Leadership Corner: The MHA Keystone Center Patient Safety Organization-2019 and Beyond

Adam Novak

The Leadership Corner features monthly updates from the MHA leadership team. The updates will provide new insights to patient safety and quality as well as information obtained from healthcare workshops and conferences across the country.

Adam Novak, MA, CPPS, director, safety initiatives, MHA Keystone Center, discusses how the MHA and the MHA Keystone Center have continued their focus on workplace safety education.

Since its initial listing as a federally certified Patient Safety Organization (PSO) in 2009, the MHA Keystone Center PSO has emerged as a leader in patient and workforce safety. This past program year was no exception and has proved to be one of the most fruitful on record.

Adam NovakAmong the many successes this year, the most prominent was the official launch of the MHA workplace safety collaborative. The MHA Keystone Center PSO has taken the lead role in convening representation from the quality, safety, data analytics and member engagement teams within the MHA to develop a comprehensive plan for members. To date, an in-person collaborative kickoff meeting and two workshops, one focusing on safe patient handling and musculoskeletal injuries and the other addressing violence in healthcare, have been held. A data collection platform has been established and is accepting the Occupational Safety and Health Administration (OSHA) data from members. In addition to the generalized incident rates submitted to OSHA, members are asked to separate data by the core collaborative topic areas (workplace violence, safe patient handling and musculoskeletal injuries, sharps injuries, and slips, trips and falls). This level of data will help to identify where members are struggling and, subsequently, where the MHA can focus its efforts.

In addition to seeing early successes with workplace safety, the MHA Keystone Center PSO has observed an increase in root cause analysis submissions for a third consecutive year and provided valuable information to members through the 11 safety alerts sent this year. These alerts ranged in topic from equipment failures, defibrillators and surgical staplers, to adverse drug events and newborn drops.  Each safety alert contains case examples of adverse event reports submitted by members along with critical findings, mitigation strategies and expert references.

Lastly, members have excelled in data entry, allowing the team to analyze larger adverse event datasets and ultimately garner much-needed insight. For example, throughout the last year, for every significant harm event submitted, 63 no-harm and near-miss events were submitted. This ratio indicates a positive culture of safety, one in which staff feel safe speaking up about and learning from near misses.  Continuing with the safety culture theme, member organizations submitted 145 MHA Keystone Center Speak-Up! Award nominations over the last year, bringing the all-time total to more than 600 nominees spanning 47 unique staff roles and 48 different types of harm prevented. 

The MHA Keystone Center was published for its work in the Journal of Healthcare Risk Management in an article titled Improving Safety Through Speaking Up: An Ethical and Financial Imperative. This article not only showcases the culture improvement aspect of the Speak-Up! program, but a cost savings analysis unveiled the substantial monetary savings associated with speaking up. It showed that, on average, $13,000 is saved each time a healthcare staff member speaks up and prevents harm. When this number is extrapolated to the statewide level, the potential savings are astronomical.

These are only a few of the many successes of the MHA Keystone Center PSO within the last year and I am confident that we will further excel in driving safety improvement in the year to come. Significant efforts for the upcoming year include: establishing a root cause analysis review team composed of subject matter experts, hosting a joint safety and quality meeting for Upper Peninsula members, administering regular culture surveys, and developing automated methods of analyzing the qualitative information in the tens of thousands of event records received to date. The MHA Keystone Center PSO will continue to work with its members to ensure the safest care possible. Contact the MHA Keystone Center with any questions or comments.

This article was featured in the MHA Keystone Center Newsletter. To subscribe, please contact the MHA Keystone Center.