Roxanna: I would just jump in on that and say that high reliability organizations really have three characteristics in common. One of those is leadership commitment and our leadership and board have made a strong commitment to becoming a high reliability organization. Secondly is safety culture. So, what MaryEllen just talked about. And then third is robust process improvement. So, being able to continually improve our work.
Host: Yeah and it’s a mindset culture as you are speaking about and there’s a component you guys have called Head Up, Speak up. Tell me more about that.
Dr. Pfeiffer: Yeah, WellSpan developed this mantra about four years ago. And it’s really a philosophy where we are just focused on constantly improving and gaps or vulnerabilities that we notice and at WellSpan it’s really not a nice to do, it’s a must do. It’s an imperative. So, we are recognizing that this complex environment really changing and dynamic and we just have to constantly improve.
Host: Yeah, so as you mentioned already, it’s incredibly complex to deliver healthcare. How do you measure reliability?
Dr. Pfeiffer: Well there are a couple of different publicly reported measures. For instance there is Leap Frog, that’s one popular watchdog organization and what I like about Leap Frog is they kind of give you some points for three different things. Number one that you share your data transparently. Number two that you do some best practice processes and then number three is the actual quality outcomes and patient experience measures. And the CMS Stars Program is another program that sort of monitors reliability and quality.
WellSpan is performing pretty well in both of those. And we actually were just awarded an A at three of our different hospitals in Leap Frog.
Host: Wow, that’s great. Congratulations. So, obviously, you want patients to know that you are doing that well. How do you go about doing that?
Dr. Pfeiffer: Well when it comes to the publicly reported measures, we have just recently launched a new webpage where we are showcasing our reliability and our quality and Leap Frog is going to be a new topic that’s going to be showing up on that webpage in the coming weeks and months. But really, the way that the community knows that we are highly reliable is their interactions with us. So, every time they come to our doors, or any part of our system, we treat them with respect. We reach their goals. We display our values and that’s how they’re going to know that we’re reliable.
Host: So, Roxanna, you’ve made progress in certain areas. Of course showing up in the Leap Frog scores. How fast do you think improvements can be made?
Roxanna: Well I think WellSpan has made tremendous progress over just even the last 18 months on high reliability but it’s definitely a journey. So, although every health system that we know of and that we interact with is striving for high reliability; no one’s there yet in this industry at least. We know some other industries have gotten really close like the airline industry and the nuclear power industry. And healthcare is definitely striving for that same kind of high reliability experience for our patients. So, we think that even in the next year, we will make again great strides compared to what we made the last 18 months and we would hope that three to five years from now, we could say we’re really close to being a high reliability organization. But it will always feel like a journey, I believe because there will be new technologies, new procedures, new ways of caring for patients and we’ll have to incorporate those kinds of things into high reliability.
Host: So, how is WellSpan showing commitment to high reliability?
Roxanna: A few different ways. I think I mentioned at the beginning leadership commitment is one of the things that organizations need to have. So, we’ve made a commitment as a leadership team to use certain improvement processes across our entire organization. One of those is Lean Daily Management. We’ve also committed as a leadership team and a board, to having top decile performance in quality and safety. And then the third thing that we’ve done is we’ve trained leaders and teams in these techniques so that they can be embedded everywhere in our operations. Finally, we’ve committed to quality at the highest levels of the organization so that a quality leader is part of the conversations moving forward on all of our key strategic items.
Host: So, MaryEllen, as we wrap up, what priorities are on deck for the rest of the fiscal year?
Dr. Pfeiffer: Well just like Roxanna was alluding to, we are not going to be sitting back and feeling comfortable now that we’ve achieved an A in Leap Frog. We’ are going to constantly be pushing ourselves for more and more improvement with the goal of zero harm for our community that we serve. So, I think we’re going to continue to focus on having high quality care in every single interaction with our patients and the people that we serve. And going where the work is done, improving through the Lean Programs and really focusing also on our safety culture, our culture of teamwork and our culture of accountability.
Host: And Roxanna, you get the last word. What can listeners do about patient safety themselves?
Roxanna: I think for every employee, we want people to know that patient safety is everyone’s role and it doesn’t matter if you are a direct care team member or if you are someone who works in a support services department. It’s likely that some of the things that you do, impact patient safety. So, just being conscious about that. Number two I think knowing your department’s results in quality and safety and our organizational results and be able to share those with your leadership and teams and then number three, take advantage of any training that’s available so that you feel that you are as up to speed as you possibly can be and contributing to our high reliability culture. And then four, one of the things we’ve been sharing with our leadership team in the last week or two is be an ambassador for WellSpan. Tell our positive story. Know our results. And be proud of the work we have done.
Host: Word of mouth. We are coming back to that, right?
Roxanna: Absolutely. Word of mouth. It’s important for both patients and employees.
Host: Well that's a great message to end on, but before we go I'd like to remind everyone of the website MaryEllen mentioned of few minutes ago where you can learn more about high relability at WellSpan and that is wellspan.org /quality. So, that will do it for this episode of Inspiring Health, a series of conversations with Roxanna Gapstur and other WellSpan leaders about WellSpan 2025. Roxanna’s guest today has been MaryEllen Pfeiffer. Thanks for joining us.
Michael Carrese (Host): Welcome to Inspiring Health, a series of conversations with Roxanna Gapstur and other WellSpan leaders about WellSpan 2025. I’m Michael Carrese and Roxanna, it’s good to be with you again.
Roxanna Gapstur (Guest): It’s great to be with you Michael.
Host: What are we going to be talking about today?
Roxanna: Today, we’re going to be talking about WellSpan’s journey to being a high reliability organization and also our work on quality and safety excellence.
Host: And you have a special guest with you.
Roxanna: I do. Dr. MaryEllen Pfeiffer is our Director of Patient Safety across the WellSpan System.
Host: Welcome MaryEllen.
MaryEllen Pfeiffer, DO (Guest): Thank you.
Host: Roxanna let’s start by defining reliability. What does it mean to you?
Roxanna: Reliability to me is standardizing our care consistently to best practices and highest quality outcomes. So, one of the things we like to say is standardizing to the science and customizing that science to the individual to make care safer and higher quality for patients and families. So, they know what to expect from us each and every time they get care.
Host: And why is high reliability something WellSpan should be striving for?
Roxanna: Well there are a lot of reasons why high reliability is a very good thing for patients and for our communities. One reason is it builds trust between us and those that we are serving. So, to be a trusted partner and attract loyal patients; which is our new vision for 2025; we need to have high reliability so we can build that trust. In addition, we want the best patient outcomes. We want healthy communities here at WellSpan. And to have healthy communities, we need the best care. And so having reliably consistently great care at all times will build those great quality outcomes.
Host: So, MaryEllen Pfeiffer, how does an organization improve quality and safety?
Dr. Pfeiffer: I think what separates the best organizations from everyone else is a strong culture. And strong culture really depends on a concept that we call psychological safety where you feel safe to share your mistakes and problems with one another and I think that’s exactly the kind of culture we’re trying to cultivate here at WellSpan. A high reliability culture also has this kind of constant vigilance. Always looking for risks or hazards in the environment and trying to develop situational awareness and going to where the work is done to figure out how to fix the problems and find a better way to deliver that high quality care.
Roxanna: I would just jump in on that and say that high reliability organizations really have three characteristics in common. One of those is leadership commitment and our leadership and board have made a strong commitment to becoming a high reliability organization. Secondly is safety culture. So, what MaryEllen just talked about. And then third is robust process improvement. So, being able to continually improve our work.
Host: Yeah and it’s a mindset culture as you are speaking about and there’s a component you guys have called Head Up, Speak up. Tell me more about that.
Dr. Pfeiffer: Yeah, WellSpan developed this mantra about four years ago. And it’s really a philosophy where we are just focused on constantly improving and gaps or vulnerabilities that we notice and at WellSpan it’s really not a nice to do, it’s a must do. It’s an imperative. So, we are recognizing that this complex environment really changing and dynamic and we just have to constantly improve.
Host: Yeah, so as you mentioned already, it’s incredibly complex to deliver healthcare. How do you measure reliability?
Dr. Pfeiffer: Well there are a couple of different publicly reported measures. For instance there is Leap Frog, that’s one popular watchdog organization and what I like about Leap Frog is they kind of give you some points for three different things. Number one that you share your data transparently. Number two that you do some best practice processes and then number three is the actual quality outcomes and patient experience measures. And the CMS Stars Program is another program that sort of monitors reliability and quality.
WellSpan is performing pretty well in both of those. And we actually were just awarded an A at three of our different hospitals in Leap Frog.
Host: Wow, that’s great. Congratulations. So, obviously, you want patients to know that you are doing that well. How do you go about doing that?
Dr. Pfeiffer: Well when it comes to the publicly reported measures, we have just recently launched a new webpage where we are showcasing our reliability and our quality and Leap Frog is going to be a new topic that’s going to be showing up on that webpage in the coming weeks and months. But really, the way that the community knows that we are highly reliable is their interactions with us. So, every time they come to our doors, or any part of our system, we treat them with respect. We reach their goals. We display our values and that’s how they’re going to know that we’re reliable.
Host: So, Roxanna, you’ve made progress in certain areas. Of course showing up in the Leap Frog scores. How fast do you think improvements can be made?
Roxanna: Well I think WellSpan has made tremendous progress over just even the last 18 months on high reliability but it’s definitely a journey. So, although every health system that we know of and that we interact with is striving for high reliability; no one’s there yet in this industry at least. We know some other industries have gotten really close like the airline industry and the nuclear power industry. And healthcare is definitely striving for that same kind of high reliability experience for our patients. So, we think that even in the next year, we will make again great strides compared to what we made the last 18 months and we would hope that three to five years from now, we could say we’re really close to being a high reliability organization. But it will always feel like a journey, I believe because there will be new technologies, new procedures, new ways of caring for patients and we’ll have to incorporate those kinds of things into high reliability.
Host: So, how is WellSpan showing commitment to high reliability?
Roxanna: A few different ways. I think I mentioned at the beginning leadership commitment is one of the things that organizations need to have. So, we’ve made a commitment as a leadership team to use certain improvement processes across our entire organization. One of those is Lean Daily Management. We’ve also committed as a leadership team and a board, to having top decile performance in quality and safety. And then the third thing that we’ve done is we’ve trained leaders and teams in these techniques so that they can be embedded everywhere in our operations. Finally, we’ve committed to quality at the highest levels of the organization so that a quality leader is part of the conversations moving forward on all of our key strategic items.
Host: So, MaryEllen, as we wrap up, what priorities are on deck for the rest of the fiscal year?
Dr. Pfeiffer: Well just like Roxanna was alluding to, we are not going to be sitting back and feeling comfortable now that we’ve achieved an A in Leap Frog. We’ are going to constantly be pushing ourselves for more and more improvement with the goal of zero harm for our community that we serve. So, I think we’re going to continue to focus on having high quality care in every single interaction with our patients and the people that we serve. And going where the work is done, improving through the Lean Programs and really focusing also on our safety culture, our culture of teamwork and our culture of accountability.
Host: And Roxanna, you get the last word. What can listeners do about patient safety themselves?
Roxanna: I think for every employee, we want people to know that patient safety is everyone’s role and it doesn’t matter if you are a direct care team member or if you are someone who works in a support services department. It’s likely that some of the things that you do, impact patient safety. So, just being conscious about that. Number two I think knowing your department’s results in quality and safety and our organizational results and be able to share those with your leadership and teams and then number three, take advantage of any training that’s available so that you feel that you are as up to speed as you possibly can be and contributing to our high reliability culture. And then four, one of the things we’ve been sharing with our leadership team in the last week or two is be an ambassador for WellSpan. Tell our positive story. Know our results. And be proud of the work we have done.
Host: Word of mouth. We are coming back to that, right?
Roxanna: Absolutely. Word of mouth. It’s important for both patients and employees.
Host: Well that's a great message to end on, but before we go I'd like to remind everyone of the website MaryEllen mentioned of few minutes ago where you can learn more about high relability at WellSpan and that is wellspan.org /quality. So, that will do it for this episode of Inspiring Health, a series of conversations with Roxanna Gapstur and other WellSpan leaders about WellSpan 2025. Roxanna’s guest today has been MaryEllen Pfeiffer. Thanks for joining us.