Overview
At MedStar Health, our vision to be the trusted leader in caring for people and advancing health will only be achieved by our unwavering commitment to both quality and patient safety. You can count on that commitment when you seek care at any of the MedStar Health hospitals, ambulatory locations, and other care sites. Your safety is our number one focus, and we know that focus will also result in the highest quality of care throughout our healthcare care network.
Our commitment to you, as your partner, includes delivering the following:
- Zero preventable harm
We strive for a culture of safety that results in the best possible patient outcomes, every time. - Highest quality of care
Here’s how we measure and continually improve the quality of clinical care, and how you can, too. - Transparency
Open communication is critical to engaging both patients and our staff in patient-focused care.
"The key to bringing health care to the next level in safety rests on creating an environment where front line caregivers recognize how the system around them facilitates errors and are empowered (and rewarded) to speak up about these hazards. This enables us to shift to a proactive system safety approach; a more effective culture than the traditional reactive personal blame model.”
Terry Fairbanks, MD, MS
Vice President, Quality & Safety, MedStar Health
Patient safety
Patient safety is our number one focus as we strive to achieve ‘zero preventable harm’.
At MedStar Health, we optimize patient safety by taking a proactive approach that encourages all patients, employees, and visitors to identify areas where we can prevent critical errors before harm occurs.
Our journey towards becoming a High Reliability Organization (HRO)
In 2010, MedStar Health embarked on a mission to become a High Reliability Organization (HRO), providing the safest, highest quality care possible. HROs are successful at preventing catastrophic consequences while navigating high-risk situations because they apply certain principles that help them uncover minor errors before they result in avoidable complications.
All 30,000 of our associates, from our frontline staff to our executive leadership, are trained to adopt the same safety language, habits, and principles that propel us towards becoming an HRO. These include:
- Preoccupation with failure. Preventing failures and errors is the very best way to keep harm from reaching patients and associates. Proactively asking ourselves about things that could go wrong is a safer approach than trying to understand why an error was made after it has occurred. By being mindful about risk, reporting near misses, and evaluating new processes before adopting them, we can make safety course corrections and avoid harm.
- Reluctance to simplify. With over 10 hospitals and dozens of urgent care centers, multi-specialty clinics, and outpatient offices, we’re a complex organization. But, we won’t settle for the status quo. Rather, we constantly ask questions and challenge long-standing beliefs so that we can uncover and resolve problems.
- Sensitivity to operations. Keeping our patients safe requires us to constantly be aware of how the systems and processes that affect patient care are working. Every associate is encouraged to speak up when they see risks or if they feel that something is not right. Our leaders consider the complexity of the real everyday work when designing processes, safety mitigations, and policy.
- Commitment to resilience. We work together to anticipate issues and quickly adjust when we need to manage unexpected challenges. High reliability organizations have within their culture the ability to solve problems and move forward without delay.
- Deference to expertise. We believe everyone should have a voice, and we listen to those with subject matter expertise and firsthand knowledge. Leaders are charged with creating a culture in which individuals are comfortable speaking up about safety issues.
Learn more about how you can help keep patients safe by watching our HRO Toolkit Refresher videos below.
Committed to achieving 'zero preventable harm'
One of the ways we measure safe, high-quality care is by tracking and comparing our performance against other health systems in the United States. We regularly use safety metrics to identify areas where we can improve processes and protocols so that we can enhance patient outcomes as we strive for zero avoidable harm.
Our patient safety improvement efforts are achieving remarkable results, including:
- Providing the highest quality and safest care
- Reducing the number of healthcare-associated infections
- Increasing and improving front-line reporting of events
- Reducing the cost of care associated with serious safety events
- Improving early detection and treatment of sepsis
Infection prevention
Depending on your medical condition, you may benefit from devices or treatments that could save your life. Unfortunately, these may also increase your risk of infection. At MedStar Health, we proactively work to minimize these risks by developing and sharing evidence-based best practices that drastically reduce hospital-acquired infections, including:
- Catheter-associated Urinary Tract Infections (CAUTI)
- Central Line-Associated Bloodstream Infections (CLABSI)
- C. Diff (Clostridium Difficile) Infections
- MRSA (Methicillin-Resistant Staphylococcus Aureus) Infections
- Surgical Site Infections
- And more
Safety event reporting
MedStar Health’s reporting system encourages all associates to report events that led to or have the potential to lead to a medical injury or harm. Our blame-free environment ensures our team members feel comfortable reporting all events, from errors to “good catches”, without fear of retaliation.
Since 2013, nearly 250,000 reports have been entered, reviewed, and resolved in the reporting system. This allows us to identify areas for improvement before they result in an unfavorable outcome. And, we regularly highlight “good catch” stories across a variety of channels to promote open communication.
We also measure and track all serious safety events (SSE) that arise when we don’t meet the standard of care or an unanticipated outcome occurs. Early reporting allows for a standardized, empathetic response including immediate care for the patient, transparent and honest communication with the patient and family, care for our caregivers, and early, systems-focused learning. We thoroughly investigate every SSE to understand what happened, what we could have done to prevent it, and what we can do to ensure it never happens again.
Safety huddles
Every hospital and outpatient office at MedStar Health leverages safety huddles to improve teamwork and communication. These brief meetings establish a safe space for each member to identify any issues or concerns related to safety at the beginning of each shift. Solutions to concerns are discussed in greater detail offline so team members can get back to work as quickly as possible.
Leadership support and accountability
At MedStar Health, our leaders are committed to creating a culture of shared learning that improves the safety and quality of medical care, both within and outside our buildings. Events that are determined to be serious safety events (SSEs) are presented to the MedStar Health Board of Directors at the Quality and Safety Professional Affairs Committee (QSPAC) which has responsibility for ensuring safe care at MedStar Health. Case summaries, contributing factors, and action plans for each SSE are presented to the QSPAC. This helps to ensure the effectiveness and sustainability of action items critical to preventing the recurrence of safety events.
Patient and family engagement
As a patient or family member of someone receiving care, you play a critical role on our safety team. We encourage you to speak up when you have questions and alert us of perceived medical errors as soon as you notice them. Your preferences, goals, and values are important to us, and we welcome meaningful conversations that help you make shared decisions about your care. We believe your experience matters, and we invite you to share your feedback, whether it’s directly with your care provider, executive leadership, or through a local patient and family advisory council.
Measuring care quality
Delivering world-class care requires a commitment to transparency and continuous improvement.
At MedStar Health, we’re proud of our reputation for high-quality medical care. And, we believe you should have access to the information you need to make educated decisions about choosing a hospital and health services. That’s why we’re committed to sharing what we’re doing well and the areas where we’re working tirelessly to improve.
How we measure care quality
We track and report national quality measures that demonstrate whether our care is:
- Safe
- Effective
- Efficient
- Equitable
- Patient-centered
- Timely
Our data are published by third-party organizations, allowing patients like you to view our performance across major clinical areas, including:
- Mortality rates for specific conditions and procedures
- Infection prevention measures that demonstrate the safety of our care
- Patient experience scores
- Process measures
We constantly review our performance so that we can identify ways to better serve our patients. Our vision is to ensure that every patient gets the right care every time.
Our performance on national benchmarks
For you to make educated decisions about your care, we are transparent about the quality of our services. Below, you'll find nationally recognized quality programs that publish our clinical care performance metrics online. You can use these tools to compare our quality performance to other hospitals throughout the country using the national averages provided.
How patients can measure quality
While data provided on third-party websites may help you make decisions about your health care, it should not be used as your only source of information. You should always speak with your healthcare providers before making decisions that affect your care, as quality can be measured in different ways. In addition to performance metrics, here are a few things you should consider when evaluating a hospital’s care quality.
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Is the hospital accredited by The Joint Commission?
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Is the hospital highly-rated by national or local organizations?
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Does the hospital and/or provider demonstrate experience in treating your condition, as measured by procedure volume?
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What do the patient satisfaction scores say about the quality of care at the hospital?
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How is the hospital actively working to improve its care quality?
Patients as partners
Patient and family engagement is the cornerstone of safe, high-quality care.
We believe it is a privilege to care for you, and we will honor that privilege through an understanding that we are visitors in your lives. Our goal is to create a caring environment that encourages the transparent exchange of information between patients, families, and caregivers around all aspects of care.
To nurture this patient-centered care environment, we:
- Welcome meaningful conversations around informed consent and shared decision-making
- Need to understand your values, preferences, and goals so we can provide care that is tailed to your needs.
- Want to know if we are doing enough to include you in your experience of care—your feedback is an integral piece of this partnership.
- Enlist the guidance of our patient & family advisory councils, and invite additional patients and families into our system-wide strategic planning.
Patients like you are guiding superior care delivery.
At MedStar Health, we’ve assembled patient and family advisory councils to provide a forum for patients, families, and national leaders in patient advocacy to advise us on strategic practices around care delivery. The councils are made up of dedicated individuals all working to help us continuously improve the safety and quality of care with a commitment to putting patients first.
You can improve the safety and quality of your care.
When unanticipated medical complications occur, it’s often a result of a series of small errors that collectively affect the safety or quality of care. As a patient, you can improve the safety of your care by taking an active role in your treatment. Here are a few things you can do to ensure a safer experience.
- Research your condition and treatment options.
- Compare doctors, hospitals, and care to see which best meets your needs.
- Keep track of your medical history, including conditions, medications, and care team.
- Discuss any questions or concerns with your care team.
- Ensure you understand what treatment you'll be receiving.
- Enlist a family member for support or advocacy.
- Follow your treatment plan as instructed.
Advisory councils
Patient and family advisors share their own experiences to better your care.
Patients and families are often first-hand witnesses to opportunities for improvement, whether they’ve experienced a medical error firsthand or witnessed it happen to a loved one. We believe engaging patients and families in our strategic initiatives is critical to ensuring we can deliver truly patient-centered care.
To learn more about our patient and family advisory councils, visit MedStar Institute for Quality and Safety.
Key initiatives
Quality and safety program highlights
Safe, high-quality care is more than just a performance metric. It’s a persistent approach to continually finding ways to improve even the smallest details so that we can deliver patient-centered care that results in the best outcomes.
Today, even more exciting initiatives related to quality and patient safety are happening here at MedStar Health as we work to make your experience of care the safest and highest quality possible. Below, you can learn more about a small sampling of some of our recent successful initiatives to improve the quality and safety of our care.
Eliminating preventable harm through measurable improvements in infection prevention
MedStar Health is committed to protecting patients from experiencing these adverse, but preventable, events. We continue to research and implement evidence-based best practices, protocols, and processes to sustain favorable outcomes. We perform case reviews on each HAI event to identify gaps in processes and develop plans of action to mitigate future events.
We strive to provide excellent care to patients by tracking our HAI rates and compare our performance with the national benchmark established by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS).
Below are strategies implemented by hospitals under MedStar Health to meet our objectives.
A persistent, systematic approach to reduce CLABSI
A central line (also known as a central venous catheter) is a catheter inserted in a large vein in the neck, chest or groin to give medications, fluids or collect blood for medical tests. This catheter may remain in place for weeks or months. Central line-associated bloodstream infections (CLABSI) occur when bacteria or germs enter the bloodstream through the central line.
MedStar Health’s CLABSI prevention efforts focus on proper and sterile insertion techniques, implementation of evidence-based maintenance best practices, and prompt removal as soon as the central line is no longer needed.
Practices in place at MSH to reduce CLABSI:
- Use of Central Line Insertion Checklist Bundle with trained Observer to ensure sterile technique
- Clinical necessity of central line assessed daily with prompt removal if no longer clinically necessary
- Daily chlorhexidine (CHG) bathing
- CHG Dressing at insertion site
- Two person dressing changes
- Use of alcohol impregnated caps on all needleless connectors
- Needleless ports disinfected with alcohol pad by scrubbing the hub when lines are accessed.
Collective efforts have resulted in continued improvement across fiscal years.
Implementing a sustained approach to CAUTI reduction efforts
An indwelling urinary catheter (also known as a foley catheter) is a drainage tube inserted via the urethra used to drain urine from the urinary bladder. A Catheter-associated Urinary Tract Infection (CAUTI) occurs when germs (usually bacteria) enter the urinary tract through the urinary catheter and cause infection. CAUTIs are one the of the most common hospital acquired infections (HAI) and is estimated that about 75% of the UTIs developed in hospitals are associated with a urinary catheter. CAUTIs are preventable.
MedStar Health’s CAUTI prevention efforts focus on proper and sterile insertion techniques, implementation of evidence-based maintenance best practices, and prompt removal when the indwelling urinary catheter is no longer needed.
Practices in place at MSH to reduce CAUTI:
- Urinary catheter insertions are performed by trained Associates with documented competency using sterile technique
- Urinary catheters are only inserted if clinically indicated. Alternatives such as external catheters are considered before invasive catheters
- Clinical necessity of urinary catheters is assessed daily and removed when no longer needed
- Nurse-driven removal protocol
- Use of securement devices
- Maintenance of a closed system without kinks or dependent loops
- Catheters are replaced when there are breaks in the closed system and still clinically indicated
- Perineal care is performed twice daily
Intense focus on prevention measures have resulted in sustained decrease in CAUTI rates over the fiscal years.
Multifactorial approach to reducing the incidence of healthcare-associated C. diff Infections
Clostridioides difficile or C. diff is a bacteria that causes diarrhea and inflammation of the colon. The Centers for Disease Control and Prevention (CDC) estimates that about 1 in 6 patients who get C.diff will get it again in the subsequent 2-8 weeks. One in 11 people over age 65 diagnosed with a healthcare-associated C. diff infection die within one month.
Healthcare-associated C. diff prevention strategies at MedStar Health focus on a multi-factorial approach that includes proper hand hygiene practices, adequate environmental cleaning and disinfection practices, and appropriate antibiotic utilization.
Practices in place at MSH to reduce C. diff:
- Patients with confirmed or suspected C. diff are placed on enteric precautions which means healthcare workers wear gowns and gloves while caring for patients and use a sporicidal product to disinfect the environment
- Healthcare workers caring for patient with C. diff infection use soap and water for hand hygiene
- Upon discharge of a patient with C. diff infection, use of ultraviolet light in addition to the sporicidal agent to clean patient’s room
- Judicious use of antibiotics and proton pump inhibitors
The multidisciplinary approach to reducing healthcare-associated C.diff infection has resulted in improved rates that are better than the national benchmark.
A life-saving sepsis awareness campaign that sparked local and national change
Sepsis is a leading cause of death in the United States, according to the federal Centers for Disease Control and Prevention. More than 250,000 people in America die from sepsis each year, yet awareness of the disease is startlingly low.
In 2017, MedStar Health launched The MedStar Health Sepsis Collaborative in partnership with patients and families involved in patient and family advisory councils. A major component of the effort is to ensure consumers can identify signs and symptoms of sepsis early and seek immediate medical care, given that 80 percent of sepsis cases begin at home, not in a hospital.
The initiative includes education for patients, family members, care providers, and support staff, and also focuses on improving emergency department processes related to recognizing and treating early signs of sepsis. The effort inspired legislation to establish a Sepsis Public Awareness Campaign Workgroup, tasked with establishing a statewide campaign to raise public awareness of the disease.
Through the personal stories of two patient and family advisory council members, Armando Nahum and Lt. Col. Steven Coffee of MedStar Georgetown University Hospital, whose families have been affected by sepsis, the impact of sepsis became tangible to clinicians and the general public. As a result, their stories have been integrated into the orientation for MedStar Health’s medical residents.
In recognition of this initiative, MedStar Health received a national award, the 2018 Sherman Award for Excellence in Patient Engagement. Other notable achievements and outcomes of the initiative include:
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20% improvements in sepsis treatment compliance rates
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Accelerated state and national action to raise awareness for sepsis prevention
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New and more effective sepsis treatment processes throughout MedStar Health
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Standardized sepsis education for new physicians
Resources
Websites, videos, and materials that can help you understand what safe, high-quality care looks like.
For patients
The following government and national agencies set the patient safety and quality standards for healthcare organizations throughout the country. You can visit these links to better understand how your hospital or provider’s quality and safety performance is measured.
- The Joint Commission
The Joint Commission is the leading quality improvement and patient safety enterprise that holds American health systems to rigorous standards for medical care. Their mission is to make healthcare better for everyone by evaluating and motivating healthcare organizations to strive for zero preventable harm. - Care Compare by Centers for Medicare and Medicaid Services
The Centers for Medicare and Medicaid Services (CMS) created Care Compare to help patients like you find and compare care quality based on your medical needs. The tool was developed to provide information for both people with Medicare and those who may not have Medicare. - U.S. News Hospitals Rankings and Ratings
The U.S. News and World Report evaluates and publishes ratings for clinical specialties, procedures, and conditions across the country. Hospitals are ranked both nationally and regionally so you can easily identify where to find the best care for your specific condition. - The State of Maryland
The Maryland Health Care Commission (MHCC) is a state regulatory agency that publishes data on the quality and costs of healthcare in Maryland so that Maryland residents can find and compare hospitals and services. On their website, patients can review consumer ratings, compare healthcare prices, and browse health topics in order to become better informed decision-makers when it comes to their care.
For associates and other healthcare professionals
The MedStar Institute for Quality and Safety (MIQS) offers a collection of publicly available resources to assist healthcare professionals and organizations with their improvement initiatives. These resources are designed for MedStar Health employees as well as Quality & Safety professionals who are looking for concise and timely resources that can be put into practice immediately.
About us
About Quality & Safety at MedStar Health
Our national reputation as innovators in safety is based on our system-wide implementation of the HRO culture, the integration of system safety engineering and human factors approaches, our proactive safety management, and our innovative event review process.
In 2010, as part of our 2020 strategic plan, Medstar Health committed to a “highest quality and safety” transformation, with a goal of zero preventable serious safety events. Compared to other healthcare systems nationally, MedStar Health takes a progressive approach to safety. This innovative approach, incorporating key factors distinguishing a High Reliability Organization (HRO), has been shaped by safety scientists, human factors engineers, patient and family advocates, frontline associates and providers, and clinical safety experts leading safety across our health system.
The goal of the MedStar Health approach to safety and the event review process is to decrease the likelihood of any future risk to patients. In order to optimize our safety culture and to drive safety events to zero, this approach must be practiced consistently across the system.
To accomplish this, we work hand-in-hand with colleagues throughout the organization including:
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National Center for Human Factors in Healthcare
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MedStar Health Research Institute
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MedStar Health Risk Management
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MedStar Institute for Innovation
Quality & Safety at MedStar Health
Our team is responsible for the quality and safety of medical operations across the MedStar Health system, including ten hospitals, and over 300 ambulatory practices. We’re dedicated to improving patient safety and the quality of clinical care that we deliver to our patients through collecting and analyzing quality data and applying systems and evidence-based solutions that eliminate medical error.We value transparency and open communication, and we work hard to foster a ‘just culture’ that empowers all frontline associates—and patients—to identify and report hazards, threats to safety, near misses, and barriers to executing best practices that improve our safety culture.
Our partnership with MedStar Institute for Quality &Safety
The Medstar Institute for Quality and Safety (MIQS) is MedStar Health’s outreach program which focuses on our quality and safety education, research, advisory and philanthropy initiatives. The MIQS leadership team works with organizations throughout the world to provide strategies, safety culture initiatives, education, and training solutions that help them improve patient care outcomes and reduce preventable harm.
Learn more about MIQS
