Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. In his professional role, Mr. Loftin serves on several advisory boards, including the Joint Commission CNO Advisory Board, and supports multiple nursing professional societies. We spoke with him about his experiences with the concept of safety across the board at his medical center.

Dr. Kendall Hall: Please tell us a bit about yourself and describe your current role.

Edwin Loftin: I am Edwin Loftin, I am the Senior Vice President of Integrated and Acute Care and Chief Nursing Officer at Parrish Medical Center (PMC) in Titusville, Florida. Parrish Medical Center is a 210-bed public, not-for-profit community medical center located directly across the river from the Kennedy Space Center on Florida’s Space Coast. In 2016, with the announcement of Parrish becoming the first nationally certified Integrated Care healthcare organization by The Joint Commission, PMC introduced Parrish Healthcare, a regional network of collaborative health service providers. Parrish Healthcare is the culmination of PMC’s vision that collaborative partnerships over costly competition are the way to improve quality, safety, service and reduce costs.  Parrish Healthcare’s collaborative network of hospitals, providers, insurers, and other allied health, social, and community-based service partners are effectively removing duplication of services and applying shared evidence-based best practices to achieve real integrated healing care for patients, families and communities. 

We are not a tertiary care center, and one of our strengths is knowing that we're not a tertiary care center. We partner with like-minded, high-quality organizations to complement the services we offer to the community we serve. For, example, we work with a privately owned nursing home, a privately owned home health agency, our medical group, and the hospital to consistently meet patient and family-centered standards. The question is not, “what is the hospital doing for the patient?” or “what does the home health agency do?” but “how do we carry the same safe evidence-based practices throughout the continuum of care for each and every individual?”

We are also members of the Patient Safety Movement Foundation Network, an organization created in 2012 focused on reaching zero preventable harm in healthcare. We all have to make a commitment and be held accountable to get to zero harm. As members of the Patient Safety Movement Foundation, we were the first hospital in the world to commit to every one of their Actual Patient Safety Solutions, or APSS, which are designed to reach this zero harm goal.

KH: Can you talk a bit about how you became interested in understanding the role of a strong culture within an institution and the idea of Safety Across the Board?  Can you talk about how those two things interact?

EL: I guess it’s a tale of two journeys.  A journey to find and be part of a culture of safety within an innovative and thought-leading healthcare organization, and a complementing journey for continuous improvement. I have been a nurse for 35 years, so I'm not young at this game. Early in my career, as an ED nurse and an ED leader, I saw a few very specific events that jeopardized the safety of patients. In the early 2000’s, I was at another hospital in another state and I was the VP of Nursing. I learned about the development of a measuring tool that, at that point in time, nobody knew anything about, called HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems). I also witnessed the development of Hospital Compare. I went to my CEO at that time, this was in 2000/2001, and said we're okay but we need to get better, we need to be willing to be held accountable, we need to be transparent. Unfortunately, he did not buy into that dream. When I began looking for my next position in 2005/2006, I was already very focused on safety, prevention of errors, and understood that I needed to work somewhere with a culture that would support that. In Parrish Medical Center, I found a place that had developed a culture of healing, something that resonated strongly with me.

Parrish Healthcare’s mission is “Healing Experiences For Everyone, All The Time®.” Seven words that guide every decision made by every leader within Parrish Healthcare from the CEO to the front line leaders. Whether it is a board-level governance decision, executive-level strategic decision, or decisions made at a nursing unit, imaging unit, or patient access level, we ask the question “how does this action or decision serve to fulfill our mission?” If it doesn’t, then we move on and focus attention and efforts on only things that will result in healing experiences for patients, visitors, our care partners, and the community we serve. This level of commitment to our mission requires us to have an equal dedication to the principles of continuous quality and process improvement.  As such, we have adopted the Lean Six Sigma principles of performance improvement and use that to methodically drive the improvements and outcomes associated with our strategic plan. Those are the two journeys – (1) developing a culture of healing and (2) the use of Lean Six Sigma to drive process and quality improvement.

During my time here, I have been very fortunate to meet people that have influenced the nation and influenced me directly. I was at an IHI [Institute for Healthcare Improvement] meeting and happened to hear Sorrel King speak about her daughter, Josie, and her work with Peter Pronovost to improve patient safety. Later that evening, I was sitting in the hallway, looked up, and all of a sudden Sorrel and others were sitting right next to me. We ended up having a conversation and that experience was very impactful. Another experience that was of vital importance to me occurred just a couple of years ago when I met Marty Hatlie, who was working with Vizient and CMS. They were conducting interviews with organizations about the impact of patient and family engagement and patient/family advisory committees. Marty came on site with two additional people and they were interviewing me and a couple of my colleagues in one of our conference rooms. In that conference room, I've got a white wall that we use for brainstorming and on it, I have pinned four pictures of people that our industry has killed, including Josie King and Josh Nahum. I have the pictures in a circle with the phrase “never again.” I use this board to emphasize our commitment and focus on the idea that these patients are all people and we can’t make these mistakes again. I was telling Marty and his partners Josh’s story and as I finished, Marty leans forward across the table from me and says, “You do realize that the gentlemen sitting to your right is Josh's dad, Armando?”  It was a profound and humbling moment.  The work that Armando and his wife have done around the nation and the world to improve patient safety, it makes it personal.

KH: Let’s go back to a couple of points you have made that I’d like to highlight. First, is this notion of a culture of healing. The other thing I’d like to discuss is this link between person and family engagement and its impact on the culture of safety. What drives that? Is it patients and families getting the institution to think about and focus on its culture, or does the engagement organically improve the culture?

EL: I think the combination of the two is the secret sauce. It’s when you have an organization that, at all levels, from strategic leadership across to a young man in high school who is working in the dish room, say that their job is to make sure nobody is harmed while under our care. When that conversation can happen, you can then engage the community. You are engaging the community by bringing in persons you've cared for, family members, and community members to have transparent and ongoing dialogue about how can we do it better. We are humans interacting with humans, which means we're going to make mistakes. That's just a fact. But when we listen to understand, instead of listening to respond, when we sit and think through the purpose of a process with the patient, the family… together that engagement changes everything. That’s where the secret sauce comes in--a mixture of organizational and individual commitment with engagement and collaboration.

KH: I really like that - I think that is the secret sauce. So, as part of that secret sauce, you want to get your entire staff heading in the same direction. With nursing, how do you engage and at what point is engagement occurring? Are you attracting nurses that are seeking this out? How do you develop a strong safety culture within your nursing staff?

EL: I’ve been asked that question in a variety of settings. My personal philosophy of nursing is that we are a profession that is focused on the person not the patient. I discuss that difference with nursing students and with my care partners.  I'll say, “okay Cindy, you’re a nursing student, you're 27 years old, what percentage of your life have you been a patient? And what percentage of your life have you been Cindy?”  The discussion lands on the fact that Cindy is a ‘person.’  She is Cindy the person 100% of the time, and may have never actually been a patient or a patient only an extremely small fraction of that time. That's what our engagement has to be from the nursing perspective. We have to recognize and honor that it is a person in the bed we are caring for. They are more than a patient and we have the honor to care for- and to partner with- them.

At our organization, it begins with our students and with our recruiting. It's been my practice that every student nurse that does a clinical rotation here begins and ends that rotation with a conversation with myself and key nursing leadership. The first conversation focuses on expectations.  As the student nurses continue their experience with PMC, the conversations about our culture of healing and safety deepen. By the time they finish their three-year  student experience with us they have gotten to know our healing and safe care culture—they feel comfortable to step up and speak up and protect patient safety, with action and not just words. We know who's going to be doing the right thing and have the integrity of doing it when nobody is looking. It’s been a normal progression for our nursing team.  I know this same type of thing has happened in other nursing teams as I talk to other CNOs. I've been very fortunate to, for lack of a better term, raise five CNOs throughout my career and I'm proud of them because as they have progressed in their careers they have continued those similar philosophies.

KH: I assume that it takes time to see the culture shift, over years. This is not something where you just came in one day and started hiring nurses who fill that safety culture piece. So how long does that take to evolve? With patient safety, organizations often start and stop, start and stop, try different things, but this work is really a marathon.

EL: It’s a marathon that has no ending. That is what we have to understand. The focus of a culture of safety is an ever-evolving, ever-improving process. If we think we got there, then we had our eye on the wrong target to begin with. If we think we’re making progress, that's a good day’s work. We have to have difficult conversations when we need to, demonstrate the focus when that focus is needed, and have a desire that never ends. You can always do better and there is always more to do.

KH: It sounds like the nursing culture is very healthy, very strong; people feel that they can speak up. How does that play with the medical staff? I can imagine that might be a challenge.

EL: It is, but our nursing team is also by no means perfect. We've got our own little fractures here and there. We do better sometimes, we struggle sometimes. I'm okay with that as long as, on any given day, we can have the conversation that yes, we're struggling right now, but we know what our core values are, we know what our mission is. As long as our goal at the end of the day is zero harm, let’s have a healthy conversation about where we can do better. After the expected learnings and demonstration of our commitment to patient safety, we now have one of the healthiest relationships with our medical staff that we've had in fifteen years. We have common purpose. Yes, every member of the medical staff has their own office practice, but we work really hard towards a common focus.

KH: So across the board, are you getting buy-in from every leader that this is the mission, everybody is working towards the same goal, they all feel across the board they can speak up?

EL: In short, yes. As I shared earlier, it is an expectation for every decision and action to be rooted in our mission and values. That expectation is set by the CEO and cascades to every level of the organization. But it takes more than leaders talking the talk; it requires leading by example.  For example, we had a difficult conversation this morning. The CEO had to challenge the leadership of the organization. It wasn’t comfortable, but it was a crucial conversation. I think that's one of the things that helps us, having the courage and humility to face those difficult conversations head on. Then through our Lean Six Sigma methodology, we make process changes, and serve to continuously improve.

KH: How do you involve your nursing staff in those tactical changes? It seems like that’s a good opportunity to get them involved in the process and that helps support the culture.

EL: It is, we do a lot of tactical processes similar to a lot of other hospitals. One of ours is called “care team rounds.” Every day, nursing staff and multidisciplinary staff have a conversation about every person under our care. We cover three topics during this conversation: plan for the day, plan for the way, and the plan for the stay. We focus on how we get the patient to the next transition point and what will demonstrate to us that their health is improving. In about 30 minutes we can cover 30 to 35 patients. The primary nurse of the patient is the one who presents but the pharmacist will have input, the case manager will have input, the hospitalist will have input, the dietitian will have input, or whoever needs to have it. We designed that using our process improvement principles, and for us as an organization, every director and above must be, at minimum, a Green Belt in Lean Six Sigma. We have incorporated that methodology into all that we do so that all of our managers and directors are Green Belt certified and must start using those techniques and tools and teachings with their teams. We try to give the nursing staff and all care partners voices for improvement.

KH: Does the culture of safety change the roles and responsibilities of the nurses? Or is it just a paradigm shift of how your thinking of the care you are providing?

EL: It’s a paradigm shift. It doesn't change the fact that the nurse needs to do a clear, concise assessment and have it documented so that when you're reading the chart you're looking at the “case” not just figures. The paradigm shift about the value of who that person is in the bed is key. We had an event, I guess it's been eleven years ago now, in which I was called to a patient’s room. Long story short, we were treating a 21-year old young man by the name of the Sam who suffered a traumatic brain injury.  We were treating Sam like a traumatic brain injury instead of like Sam, a 21- year old man. We have done many things that call for culture progression, documentation, and communication that focus on who that patient is as a person. We now have a component in our records called “My Story” that documents personalized information about the person in the bed. That person is Sam W., a 21-year-old man who wanted to be a paramedic and that wasn't going to be an option for him anymore. Or, this is Sue T., a 65-year-old grandmother of four and all she wants to do is recover from congestive heart failure and be able to go outside and walk in the yard with her grandkids. Adding this level of personalization into the records allows the nurse and care team to inspire meaningful patient engagement in achieving their daily goals. For example, instead of having a rehab goal of walking 50 feet with the pulse oximeter not going below 94, the goal would be to walk from the bedroom to the backyard of the house and not be winded. It’s the same goal, but it allows for a deeper connection between the care team members and their patient, which is rewarding for all involved.

KH: That idea really resonates - bringing together the culture and person and family engagement as methods to operationalize safety across the board, where Safety Across The Board is building the capacity for safe, reliable care. Are there other components of that Safety Across The Board concept at play here?

EL: A lot of it is terminology and conversation. Regarding terminology, I told you our mission statement.  Our vision statement is Healing Families--Healing Communities®. We believe in the ripple effect of healing.  When you improve the health of one person and that person goes home, maybe that improves the health of their family, and healthy families contribute to the health of their community. We try not to use the term “staff” or “employee.” Instead, everybody here is a care partner. We are all partners in the care of people that we have the honor to serve. We know from evidence that storytelling is one of those practices that strengthens a civilization, a culture, a community. We share stories formally every week about how we fulfill our mission and values during 10-minute stand up meetings to include care circle discussions about what’s going well, what barriers to safe care need to addressed, and what opportunities we have to improve.

KH: With regards to your overall safety record, are you seeing dramatic shifts in any particular areas as you go through this journey?

EL: Our publicly reported data is not perfect; we struggle with a couple of things. But care at the bedside, and of course I am a little bit biased, is very good. We have been able to focus on some things. We had a challenge with C. difficile a couple years ago and using the “no blame” methodology, we were able to dig into what the real issue was. We have all but eliminated hospital-acquired C. difficile and we are doing the same things with MRSA and a couple of other things right now. We had some data that was not very positive regarding respiratory failure post-surgery, and come to find out it was associated with one physician that didn't want to be called into the ICU on Friday night after five o’clock.  We confronted that and patients are now receiving better care.

KH:  Those facets are the underpinnings of safety – you need to get those foundational elements in place?

EL: It is vital to having a culture of safety in place before you can do meaningful work outside of that. It’s the same old adage, it’s not that we are doing something new or doing something different, we're focusing on zero preventable harm. We may have to try five things, fifty things, before you get to the right thing for this, and then what's the side impact on the next process. That’s the continual learning mode.

KH: As we wrap-up, is there anything else that you'd like to discuss?

EL: Be willing. It’s very important to be willing to look hard at yourself and as an organization and challenge your norms. One of the phrases that I've used around here for years is, be comfortable being uncomfortable. If we get comfortable in a process that you think you get perfect 100% of the time, that is when you are going to make a mistake and that mistake is going to harm somebody's mother, brother, father, sister. Be comfortable being uncomfortable.