When Ballad Health's Chief Clinical Officer Amit Vashist, MD, sent quality, safety and infection prevention teams to several member hospitals' operating rooms unannounced to assess safety culture, he was met with revolt — but not in the way one might assume.
"As many other facilities got wind of what we were trying to do across these three or four facilities, they basically raised a banner up in revolt, saying they wanted to be included in the surprise visits, as well," Dr. Vashist told Becker's.
Hospital leaders' response speaks volumes to the strong culture of safety the system has diligently worked to rebuild in the wake of COVID-19. Like many systems, Ballad Health's patient harm metrics took a steep nosedive amid the pandemic, as many nonessential quality and safety efforts were paused to respond to the public health emergency.
Today, the Johnson City, Tenn.-based system is outperforming 90% of peers nationwide in half of its harm measures. In seven of 11 patient safety indicators, the system also ranks among the top decile in the nation. Since the peak of the pandemic, Ballad Health's mortality rates have dropped by more than 37%, central line-associated bloodstream infections have fallen 48% and methicillin-resistant staph aureus infections are down by more than 66%, among other notable improvements.
However, what drives Ballad Health's commitment to quality is not peer comparisons or excellence in national rankings, but the pursuit of zero harm, according to Chief Quality Officer Mary Breslin-Rodriguez, BSN, RN.
"It doesn't matter if we're performing better than another hospital because we had one less fall," she told Becker's. "We want to have zero falls and that's our target."
Ms. Breslin-Rodriguez and Dr. Vashist, a practicing physician, recently spoke with Becker's about the efforts underpinning these quality improvements and where their work goes from here.
A formal high-reliability journey
Ballad Health saw high turnover rates during the pandemic, and many new team members were onboarded virtually, so the system's culture of zero harm and safety was not strongly established, according to Dr. Vashist. As COVID-19's immediate strains on the health system subsided, Ballad Health's primary focus shifted to rebuilding this safety culture.
In August 2022, the system partnered with Press Ganey to formally launch its high-reliability organization journey. Via the new partnership, the health system focused on fortifying employees' core leadership skills around building a just culture. The system also introduced numerous classes and training for employees to master the building blocks of quality, such as hand hygiene.
"We have had people come to us, and say, 'I did not understand why after my shift I was scheduled for hand hygiene training until they asked me to give a demo and I realized I was doing it correctly only 30% of the time," Dr. Vashist said.
Though the system's formal high reliability journey started in 2022, its roots date back to 2018, when the system was formed through the merger of Mountain States Health Alliance and Wellmont Health System. One of the newly formed system's core values was quality, within which was included a goal of zero harm. In 2019, the system also launched tiered safety huddles systemwide as part of this effort.
"So I think we were taking some incremental steps [toward high-reliability] but what we lacked was systemness, cohesiveness, and everyone rowing in the same direction. Obviously, the COVID-19 pandemic did not help and dealt a severe blow to our efforts, Dr. Vashist said. Now, Ballad Health is nearly two years into its formalized action plan to fortify this culture.
In early 2024, the system trained leaders on high reliability principles, including starting all meetings with mission moments, use of visual management systems, structured leadership rounding, just culture and error analyses. In the next phase of its high reliability journey, Ballad Health will roll out this training to 12,000 employees systemwide, including registration clerks, phlebotomists, respiratory therapists and transcriptionists. This effort will ensure all team members — not just front-line clinicians — understand their role in delivering top quality of care to our patients and have a shared language and vision in this effort.
"The first thought is, well nurses and physicians drive all of this, and it's not true," Ms. Breslin-Rodriguez said. "It's really getting everybody to understand what role I play with what I do and what skill set do I bring to the table to impact or reduce harm to the patient?"
Alongside empowering team members with high-reliability principles, gap analyses have emerged as another important effort in the system's quality work. Ms. Breslin-Rodriguez stressed the importance of having "boots on the ground" to understand what's occurring on a unit level. Health systems can have resources and best practices in place to support quality work, but there may be obstacles that prevent staff members from following them, she said.
Dr. Vashist and Ms. Breslin-Rodriguez also identified psychological safety as a key aspect of the system's high-reliability journey. Ballad Health has implemented a strong root-cause analysis process for adverse events that focus on the process, not the person. Leaders also regularly welcome reports of safety concerns.
"One thing we always try to propagate, and I am super passionate about — and that shows in our safety journey — is the emphasis on psychological safety," Dr. Vashist said. "Say something when you see something. So when I see a spike in the reporting of some adverse events, I actually welcome that because people are starting to feel secure to report these incidents without any fear of repercussions, and that is what is driving our safety journey at Ballad Health."
A data-backed quality strategy
The second core focus of Ballad Health's quality strategy is leveraging the capabilities of data and analytics. Ballad Health rolled out Epic across half the organization during the pandemic, but the quality team was never able to exploit its full capabilities. Now, all 20 of Ballad Health's hospitals are integrated with Epic. As low-hanging fruit, the system is working to remove variation in its order sets and reduce best practice alerts to ease alert fatigue and promote nimble, crisp workflows for clinicians.
On a larger scale, the system's quality team — led by Ms. Breslin-Rodriguez — is working to integrate robust dashboards to analyze adverse event trends and curate common sets of best practices or actionable interventions that can be standardized systemwide. These insights will help the system understand where improvement opportunities exist and what the root cause of disparities are to better tailor interventions.
Once these opportunities are identified, leaders must ensure they're presenting the insights to front-line clinicians in a clear, digestible manner.
"Leaders must dissect their data very carefully to provide crisp insights that leverages the cultural alignment that your physicians and nursing staff may have, so they can indulge in process improvement," Dr. Vashist said. "Sometimes I think people are not able to commit to quality and process improvement because those things seem so far away, so unattainable and buried in reams of undecipherable data. We need to be able to separate the signal from all that noise and provide our clinical teams with precise and curated actionable insights to bring about positive change in our processes and workflows."
While technology and data analytics have immense potential to accelerate quality work, leaders must not view them as miracle solutions. These tools are only as effective as the safety culture that supports them — a critical fact that leaders should always keep in mind, according to Dr. Vashist.
"As you build up teams, the ability to think critically around systems and to incorporate holistic solutions [is crucial]," he said. "Very often what I'm starting to get a little cautious about is this over dependence on anything and everything virtual, digital or AI-driven is going to solve our problems in healthcare. That ain't gonna happen. … At the end of the day, healthcare boils down to a very sacrosanct interaction between a sick patient and a clinical caregiver, nothing more and nothing less. Please do not lose the salient human touch around culture and psychological safety."