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Patient Safety in Action: Fort Belvoir Community Hospital Customizes Leading Practices to Advance Quality and Safety of Care
Staff at the Fort Belvoir Community Hospital prepare a room for a patient. The Tri-Service team at FBCH provides excellence in safety, quality and compassion to those entrusted to their care on a daily basis at the state-of-the-art facility in Virginia. DoD photo by Reese Brown.
Staff at the Fort Belvoir Community Hospital prepare a room for a patient. The Tri-Service team at FBCH provides excellence in safety, quality and compassion to those entrusted to their care on a daily basis at the state-of-the-art facility in Virginia.​
(Department of Defense photo by Reese Brown)
By: DoD Patient Safety Program​

FORT BELVOIR, Va. (March 1, 2018) -- The Military Health System continues to advance its journey toward high reliability. Fort Belvoir Community Hospital in Virginia has customized leading practices to align with their targeted improvement efforts. Continue reading to learn how the staff at FBCH have put their own touch on leadership rounds, staff engagement and staff recognition of patient safety concerns.

Leadership Rounds

Every third Thursday of the month, the Board of Directors are dedicated to conducting leadership rounds throughout the facility. Before rounds, the group watches and then discusses (debriefs) a video related to quality, and then visits an assigned unit in two- to three-person teams.

“The Board of Directors spends 30 to 40 minutes visiting various clinics and spaces in the hospital. Then we come back to brief each other on our findings, such as positive things and areas with opportunities for improvement,” says Cmdr. Michelle Liu, deputy director of Health Care Operations and chief of Quality Management at FBCH. “During these rounds, we may be told of a situation that resulted in a work-around or find that a department is doing an outstanding job with limited resources. It’s become a way for us [board members] to have higher visibility in the command and board room and bring some of those less frequented areas to the group’s awareness.”

While it’s impossible to discuss everything in a short time, all feedback is collected, collated and shared internally on an intranet site. 

Staff Engagement

The Joint Commission is an independent, non-profit organization that accredits and certifies health care organizations and programs in the U.S., including military treatment facilities. Clinical staff at FBCH volunteer to inspect different areas of the hospital as if they were Joint Commission inspectors in what is known as “tracer rounds.” The tracer method is used to follow the experience of care, treatment or service for patients through an organization’s entire health care delivery process. These tracers are the cornerstone for Joint Commission accreditation. 

“Similar to what The Joint Commission does, we provide staff with a tool to inspect a space in an organized, objective way,” Liu says. “For example, if we’re doing a tracer for a knee replacement patient, we may look at all the staff involved and their credentials. Or we may do a tracer from an infection control perspective to better understand how we can improve care delivery to prevent infection after surgery.”

Additionally, FBCH is the only MTF in the National Capital Region to set up a Clinical Outcomes Committee that enhances physician engagement and partnership with nursing staff to improve patient engagement. The committee was established four years ago and designed to engage clinical staff about hospital quality metrics followed by The Joint Commission: HEDIS and ORYX.

  • HEDIS: The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of the National Committee for Quality Assurance (NCQA).
  • ORYX: The Joint Commission’s ORYX® initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission-accredited organizations in their quality improvement efforts. ORYX is not an acronym. The initiative is named after the animal oryx, a swiftly moving and graceful gazelle-like animal by definition. This information, along with the fact that it is a short, unique catch word, comes together to provide an explanation as to how the initiative received its name.

Ten multidisciplinary teams, co-led by physicians and nurses, examine both inpatient and outpatient data and look for ways to improve performance for all departments by looking at processes. 

The committee and resulting engagement of clinical staff has “resulted in a rightward shift in our cancer screening rates and improved diabetes screening among patients seen at the hospital and outlying clinics,” Liu explains. Enhancing the rate of flu vaccinations is also something the committee is focused on.

The Joint Commission has set a standard that 94 percent of the inpatient population at a health care facility get screened for flu vaccine and receive it, when appropriate, prior to discharge. FBCH’s Clinical Outcomes Committee has developed plans to achieve this goal by educating all staff, setting reminders, and engaging the healthcare teams to accomplish this goal.  It has involved audits, case reviews, and process improvement for them to enhance their performance, compared to what it was a year ago.

“To date, we have achieved a screening and vaccination rate of 90 percent for flu vaccination among inpatients; ranking us among the top three military treatment facilities for this standard,” Liu said.

To keep track of this and other activities, a new “Quality Corner” in the internal intranet resource, “Shift Report,” is leveraged by the quality management department to educate and remind staff of upcoming activities, make process improvement announcements and share success stories. This has reduced the number of mass e-mails that are sent for various announcements and improved communication with staff, Liu said. 

Staff Recognition

“Our goal is to improve patient safety culture,” says Liu. “Recognizing people who actually raise their hand and admit ‘I made a mistake,’ or ‘We failed in our process’ are recognized for that. People expect retribution for making a mistake, but we have a program in place to say ‘Good catch! You recognized an unsafe condition.’”

Every week, Cmdr. Liu and her team review all FBCH submissions in the Joint Patient Safety Reporting system. Based on those reports, they recommend to the Board of Directors which staff to recognize with a ‘Good Catch Award.’ 

“This is my favorite part,” Liu said. “We have a fish on a plaque that sings and folks who report a patient safety issue get to parade it around.”

To date, more than 30 staff members have been recognized by the Department of Quality and Board of Directors for speaking up about an unsafe condition and preventing it from reaching the patient. 

“Because the JPSR is primarily used to select Great Catch Award recipients, we anticipate an increase in patient safety report submissions,” Liu said.

All MHS direct care facilities are encouraged to self-report potential events, near misses and actual events across all levels and types of medical and dental care in JPSR to foster continuous improvement and provide the safest patient care possible

  • Direct Care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.