Heidi Wald, MD, MSPH

Safety First: Creating a Culture of Patient Safety

​Working in a hospital is a high-stakes practice. From medication errors to superbugs, potential patient safety issues appear regularly.

For Heidi Wald, MD, MSPH​, this hit home early in her career. “Just as I was finishing my residency, the Institute of Medicine report on medical errors came out,” she said. “That really resonated with me. From then on I knew I wanted to focus on patient safety.”

Dr. Wald is now vice chair of quality for the Department of Medicine at the University of Colorado School of Medicine. She trained as a geriatrician, and in 2003 started focusing on the overuse of catheters to manage patients’ urinary output.

In 2007, she applied for a grant from the School of Medicine Clinical Effectiveness and Patient Safety Small Grants Program to study the area. She discovered that a group of research nurse scientists was also concerned about the issue, which prompted a seven-year multidisciplinary collaboration between their respective departments.

Success by Collaboration

“This was a great experience,” Dr. Wald said. “The structure of this team really became a model for how the hospital could address their core measures. Over the years, we’ve achieved very good performance in catheter-associated UTI (CAUTI) rates, and we’ve been below benchmark in this metric for many years.”

The reduction in CAUTI rates is due to Dr. Wald and the team’s training on how to insert catheters correctly, care for them once in and remove them as quickly and safely as possible. The team also provided alternate options for emptying patients’ bladders and education on how to use bladder scanners.

Much to Dr. Wald’s surprise, CAUTIs became a hot topic in health care policy in 2007 when Medicare selected the issue as a core performance measure regarding preventable harm in the hospital.

“Up until then, no one seemed to care about urinary catheters; they were seen as a secondary problem,” Dr. Wald said. “Medicare’s move to include this adverse event really elevated it as an important topic for the health care community.”

In January 2016, Dr. Wald stepped back from the CAUTI prevention team to focus on her other duties for the Department of Medicine. One such duty is her effort to establish a “patient safety culture” in the hospital.

Changing a Culture

“Our program has had a major focus on building this culture,” Dr. Wald said. “It started with an idea from Doug Jones, MD​, who suggested we consider how we perform peer review.”

Dr. Wald created a Department of Medicine taskforce to address this issue, and decided to shift the focus of their morbidity and mortality (M&M) conferences from rare cases to safety concerns that happen regularly.

“Our goal has been to use the M&Ms to stimulate quality improvement and the reporting of events,” she said. “They allow us to create shared models of care, and to improve the manner in which we identify and react to individual errors of judgment. When someone makes a decision that ends up being the wrong one, we try to look at the context. We’ve moved away from a position of blame and aim to support a patient safety culture rather than a punitive culture.”

The new M&M conferences also offer Dr. Wald the opportunity to show she is responding to concerns in the hospital and creating improvements.

“We now develop process improvement projects from issues discussed at the M&Ms and have a sizable dataset to look at the types of events that come to our attention. Because we can only look at a small number of high impact cases in M&M settings we developed alternative review venues, such as the Hospital Medicine and Ambulatory Care case review processes.”

The new M&M model is now expanding across departments, starting with the Department of Emergency Medicine, where Dr. Wald has been collaborating with leadership to share models of care and improve safety. Four times a year Dr. Wald and her team replace traditional grand rounds with jointly sponsored M&M conferences, inviting departments from neurology to pediatrics to participate.

“We feel this has been a really exciting way to engage with other departments, disseminate this work and improve care,” Dr. Wald said.

Quality Improvement with Bite

In addition to the M&M conferences, Dr. Wald is working to extend the idea of a patient safety culture and continuous improvement throughout the hospital. She explains that this started with the acknowledgement that quality improvement is not research, and that the typical research-proposal process may not be the best way to present quality improvement ideas.

“We wanted to open up our improvement work across the department. We developed a Shark Tank competition, where we sent out a call for proposals for a quality improvement project the department could focus on for the year. There was a preference for projects that could demonstrate a focus on high-value care.”

Applicants went through a two-stage process to identify four finalists who gave five-minute presentations in front of judges who came from outside the internal medicine department. The winning proposal concerned central line–associated bloodstream infections (CLABSIs), and was presented by Isaac Hernandez, MD.

Jeffrey Glash​een, MD​​, chief quality officer for the University of Colorado Hospital and associate dean for Clinical Affairs in the School of Medicine, says that Dr. Wald has proved a tremendous asset to the organization.

“Heidi has been a true pioneer in safety locally and nationally. From her push to create a safe environment to discuss harm to her work with catheter-related UTI to her most recent foray into the ‘Shark Tank​,’ Heidi has been a true innovator and leader in the field of patient safety.”

As for the future, Dr. Wald says she is excited to develop her new passion for antimicrobial stewardship – what she calls the “flip side of infection prevention” – and to partner with the winning Shark Tank team.

“There are a lot of parallels between the Shark Tank proposal and my background in catheter-associated UTI rates,” she said. “I’m really excited to take what I’ve learned from our CAUTI program to work with the hospital to focus on reducing CLABSI rates.”