Repair the Roof When the Sun Is Shining

Donna Sollenberger, EVP & CEO, UTMB Health SystemPresident John F. Kennedy once said, “The time to repair the roof is when the sun is shining.”

It’s true—most of the time, we don’t go about our day with an expectation that an adverse event will occur. But unfortunately, sometimes there are emergency situations, whether or not we are prepared for them. And sometimes in health care, people make mistakes that result in patient harm, despite having the best intentions when caring for someone. This is why it is so important that at UTMB, we devote ourselves every day to promoting patient safety, environmental safety, proper patient identification, medication safety, infection control and effective communication, whatever our role may be.

For some time now, the Health System has been on high alert, busily preparing for our Joint Commission re-accreditation survey. However, the preparations and safety measures on which we are currently so acutely focused are things we should always be doing to ensure the safety of our patients and staff. Whether it is focusing on prevention, communication, processes, documentation, or ensuring pathways are clear in case of emergency, we must always be alert. Our re-accreditation survey window, which extends through the next two months, has been a great opportunity to reinvigorate our current efforts to ensure we are providing the safest possible care for our patients, families and one another.

Just as achieving high reliability in health care is a daily endeavor, our successful completion of the survey will require the cooperation and support of every provider and staff member. After the survey, our competitors, affiliates, managed care and insurance companies, referring physicians and, most impor­tantly, our patients and their families will be able to read the details of our performance. I believe the results they see will truly reflect that every UTMB faculty member, clinician and employee at every level is committed to providing excellent patient care!

Why is a good accreditation survey so important? The Joint Commission accreditation survey is a nationwide seal of approval indicating that UTMB meets high quality and safety perfor­mance standards. It says we deliver the best care to all of our patients in a safe environment. Therefore, we must remain committed to zero patient harm, a culture of safety, and continual process improvement. Never ignore or tolerate unsafe conditions, behaviors and practices, and when or if we see something that could be unsafe or cause harm, we must communicate clearly and close the loop on conversations with our team. If needed, escalate issues. It’s simply the right thing to do for our patients.

Our success on the survey will require everyone’s familiarity with Joint Commission requirements in their particular area, and I have full confidence in our teams that we will be fully prepared for the survey. Please review the materials provided on UTMB’s Joint Commission website, including readiness checklists and the preparedness handbook. If you are a manager or supervisor, review employee readiness tips with your team when you have your weekly relay meetings, especially handbook sections “How to Participate in the TJC Survey” and “Other Helpful Hints for the Survey” on pages 12-13.

Spanish novelist, poet and playwright Miguel de Cervantes once said, “To be prepared is half the victory.” Perhaps the other half is to remain vigilant!

If you have questions about Joint Commission standards, please contact Janet DuBois, Associate Director of Accreditation. For more information on Joint Commission Accreditation preparedness in your area, please visit

Thank you for your dedication to delivering excellent care and service to our patients and families!

Unless we think together, we will fail to get the best out of one another!

Donna Sollenberger, EVP & CEO, UTMB Health SystemThere once was an executive named Joe, who worked for a medical device company. Joe was very worried about the device that he was working on. He thought that it was too complicated, and he thought that its complexity created margins of error that could really hurt patients.

He wanted to find a way to help, but when he looked around his organization, nobody else seemed to be at all worried. So, he didn’t really want to say anything. After all, maybe they knew something he didn’t. Maybe he’d look stupid. But he kept worrying about it, and he worried about it so much that he got to the point where he thought the only thing he could do was leave a job he loved.

In the end, however, Joe did find a way to raise his concerns. And what happened then is what almost always happens in this situation—it turned out everybody had exactly the same questions and doubts! So now Joe had allies, and everyone on his team was thinking about how to solve the problem together. And yes, there was debate and argument, but that allowed everyone around the table to be creative, to solve the problem, and to change the device.

By speaking up, Joe wasn’t undermining anyone’s work. In fact, he was improving the overall quality of the team’s work and protecting others from harm. Joe had always been passionately devoted to his organization and the higher purposes that the organization served, but he had always feared the conflict that would result from speaking up. When he did finally speak up, he discovered that he had not only contributed much more to the team than he had ever imagined, but his colleagues did not think negatively of him—they thought of him as a leader.

The story above was borrowed from a presentation by Margaret Heffernan, a writer and keynote speaker who frequently presents on how conflict avoidance and selective blindness can lead organizations astray. Fear of conflict is the very thing that leads to communication breakdowns and broken processes, which in turn, result in preventable errors.

We know from the premise of our Culture of Trust that significant safety failures are almost never caused by isolated errors committed by individuals. Rather, they result from multiple, smaller errors in environments with serious underlying system flaws. This is why regular feedback and communication is important.

A couple weeks ago, I shared a story about my own experiences with constructive feedback, and how at times, I have also found it uncomfortable to give and to receive. However, I realize the importance of constructive conversations, and even though they may involve a difference of opinion, they are a very necessary part of conducting safe, effective and successful work for several good reasons:

  1. We don’t always have an internal cue that lets us know that we’re wrong about something until it’s too late.
  2. Without a shared understanding of people’s points of view when it comes to concerns, people might blame problems on other people, and not where it actually should be, like broken or inefficient processes.
  3. Continual two-way feedback allows people to focus on one or two areas for improvement, rather than having to address a much larger problem that has already caused harm or will require significant intervention and time to resolve.

If we truly care about providing the safest care for our patients, we will be committed to speaking up. Continual quality and safety improvement is the right thing to do. As we observed in Joe’s case, speaking up helped the team and the individual to achieve success. That is why we have to be willing to listen to and consider what others are saying to us. Individually, we must keep an open mind and be willing to work through problems strategically. As a team, we know this is important because it will ultimately help us succeed. Unless we think together, we will fail to get the best out of one another!

Whether we have a gut feeling about the condition or functionality of a device, or we feel concerned that a care process may be unsafe, we need to act with safety in mind and speak up. In health care, we are accountable for our own actions and for those of our team. As we go about our important work, let’s be conscious of any system design that may potentially cause harm if we do not identify the flaws and fix them before a patient is affected. Instead of being afraid of conflict, we have to address the issues head-on.

My job is to make sure that you have what you need to be able to take care of our patients. If you don’t, my hope is that you will make your manager aware, and if you are the manager and you cannot get what you need to ensure your team can provide the right care at the right time in the right way for your patients, you will continue to escalate the matter, without fear of consequence, until you get a resolution. This does not mean that the decision will always be exactly what you want or asked for, but you should receive an answer and a resolution that leaves you with a sense of closure.

Remember: “You can blame people who knock things over in the dark or you can begin to light candles. You’re only at fault if you know about the problem and choose to do nothing.” – Paul Hawken

Create a culture in which excellence can flourish.

Donna Sollenberger, EVP & CEO, UTMB Health System“Whatever you or the public may consider quality to be, this definition is always a safe guide to follow: Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” ~Will A. Foster

Each New Year is a chance to commit to what we hope to achieve in the future. Last week, we established four areas in which we will focus to be successful this year: continued investments in our people, quantum leaps in quality and safety, transparency with our outcomes, and the wise use of our resources. In this first Friday Flash message of FY16, I’d like to explore our focus on quality.

Quality is defined as the standard of something measured against other things of a similar kind—the degree of excellence of something. It can mean everything from caliber or condition, character or worth, and it can be good or poor. Defining health care quality, however, is a little more technical. In fact, if you conduct an internet search for the words “health care quality” you’ll find a long list of organizations working to promote health care quality in hospitals, and you’ll also see numerous guides on how to improve in areas like patient outcomes, 30-day readmissions, and healthcare-associated infections. You may even find an infographic or two on reimbursement calculations!

To make a long story short, much of what is out there is written by the health care industry for the health care industry—and it is complex! As an industry, we even have had to find a way to state it simply to steady our focus. The Agency for Healthcare Research and Quality (AHRQ), the federal government’s leading agency, defines quality health care as “doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results.”

But what do our patients and their families think “quality” health care means, and what do they expect of us when we say that we are committed to quality? Several years ago, in an issue of the Journal of the American Medical Association (JAMA), Dr. Allan Detsky, an internist and health policy expert at the University of Toronto, identified criteria that patients expect when asked what they really want from health care.

He found, as one would expect, that patients want the best health care—they want to know that their care team is highly qualified and experienced, and they want to know the care they will receive is reliable, based on feedback from people they know, a referring physician, or other patients. This is not to say that patients don’t value statistics—our quality performance is currently publicly reported, so patients can compare us against other providers and know whether or not we are an excellent place to come for health care. It’s simply that they are more focused on whether the treatments they will receive will work in their specific case or condition.

The list of criteria is long, but the following are the most important aspects of care patients identified:

  • Timeliness. Patients desire access to services in a timely fashion.
  • Kindness. Patients want to be treated with kindness, empathy, and with respect for their privacy.
  • Hope and certainty. Even in dire situations, patients want to have hope and be offered options that may help. Patients and families are uncomfortable with uncertainty about diagnoses and prognoses. Therefore, they want to feel well informed, participate in decision making, and prefer active strategies.
  • Continuity, choice, coordination. Patients want continuity of care and choice. They want to build a relationship with a health care professional or team in whom they have confidence and have that same person or team care for them in each episode of a similar illness. They want the members of their health care team to communicate with each other to coordinate their care.
  • Privacy. Patients want to be hospitalized in their own room with their own bathroom and no roommate (this is something we proudly offer our patients at UTMB).
  • Low out-of-pocket costs. Patients want to pay as little as possible from their own pocket at the point of service delivery.
  • Medications and surgery. Patients prefer treatments that they perceive will require little effort on their part. Essentially, they want to feel “well taken care of”.

There is a much more important, patient-focused reason for making quality improvements: it’s the right thing to do. When we safely heal people and they have a positive experience in our care, they are more likely to follow through with their doctor’s advice and manage their disease processes, which leads to better patient outcomes and healthier patients in the future.

So, let’s focus on our patients’ experiences, with the understanding that they already trust us to do the right thing by delivering safe, evidence-based care and they trust us to monitor our own performance, much in the same way that we all trust airlines to make sure the plane is functioning well before takeoff!

Every individual in every role at UTMB impacts the patient experience in one way or another. This is why we must all focus on making the necessary changes to create a culture in which excellence can flourish. Whatever our work entails, we should reflect on the following:

  • Do we work together as a team, and are we committed to a culture of trust and safety, in which we can express our thoughts and concerns and constructively think together?
  • Do we demonstrate integrity by always doing the right thing for our patients and their families?
  • Do we show compassion and respect to all, so we not only work well together, but so that we are able to comfort patients and families during challenging times, or support them so they are motivated to heal? Do we promptly respond to patient and family concerns, whether by phone or the call button? Are we willing to take the time to explain things clearly and answer all of their questions?
  • Do we value diversity so that we can understand patients’ perspectives and preferences and fully engage them and their families in making decisions about their care and treatment?
  • Are we committed to lifelong learning, so that we are able to apply new knowledge and always explore better ways to enhance outcomes while remaining vigilant to assure patients’ safety?

If we are firmly committed to quality, and we practice safety measures the same way, every patient, every time, we will not only improve our performance, but we will be better able to focus on the experience of our patients and their families. At UTMB, we should always be able to look people directly in the eye and say: “The care you will receive at UTMB Health will be the same care I would want my most cherished of loved ones to receive.”

Trust: The Most Essential Ingredient

Donna Sollenberger, EVP & CEO, UTMB Health SystemLast Friday, I began physical therapy to rehabilitate my knee. On my way to the appointment, I was incredibly nervous. I had been told by my doctor that any slight movement could cause the patella to slip, and if it did, I would face the potential of surgery.

As I got myself into the passenger seat of the car, I started worrying about all sorts of things. What if we got into an accident and I injured my knee? What if I started movement of the knee at therapy, and the patella slipped?

Once in the treatment room, my physical therapist, Patrick, began explaining to me that we would start out by “loosening” the knee, seeing how far we could bend it, and we would end the session with trying to ride the stationary bicycle (only using some simple back and forth motions, not full rotations).

To say I was reluctant to let Patrick begin therapy on my knee was an understatement! I am so used to being in control, and at that moment, I was anything but in control. As I halfheartedly let Patrick begin therapy, I realized that in order for this to work, I had to follow his lead and completely trust him with the process. Without trust, this situation was not going to get any better. He was the expert; I was not.

Then, I remembered a quote by Stephen Covey about trust: “Trust is the glue of life. It is the most essential ingredient in effective communication. It is the foundational principle that holds (together) all relationships.”

As I did the exercises over the next hour, I began to think about how many times we are called upon in our lives to trust one another. Why was I so quickly able to trust Patrick in this instance? I trusted him because he had been my therapist four months earlier after a previous surgery, and the results were exceptional. I developed trust in his work, and the outcome of that trust was a well-functioning knee. I remember so many people commented on how well I was walking, they couldn’t even tell that I had surgery.

In many respects, developing trusting relationships is not unlike the work we do at UTMB, particularly in patient care. Our patients trust us to help them and to do the right thing. For that to happen, we must effectively communicate with any number of individuals on the care team. Creating a culture of safety requires trust and respect of all people working together on behalf of the patient.

A culture of safety does not happen when people are afraid to speak up. When people don’t speak up, there is no trust, and that has the potential to be harmful. We all have a responsibility to speak up when we see that shortcuts are being taken, rules are being bent, or that the system or process has the potential to do harm. As a member of the team, we must be ready to graciously welcome the feedback, because we realize that concerns are being voiced purely out of concern for someone’s safety and well-being.

Anytime a person speaks up and they are responded to with disrespect or disregard, trust is eroded, and the person who spoke up will be much less likely to speak up in the future. The person who will be harmed in such a scenario is innocent: the patient. That is not at all what we want.

In a culture of safety, the person who speaks up also has a responsibility to do so in a caring and respectful manner. It is hard to admit one is wrong or about to take a risky shortcut, so if the communication is not handled respectfully and tactfully, a loss of trust is also at stake. It is important not to point blame at the receiver of the message—no one wants to feel blamed; rather, the concern is being voiced in the context that it is helping to avoid a potential mistake.

I recently read an article about why people are reluctant to speak up, and I can relate to each reason:

  • Confronting people is difficult; too many people prefer to avoid conflict rather than respectfully addressing the issue
  • Others feel that speaking up is “not their job”
  • Some are not confident that speaking up will do any good
  • And other obstacles are time and fear of retaliation

My physical therapy has shown me the importance of trust in carrying out my plan of care, but I also feel I have a responsibility to speak up if any of the therapy movements are causing me pain or I do not “feel right”. The saying, “no pain, no gain” may be true in some instances, but it is better that I speak up and let Patrick consider if we should continue or not. If I do not, I am not being a responsible participant in my care.

I hope as we go about our work this week, we will think about our personal responsibility to create a culture of trust and safety by respectfully speaking up, or if we are on the receiving end of the message, to graciously accept our colleague’s message.

Always Trust your Instincts

Donna Sollenberger, EVP & CEO, UTMB Health System“Always, always trust your first gut instincts. If you feel something’s wrong, it usually is.”

It was a Thursday morning three weeks ago, and I had started my morning the way I usually do – I got up, got ready for work, and went into the kitchen to grab my lunch from the refrigerator before leaving the house. As I rounded the corner, I was greeted by small bugs all over my kitchen floor! I immediately grabbed the insect spray and started spraying. The bugs were exterminated, but now the floor was very slick. I knew it was too dangerous to leave it that way, so I grabbed a mop and began cleaning the floor.

With the chore completed, I picked up my keys and briefcase, but I remembered I still had not grabbed my lunch. As I started carefully walking across the kitchen floor, it occurred to me that doing this was probably not a good idea—what if the floor wasn’t completely dry and I slipped, or worse yet, fell? The moment after I had that thought and yet took another step, my left leg slipped forward, my right leg bend backward, and I heard something snap. You guessed it; I broke my leg.

I cannot tell you how many times I have replayed that split second in my mind. Each time I think: “What if I had listened to my gut? I knew better, but I did it anyway!” We all have an internal alarm system that alerts us when a situation feels wrong. I ignored my instincts, and now I am dealing with the consequences.

In many ways, this reminds me of conversations we have had about patient safety and our own efforts at UTMB to create a safer environment for our patients and employees. Our culture of safety demands that we should always speak up and stop what we’re doing if we see or even instinctively feel that something could have the potential to harm a patient.

Last week, the National Patient Safety Foundation released a report entitled, “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.” The report asks hospitals and health care providers to approach close calls or observed systemic flaws with the same rigor that they do when a major safety event occurs.

The report says that even though the use of the term “culture of safety” is common in health care today, as an industry we have not really made the necessary progress, because creating this culture involves “hard, continuous work and can challenge the status quo.” The report points out that often, safety event reporting systems like our Patient Safety Net (PSN) are used to report what has already happened, not what could have happened, simply based on the system’s design.

As health care providers, we must constantly evaluate the systems in which we are delivering care, and when we are concerned that any system may have flaws, we need to act on those instincts. If we do not, we may be putting our patients at risk.

Once, in a hospital at which I’d worked, a nurse submitted a PSN report to document that the new tubing we had transitioned to for IV delivery was occasionally crimping, thus slowing the delivery of the patient’s medication. Our safety team went to the unit, looked at the new tubing, and realized the nurse was correct. They immediately ordered new tubing, replaced it throughout the hospital, and addressed the problem.

In this instance, the nurse’s instincts were right, and she acted on her instincts. Although we will never know the actual number of patients’ lives that were positively affected by this nurse’s decision to act on her instinct, what we do know is that we were able to correct a system flaw before any patient’s well-being was compromised.

I am certain there are countless stories we could tell of nurses, physicians, residents and other health care staff who have acted on their instincts to keep patients safe. The point is that they acted.

As we go about our important work, let’s be conscious of any system design that may potentially cause harm if we do not identify the flaws and fix them before a patient is affected. Let’s act on our instincts. I certainly wish I had three weeks ago!

Teamwork and Trust

Donna Sollenberger, EVP & CEO, UTMB Health SystemContinuing with last week’s theme of college basketball (and in honor of March Madness), I thought it would be interesting to talk about some of the different aspects of basketball that foster teamwork and trust. It is fascinating to me that a group of individuals can join together as a team, and even though many of the team members may have never played together in the past, they can become good enough over the course of two to four years that they can always count on one another to be at a particular place on the court during a set point in a specific play.

Practice after practice, the team drills the offensive and defensive plays developed by their coach to become consistent, and through this intense practice and repetition, the plays become second nature—the team develops an intense trust of one another and their coach, and decisions about passing and shooting become instinctive.

The one move that amazes me most is the blind pass, which occurs when the player with the ball looks in one direction but passes in another. This is done to confuse the opposing team’s defense. It is not an easy move, and it is definitely risky, but when it happens and works, it is truly remarkable. I remember the first player I ever saw do this with any regularity was Pistol Pete Maravich, but other greats such as Isaiah Thomas, Magic Johnson, Larry Bird, Steve Nash and Michael Jordan all also used this pass with some regularity. And most of the time, this type of pass successfully caught the other team off guard, resulting in points scored.

I would imagine in order to effectively carry off the blind pass, each member of the team must understand everyone’s roles well, knowing they can count on one another to be where they should be at a specific moment and time, doing their defined job; they also have to believe their teammates are sufficiently capable. This is really the only way any team can optimally perform!

In many respects, we have our own blind passes in health care. For example, think about how important it is for each member of the team in the emergency department to know their own role as well as that of others on their team. They must trust and have confidence in one another. When seconds matter, as they often do in the ER, being able to act deliberately, consistently and predictably can mean the difference between life and death. And, it is the same in the operating room and on the inpatient units when acting decisively is critical to the outcome for the patient.

In the clinics, the pressure of time may not be as intense, but when a patient needs an appointment or calls with an issue they need to discuss with us, it is important for each member on our team to know their role and perform predictably. If not, we ultimately let the patient down, and our lack of responsiveness could mean we have lost the opportunity to intervene during a time when we could help prevent the patient from becoming increasingly ill and/or having to be admitted to the hospital.

Finally, a good blind pass requires great communication on the court—and, so it is with health care. As we work in teams, being able to be open and forthright with each other regarding the care of each patient is essential. It is critical that every member of the team respects one another and encourages each other to speak up when they are concerned about any aspect of the patient’s plan of care. After all, it is only in an environment of mutual respect and explicit trust that people feel comfortable speaking up. A team is not a group of people who merely work together; a team is a group of people who trust each other.

Phil Jackson is an American professional basketball executive, former coach and former player, who currently serves as president of the New York Knicks in the NBA. He says, “Good teams become great ones, when the members trust each other enough to surrender the ‘me’ for the ‘we’”.

So, how will WE work together to work wonders for our patients and their families today?

Perception is Reality

Last weekend, I had the chance to go to the Georgia Aquarium in Atlanta with my cousin and her grandson. I have always loved going to the aquarium. The vibrant colors in nature, like the intense yellow of the angel fish, amaze me. I enjoy watching the sea otters as they play together and swim through the water. My favorite habitat at the aquarium, though, is that of the penguins. I always laugh at their silly waddle and the way they flop forward onto their belly and then slide right into the water—they’re comical on land, but such fast and graceful swimmers.

11-15-14 seeing thingsAs I watched my cousin’s grandson, Cole, observe these sea animals for the first time, I felt almost like it was my first visit. I watched him as he scrutinized each creature’s movements; he laughed as the otters swirled and glided through the water, and he eagerly pointed out a whale shark as it passed over us in the glass tunnel. I have no doubt there will be many more visits in his future!

Watching Cole carefully examine each creature and point out every detail about them made me realize something—as we become more familiar with our surroundings and activities, we often miss the small details. We end up taking what is in front of us for granted, because it becomes a common experience to us.

This is an actual phenomenon, which psychologists refer to as “habituation”. Simply put, it is a decrease in response to something after repeated presentations—the more often we see something, the less we notice it.

This made me think about health care settings, and the fact that as caregivers and employees, we eventually become accustomed to our patient care environments. We become so used to seeing the same setting every day, we may hardly notice when something is out of place, something has collected a little dust, or that a new, unsightly blemish has appeared on a wall, a piece of equipment or furniture.

Because providers and staff are busy focused on patient care, these small details might be easily overlooked; however, patients are looking. I know from my own experience as a patient, when I’m waiting in an exam room, I usually have enough time to give it a thorough inspection. Small details and first impressions have the potential to create a powerful set of assumptions. If patients see something askew or neglected, it may plant seeds of doubt in their minds about quality of care. As an inpatient, one has even more time to examine the details of a room. If something is not working or doesn’t look clean, it may signal to the patient that we don’t care, which is certainly not the case.

Perception is reality to our patients and their families. That’s why as providers and employees we have to practice seeing every aspect of our interaction with patients from their perspective—it’s more important than most of us think.

In fact, a number of studies link a range of aspects of the physical environment to patient safety, patient and family stress and healing, improved overall health care quality and cost, and even staff stress and effectiveness. The physical environment shapes every patient experience and all health care delivery, including those episodes of care that result in patient harm, according to the Agency for Healthcare Research and Quality (AHRQ). According to the NIH, various studies conducted at ambulatory care centers also show the physical environment has been associated with favorable patient outcomes.

The lists of physical features in care environments that are associated with positive patient experiences can be quite comprehensive, but some of the principle demands are an environment that:

  • Promotes safe behavior by patients, staff and visitors – for example plentiful, visible hand washing and hand disinfection stations.
  • Prevents accidents – for example ensuring spills are promptly cleaned up to prevent slips and falls.
  • Encourages patients and staff to feel reassured – through adequate interior and exterior lighting, visibility of security personnel, and, in the case of inpatient care, secure storage for personal items such as glasses, keys and money.
  • Reduces stress, anxiety and aggression – through the provision of pleasant, comfortable waiting spaces, feedback and communication on waiting times and priorities, attention to ambient temperature, light and noise, etc.

These aspects can be further supported by robust monitoring and reporting, demonstrating a Culture of Trust, and having a sense of personal responsibility and willingness to admit safety concerns and report mistakes, should they occur.

On a regular basis, take an unbiased look at your patient care or service environment. Try seeing it from the patient’s perspective. What would be your first impression of the waiting area? Does furniture or equipment need repair? Is it dirty or scuffed? What does the front desk look like? Is there excessive or old signage? Are patients and family members warmly greeted on arrival? What do the exam rooms and/or inpatient rooms look like? Are ceiling tiles damaged? Is the work area cluttered? Is paint peeling or scuffed?

These are just some examples of things of which we should remain aware. I believe we do a wonderful job at UTMB of providing an excellent care environment, but we should always be vigilant. We need everyone’s help!

  • Report facilities issues that need maintenance; if the problem does not get fixed or you don’t have a response within a week, escalate it to your supervisor
  • Keep clutter out of the hallways
  • Assure all supplies are not expired and that they’re properly stored
  • Check for expired supplies and medications
  • Ensure refrigerator temperature monitoring, proper food labeling, and cleanliness
  • Make sure linens are covered
  • Eliminate dirty, cluttered work areas

It’s very easy to quickly resolve issues that impact patient care by dialing one number: 2-4040. Requests may also be made with each area’s designated Zone Mechanic. Calls will be routed to the UTMB Service Response Center, which has expanded its service to act as the single point of contact for all clinical support services in the following areas: Environmental Service, Pest Control, Food and Nutrition, Clinical Equipment, Nursing Unit Support, Maintenance, Utilities, and In-house Construction.

More information on these topics can also be found on UTMB’s internal web site, The Joint Commission:

Thank you for the part you play in keeping UTMB hospitals and clinics beautiful and safe for our patients and our staff!

Safety Doesn’t Happen by Accident

Donna Sollenberger, EVP & CEO, UTMB Health SystemGrowing up, I was somewhat of a rebel. My mother and father were often frustrated with me, because I didn’t want to follow their rules. I couldn’t understand why they got so upset about things like missing curfew, driving outside of town, and having a summer job. I was even more perplexed when they told me they established all of these rules to keep me safe. Really? I thought that sounded a lot like an excuse and not a reason!

But as I became an adult and had children of my own, I experienced what many of us have – I started sounding a lot like my parents when I started creating and enforcing “the rules”. When my kids pushed back, I cringed a little as I heard my own voice echo the words of my mom and dad: “These rules are meant to help you. They’re meant to keep you safe!”

I had to admit, my parents were right—it’s easy to think you’re safe from harm in your own backyard. It’s easy to underestimate that something harmful might happen to us  because the odds seem so small. We sometimes take our safety for granted, not realizing the potential hazards that can be present in our everyday activities. We feel a little overconfident at times, perhaps because we’ve done something so many times before, or we’ve become a little complacent and discount the risks—we think we’re being “safe enough”. However, taking risks and acting hastily are often the very elements that create an environment conducive for an error or accident to occur.

The same is true of safety cultures, and the longer I have worked in health care, the more I have come to appreciate the rules that are in place to keep employees and patients safe. We often emphasize the importance of safety in health care with the patient at the forefront, but the safety of our staff is equally important.

It’s easy to go through the motions of something as common as patient handling, drawing blood, or administering intravenous medications, but these are also some of the most common ways both health care workers and patients can be potentially harmed. Therefore, safety interventions, such as proper hand hygiene and safe lifting techniques, protect not only our patients, but our staff as well. This is why it’s important to practice these safety measures the same way, every time.

A perfect example of a safety intervention in place at UTMB is the barcode medication administration system we recently implemented. This is the system where the nurse scans his or her employee badge, scans the patient’s wrist band, and then scans the medication. Then, the system confirms for the nurse that they have the right patient, the right medication, the right dosage and it’s the right time for administration. Using this system is critical to assuring that we keep the patient as safe as possible. When we follow this process exactly, we almost completely rule out the possibility of a medication error, and that keeps the patient safe!

In areas where we do invasive procedures on patients, rules are in place to assure we are doing the correct procedure. If the procedure is a surgery, for example, the nurse asks the patient to confirm his/her name and birthdate to make sure it is the right patient. Then, the nurse or physician confirms with the patient the procedure they are about to undergo, and they mark the patient’s body on the correct side and specific location where the procedure will be performed. This process is repeated again once the patient is in the procedure room, when the physician calls a “time out”. Here, the physician again confirms the patient’s name and birthdate, the procedure to be performed, and the location. Then, anyone present may speak up to express concerns they have about any aspect of the procedure. These processes are in place to keep the patient safe and to assure that the staff proceed as planned.

If we watch other people on our team for “state to error” risk patterns, every time we see one, it will automatically make us think more about what we are doing. And if what we see is sensational enough, we’ll do more than think about it—we’ll actually react to it. This will not only protect our patients from harm, but we’ll also protect one another.

At UTMB, we work to do everything we can to create a safe and highly-reliable environment for our patients and employees. It is crucial all of our staff remain alert and work together as a team at all times to recognize and avoid potentially unsafe conditions and activities for the safety of all. Remember:

  • Everyone has a part to play in creating a safe and reliable care environment.
  • Slow down. Be methodical and mindful.
  • Support effective safety measures and demonstrate accountability at every step.
  • Report mistakes and system flaws — it is safe and valued.
  • Recognize individuals who act with safety in mind.
  • Speak up when you see something that feels unsafe, if you feel concerned, uncomfortable, or think the team should stop and reevaluate a situation.

Although health care settings are varied and present both common and unique safety issues, interventions to improve safety for patients also improve safety for employees. After all, safety doesn’t happen by accident!

“For safety is not a gadget but a state of mind.”  ~Eleanor Everet 

Recognizing Team Accomplishments, Sharing a Vision

Donna Sollenberger, EVP & CEO, UTMB Health SystemThis week, I came across a posting of monthly clinic stats for the PCP Pediatrics Clinic developed by Practice Manager Ashley Dusek. The creative style she used to help inform her team of the most recent numbers for completed patient appointments really stood out to me. She did much more than simply reveal the data—she helped her team understand why the work they did during the month of February mattered to the 1,421 patients they served.

The post began, “Total Number of Completed Appointments 1,421. Why do I care you ask?” The communication continued:

“Because of you…1,421 patients were reassured their vitals were stable and that their lab work, which you drew, would be processed in a timely manner.

Because of you…1,421 patients were able to receive specialty care, immunizations, or just a simple reassurance by having their medical questions answered.

Because of you…1,421 patients were examined and given the right medications to make it all better!

Because of you…8,943 patient phone calls were answered. They were able to make appointments, ask questions, get test results, get prescription refills and know that we were there to answer and help with whatever they needed.

If you got to the end of this and you still believe you are too small to make a difference, Try sleeping with a mosquito!”

Ashley acknowledged the work her team had accomplished and also recognized that their efforts had positively impacted the patients’ experiences.

When I speak with individuals across the institution, whether their role is in direct patient care or they work behind the scenes, it is clear to me that as an organization, we believe we are ultimately here to serve our patients and their families. We find the greatest satisfaction in our roles when we know that we have provided good service to them and that we have truly made a difference.

Several months ago, when Sharon Johnson, a senior radiation therapist at UTMB, was asked how she felt she impacted the patient experience, her response wasn’t made in reference to the tasks she performs daily to deliver patient therapy alone. Instead, she answered, “I just try to be who they need me to be at that moment. Sometimes it’s a shoulder to cry on, sometimes they need a sister or a mother figure, sometimes it’s just a friend to hold their hand. I give a little piece of myself to the patients and I gain so much in return.”

While we all do what we do at UTMB because we receive the intrinsic reward of helping our patients and families, it also feels good to receive direct feedback that affirms we have made a difference. When our patients are satisfied, we feel satisfied with our performance. However, it can sometimes seem that we more frequently receive feedback about the areas in which we have yet to improve, and perhaps less frequently that our names are called out in a moving patient testimonial that so eloquently describes the true impact that we have made.

That is why, as team leaders, we must be supportive of the work our teams do. It is not always just about celebrating the major milestones; it is also about celebrating the small successes we have made along the way. When we feel good about what we do, we also develop a desire to continue that success—we have a sense of pride and ownership. Therefore, even when we do identify areas needing improvement, we must take care that we are constructive in our approach to both delivering and receiving the message. We want to emphasize fixing our processes, not assigning blame—that is a Culture of Trust.

Much of the work we do in health care today takes place under an umbrella of a changing health care environment. While this change is sometimes difficult, many of the best components of these changes are embedded in improving the quality and efficiency of care as well as the experience of the patient. It will take teamwork to be successful, and this means we are all involved, at all levels of the organization. This is a positive process! It’s important that we share information, celebrate accomplishments and provide timely, consistent and authentic feedback. Our focus of discussion is on how we can build on strengths and past positive experiences. We must do more than identify what is already working well; we need to identify what else can be done to enhance this work.

Tom Morris, author of If Aristotle Ran General Motors: The New Soul of Business, explains that while the pace of change may be at an all-time high, the challenge of change has always been with us. Change is the condition for positive, creative growth. At UTMB, we must stand firm in our values of compassion, integrity, respect, diversity and lifelong learning. We share in the vision of the road ahead, and we will work together to achieve it. We are here to work together to work wonders for our patients and their families!

If you would like to recognize an accomplishment or creative solution, please share with it us! Email us at

New Year’s Resolutions

Donna Sollenberger, EVP & CEO, UTMB Health SystemEach New Year presents new opportunities—opportunities to learn new things, to focus on what we hope to achieve in the future and to treat one another and ourselves better. As we bring one year to a close and embark on a new stage in our journey, it is important for each of us at UTMB Health to reflect on the changes we want (or need) to make, set our sights on what we’d like to achieve in the next 12 months and resolve to follow through on those changes.

On an individual level, we can choose what we want for ourselves in the New Year; on an organizational level, we share in many of our goals, and we are guided by core values that help to define our culture. As an academic medical center, faculty members, health care providers, staff and students all share in the responsibility of caring for our patients and improving health in the communities we serve. Sharing a common vision keeps everyone moving forward. Teamwork and collaboration are the very basis for the great accomplishments that we will achieve.

If we resolve to place the patient at the center of everything we do and to abide by our core values in all of our endeavors, we will meet with success in not only achieving our goals, but ultimately by providing the best care for our patients and their families. We’ll also go a long way toward creating a safe and positive work environment for everyone at UTMB.

So let us begin 2014 by reaffirming the values which serve as the cornerstone of UTMB’s reputation as a leading academic health center and an institution deserving of the trust that our patients and their families place in us:

We demonstrate compassion for all. The letters I receive daily from our patients reflect that compassion is alive and well at UTMB. Caring for others is why we are here! In 2014, may we always maintain an awareness of others and consider what life may be like after walking a mile in their shoes. Many of you may have seen the video “What if you could read their thoughts?” in which Cleveland Clinic explores what empathy really means and explores how our interactions with others would change if we knew what they were feeling and thinking. In a hospital, empathy underpins human relationships, and I encourage you to view the video if you haven’t already.

We always act with integrity. Everyone plays a part in creating a safe and reliable care environment. Each of us holds ourselves accountable and each of us expects one another to do the same. As the saying goes, “Character is who you are in the dark.”  When no one’s looking, we are the ones to whom we answer. Having integrity means we believe in what we do and why we do it, and essentially, we trust one another to do the right thing. Moreover, our patients and their families trust us do the right thing. They trust us to be honest, qualified, knowledgeable and to not only have one another’s best interests at heart, but to especially have at heart what is in their best interest.

We show respect to everyone we meet. It is widely acknowledged that there are different kinds of respect. Respect can be defined simply as a behavior or it can be defined as an attitude or feeling. However, respect is always directed toward, paid to, felt about, or shown for another person. We can show respect to others by valuing and appreciating them as unique individuals and when in the work environment, also treating them as esteemed colleagues. We show respect by listening and engaging during discussions and meetings. We value the thoughts and opinions of others, even when we may think or feel differently. Finally, we regard one another not merely as a means to serve a purpose, but as valuable human beings. Therefore, we should all work in partnership with one another because we are all here at UTMB, in whatever our role, to serve a single purpose: to provide the best service and safest possible care for our patient and their families.

We embrace diversity to best serve a global community. The concept of diversity encompasses acceptance and respect. It means understanding that each individual is unique and recognizing our individual differences, including dimensions of race, ethnicity, gender, sexual orientation, socio-economic status, age, physical abilities, religious beliefs, political beliefs, or other ideologies. It is the exploration of these differences in a safe, positive, and nurturing environment. It is about understanding each other the best we can and moving forward in our encounters with respect of those differences, including how we communicate, educate and provide patient care. We should embrace and celebrate the rich dimensions of diversity contained within each individual.

We promote excellence and innovation through lifelong learning.  Through innovation and by exploring new solutions, we not only gain knowledge, but we are also then able to contribute to the greater body of knowledge. Lifelong learning makes us successful, no matter what our definition of success may be. We grow as a person through learning and when one masters a subject through continuous learning, it brings satisfaction. Lifelong learning enables us to be confident, competent, and knowledgeable; it increases productivity and makes us better leaders.

I’ve said it before, but I am proud to be part of an organization like UTMB and to work alongside each of you. Everyone is doing a truly remarkable job, both by helping one another and going the extra mile to serve our patients and families. So this year, let’s embrace the values of compassion, integrity diversity, respect and lifelong learning and embark on the beginning of a very successful 2014!

Be sure to share the great achievements you and your teams accomplish along the way!