Process Makes Perfect
PROCESS MAKES PERFECT
Embracing a Passion for Quality, the RGHS Sands-Constellation Heart Institute has Become a National Leader in Cardiac Care
The Sands-Constellation Heart Institute (SCHI) at Rochester General Health System (RGHS) is frequently recognized as a cardiac program of exceptional quality – a true regional and national leader. But to Ronald Kirshner, MD, SCHI’s Chief of Cardiac Services and Cardiothoracic Surgery, those “raves” that compare his program to others around the country offer, at best, an incomplete measurement of his program’s success.
The SCHI standard, according to Dr. Kirshner, is simple. “Nothing less than perfection,” he says. “Anything less than that means there’s still room for improvement. So we aim for perfection every day.”
For the Sands-Constellation Heart Institute, the route to perfection requires precision; and the key to precision is a process that unites surgeons, cardiologists, physician assistants, nurses, technicians and other care providers toward the pursuit of excellence in every aspect of patient care.
“Traditionally, working in healthcare means doing things a certain way,” Dr. Kirshner says. “We wanted to create a system that worked the way we wanted it to work – not the way it had worked all along.”
That meant redefining team relationships, and taking a hard look at any unnecessary or illogical steps in the customary cardiac-care model. “If there’s something that doesn’t make sense or that should be changed, we fix it or we get rid of it. There’s no tolerance for things that slow us down, or that stand in the way of patient care.”
Along the way, the team was prompted to consider the distinction between safety and quality. “Of course safety is important. But a system that makes safety the top priority can still accommodate small mistakes that don’t result in patient harm,” Dr. Kirshner says. “But if you develop a true quality-based program like we have – one that demands perfection from the process itself – then even the smallest error stands out as something to eliminate. And that’s important, because who knows what a small error today could do tomorrow? The quality-based process is the best way to arrive at not only patient safety, but the absolute highest quality care possible.”
The operational core of the SCHI quality-based process is standardization – creating repeatable models that facilitate efficiency at every stage of patient care. For example, because reduced surgical times also reduce the risk of complications and infections, a streamlined surgical process has been created by standardizing the cardiac surgical service.
That’s why there are fewer tables of instruments in SCHI’s three operating rooms than you’ll find in typical ORs. “When you only need one table of instruments, setting up more than that just takes unnecessary time,” Dr. Kirshner says.
Those instruments and other necessary equipment are also set up the same way in every OR. “Once we thought about it, we knew it just didn’t make sense to have different arrangements for different doctors,” says anesthesiologist Dr. Robert Cafarell. “Having everything consistent definitely minimizes the potential for errors.”
Caroline Kenyon, RPA, a Physician Assistant who regularly assists in the OR, attests to the benefits of that consistency. “It’s like a ballet in the OR – everything’s so well organized and thought out, and it happens the same way every time.”
Pre- and post-op nursing procedures are equally well orchestrated – everything from the advance designations of specific pre-op beds for incoming surgical patients, to the standardized infection prevention measures that have helped SCHI reduce MRSA incidents and achieve a zero chestwound infection rate for the last two years.
RGH RECEIVES HIGH MARKS FOR CARDIAC CARE
The cardiac program at Rochester General Hospital was named a state and national leader in the latest report from CareChex®, a division of The Delta Group.
The CareChex 2012 study provides hospital rankings in the categories of Medical Care and Patient Safety, with awards based on an institution's cumulative performance across the most recent three years of public data. RGH received the highest rankings in categories including Major Cardiac Surgery (#1 in New York State, #3 in the United States), Cardiac Care (#1 in New York State), Overall Surgical Care (#3 in New York State) and Overall Hospital Care (#3 in New York State). RGH led the greater Rochester region in all of these categories.
For a complete analysis of hospital performance data, visit www.carechex.com.
The nursing teams understand and embrace the process so well, that they can accommodate changes that track to individual patient needs before returning to the set process without missing a step. “Everyone goes above and beyond to make people feel cared about – not just cared for – before and after surgery,” says Virginia Riggall, RN, a Clinical Nurse Specialist in the CTICU.
As these standardized protocols have proven their value in the cardiac service, other service lines within RGHS have begun adapting and integrating them with their own processes, as well.
Such a comprehensive process wouldn’t work without total collaboration among team members.
“Anybody who goes near a patient – from the surgeon to the nurse to even the housekeeper – holds in their hands the ability to affect that patient’s outcome,” says Linda Greene, MPS, RN, CIC, Director of Infection Prevention at RGHS. “That makes it important for everyone to understand how vital they are to the process, and how vital it is for everyone to work together.”
Structured communication takes two forms at SCHI. First are the daily huddles in the CTICU and Progressive Care Unit, brief meetings for sharing updates about the specific patients on the floors, and for teaching opportunities from nurse and physician leaders. Then there are the Friday morning meetings, where more long-range topics are discussed – and decisive solutions are encouraged.
“At the Friday meetings we’ll discuss an issue, and then we’ll make a change. If we need to adjust it later, we will,” Dr. Cafarell says. “The philosophy is, the longer we wait, the longer a problem goes unresolved.”
For his part, Dr. Kirshner is energized by his team’s successes – and by the inevitable human error or mistake. “We always learn from our mistakes. In fact, our mistakes make us stronger,” he says. “And every time I see how well we’re doing, I think, ‘So how come we’re not perfect?’”