There are numerous places in a hospital where things could go wrong. As a result, the Clinical Laboratory and Anatomic Pathology Flight at the David Grant USAF Medical Center (DGMC), located at Travis Air Force Base in California employs “Trusted Care” principles to combat errors and reinforce a zero-harm patient care environment.
DGMC operates the Air Force’s largest clinical laboratory, supporting 465 health care providers and more than 325,000 patients per year. The staff of 91 medical laboratory scientists, technicians, phlebotomists, and five board certified pathologists perform 1.2 million tests annually.
But what really distinguishes the lab from its civilian counterparts is that 85 percent of the staff are active-duty enlisted members with an average of three years of lab experience. Civilian technicians have around 14 years of experience.
Unlike civilian labs, the DGMC lab also must contend with constant personnel turnovers, deployments, and a staff called on to perform additional duties and complete military training requirements. Despite this, the DGMC lab continues to deliver high-reliability test results and blood products by embracing the principles of Trusted Care.
In 2014, the Military Health System and its civilian partners embarked on a mission to evaluate its healthcare system to ensure the best care was being delivered to patients. After researching and studying the leading practices in the civilian sector, the Air Force Medical Service adopted the Trusted Care principles. The DGMC was a pilot location.
“The Air Force hired a civilian company to walk us through from adoption to implementation of high reliability principles,” said Elizabeth Nelson, DGMC patient safety manager. “We’ve been on the Trusted Care journey a little over three years now and we’re getting closer to that goal of zero harm.”
Domains of change
The four domains of change are: (1) leadership engagement; (2) culture of safety; (3) continuous process improvement; and (4) patient centeredness. Each domain builds upon each other to achieve high reliability and the goal of zero harm.
“What we want Trusted Care to mean to our patients is that we are constantly working toward zero harm, so they can completely and absolutely trust us—literally with their lives and the lives of their loved-ones,” said Lt. Col. Heidi Clark, Nutritional Medicine Flight Commander and patient safety coach to organizations like the laboratory, which is assigned to the 60th Diagnostics and Therapeutics Squadron.
DGMC has more than 70 safety coaches—staff members trained to help reinforce specific behaviors that have been proven to develop safe medical care.
“Behaviors like exercising a questioning attitude or concern in an incremental way such as: ‘I have a concern about this situation,’ or ‘I am uncomfortable with this…we need to stop until my concern is addressed,” explained Clark.
Staff Sgt. Kristopher Walton exercised a questioning attitude that, several years ago, could have earned him a reprimand. Walton was on weekend-duty when a physician requested a test that the lab’s hematology equipment wasn’t calibrated to perform. He explained this to the doctor, but she insisted he run the tests based on previous research.
“I didn’t want to provide inaccurate results, so I called the on-call pathologist,” said Walton. The pathologist called the doctor to discuss the issue and finally gave Walton the green light to perform the test. Instead of a reprimand, Walton was selected the DGMC “Hero of the Week.”
Supporting fundamental change in culture and behavior
“I think what’s different now is that we are patient-centered and operating in a ‘Just Culture,’” said Lt. Col. Patrick Kennedy, Clinical Lab and Pathology Flight Commander. A just culture encourages staff to speak up when they see situations and issues that could negatively impact a patient. This is incredibly important in the lab where four out of five patient diagnoses are made.
“Labs today help control healthcare costs. If we make the wrong diagnosis and the patient goes to surgery, that would cost the patient about $30,000 plus the pain and suffering,” said Col. (Dr.) Al M. Elsayed von Bayreuth, associate chief of professional staff, staff pathologist, and the primary medical review officer.
“When a patient comes to the emergency department with chest pain, we don’t know what the cause is, but the doctor can draw blood to test the level of troponin and we will know in less than 15 minutes if it’s heartburn or a heart attack.” Treatment is “personalized” to the patient, Elsayed von Bayreuth said.
Quality assurance team
Even though the lab is vested in Trusted Care principles, the staff couldn’t do the job as well without the quality assurance (QA) team. The QA team are lab technologists with at least a bachelor’s degree and 10 or more years’ experience in all areas of the lab.
“We have numerous indicators to make sure that the test results and blood products we send to providers are highly reliable, so they can take care of our patients,” said Maria Langeslay, QA manager.
The Travis AFB lab is accredited by both the College of American Pathologist and AABB.
Nelson said it generally takes 10 years to see some of the changes she is seeing throughout the medical center. When she arrived at Travis AFB in 2014, she said it was hard to discuss things that went wrong.
“We had to shift the focus from a ‘who’s fault is it’—blame and shame—to a just accountability that focuses on the process,” she said. “The daily safety huddles are one of the tools used to change the culture.”
The optimal time in the lab for the huddle is at shift change.
“Every day at 8 a.m., we hold a safety huddle to discuss patient safety issues from the previous night and what might crop up during the day,” said Master Sgt. Kristin Barber, QA section chief.
“We want to know things like: Are we low on supplies? Are we only 80 percent manned today? Do we have enough people covering the lab during lunch?”
The QA team and lab leadership ensure that technicians, pathologists, and even the administrative staff remain competent. They assess this by direct observations, blind tests, reviewing test results, and asking numerous questions.
“One of my jobs is to go onto the floor and talk to my techs; ask if they have any problems, give them a scenario and see how they solve it,” said Kennedy.
Training is one of the key elements to having a competent staff, but training is a challenge considering that the military staff move to a new assignment about every three years.
“We are constantly trying to improve training,” said Barber. “Each section has a civilian supervisor who has worked in this field for a long time. We rely on them for training and continuity, so no harm comes to a patient or staff.”
Trusted Care principles permeate everything in the lab from providing reliable test results to improving customer service.
When the QA team realized in March (2018) that patients were waiting an average of 45 minutes for a blood draw, they conducted an Evidence-Based Project identifying the lab’s peak hours.
“We had talked about the problem being manning, but it turns out that we only had one window open from 7 a.m. to 1 p.m.,” said Langeslay. “Also, too many people were taking breaks at the same time, others were doing administrative work, or training students and personal care nurses.”
By opening that second check-in window during peak hours and shifting training and paperwork to the afternoon, the lab reduced patient wait time from 45 minutes to 17.5 minutes.
“And we want to get it down to 15 minutes or less,” said Langeslay.
Blood waste management
Quality assurance also identified a problem that was costing the Air Force money.
“When I started to work here in 2013, we were wasting 64 units of blood per month,” said Langeslay. “I came from the private sector and the Veterans Administration where we saved as much as possible, so when they gave me that first report, I almost passed out.”
The lab has dropped blood waste from 64 units per month to zero units. The difference is due in part to better inventory management.
“One of the problems was that our supplier was sending blood products that were close to the expiration date and we were accepting it,” said Kennedy who arrived at Travis AFB in 2016.
“We looked not only at how the lab was using blood, but also how our counterparts on the wards were using it. We provided them a window of time when unused blood has to be returned to transfusion services before it becomes waste.”
The lab also contracted with a different supplier who only charges for the blood used if the lab sends back the unused product in a timely manner.
“Quality assurance and Trusted Care go hand-in-hand,” said Langeslay. “For me, QA is everything. We need that constant monitoring to deliver the best tests results.”
Speaking of test results, metrics are another high priority in the lab.
“Critical results need to be reported in 15 minutes or less,” said Barber. “Stats need to be completed in less than an hour. We want to reduce that time even more.”
A big-screen, wall-mounted TV allows techs to track stats and critical requests. The lab also uses a whiteboard, which is the first thing technicians see when they enter the lab, so staff can document concerns, and issues that need to be elevated to senior staff.
Perhaps the biggest culture change throughout DGMC is that leadership constantly encourages staff to submit patient safety reports, or PSRs.
“PSRs are enlightening; they help us track trends to see if we’re getting better or worse,” said Kennedy. “PSRs impact all areas in the medical center. If something happens in surgery, we want to learn from it, so it doesn’t happen in dermatology or another department.”
The definition of a high-reliability organization is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to the risk factors and complexity.
If something does go wrong in the lab, the team uses an algorithm to determine the root cause and what to do about it.
“We ask if it was deliberate or an accident? If an accident, how can we prevent it from happening again?” said Barber. “Is it a lack of training or is it the process?”
Every staff member at DGMC is committed to providing the safest care to patients, said Clark.
“The only appropriate goal is zero harm, knowing that we may never reach it,” she said. “Any less of a goal is unworthy for the trust that we are given as medical professionals. Any lesser goal encourages people to be satisfied with less than perfection; we have to keep striving to improve.”
The lab staff understands that. In 2017 the Travis AFB lab was MLO’s Lab of the Year!