In May 2017, St. Luke's Health System (Boise, ID) was named a finalist for ECRI Institute's 11th Health Devices Achievement Award for the strategy it used when implementing a major change—the complete redesign of the health system's recall management program—so that the change would yield lasting results.

The Health Devices Achievement Award recognizes innovative and effective initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. For details about the winning submission and other finalists, see The Health Devices Achievement Award: Recognizing Exceptional Health Technology Management.

ECRI Institute congratulates the project team members: Crystal Geibel and Paul Lambert.

The Challenge

To transition the health system's recall management program from a disconnected, paper-based process to a centralized, automated system that allows better tracking of reports, enhanced and reliable communications, documentation of actions taken, and real-time reporting.

The Landscape

1. The need to improve how recalls were managed at St. Luke's Health System (SLHS) was highlighted in a May 2014 internal audit report.

a) At that time, recalls were handled by mailing paperwork to independent locations, with no centralized communication.

b) The report cited the need for governance, centralization, standardization, and automation of how the organization handled recalls.

2. By early 2015, the organization had implemented several measures that would help it achieve that goal:

a) In February 2015, the Operations Council approved the creation of the SLHS Recall Program.

b) In March 2015, a recall analyst was hired to coordinate the program.

c) In April 2015, the organization implemented ECRI Institute's Alerts Tracker, an online recall management system. Throughout that year, employees were added to the Alerts Tracker workflow.

3. The St. Luke's team recognized, however, that simply instituting a new recall program and purchasing new technology would not yield effective and lasting change. Thus, they developed and implemented a strategy to improve the likelihood of a successful implementation.

The Process

Referencing John Kotter's Eight Steps to Successful Change,[1] the St. Luke's team focused their plan on optimizing technology, systematizing processes, and mobilizing people.

1. Optimizing technology

a) Communications

(1) The recall program incorporated a communications solution from an external vendor that supports mass communication with staff receiving recalls and other alerts, with management, and with leadership when an incident or alert requires immediate action.

(2) The closed-loop communication system allows management to see all users who have or have not responded, along with any comments entered.

b) Alert identification: Automatch

(1) St. Luke's uses the Automatch feature available with Alerts Tracker to identify whether any supplies in inventory are the subject of an alert.

(2) This feature allows faster notification of relevant alerts and makes it easier to locate affected products among the various facilities within the health system, leading to more timely responses to alerts.

(3) Additionally, feedback that the St. Luke's team provided to ECRI Institute resulted in product enhancements that improved the Automatch workflow for, and compliance among, the St. Luke's users.

c) Assignment tracking

(1) Reporting functionality within the Alerts Tracker system is used to identify individuals who have unresolved alerts, as well as the percentage of employees who have completed assignments within a specified time frame.

(2) St. Luke's notes that this information has helped to incentivize employees to "join the new normal" as the organization improves its recall response times.

d) Additional reporting capabilities

(1) St. Luke's developed its own dashboard that uses data from the Alerts Tracker system to communicate compliance trends and resolution times with the organization's leadership and employees. The organization has found this weekly report to be an effective platform for highlighting program advancements and informing leadership of actions needed for the program's success.

(2) St. Luke's also partnered with an analytics organization to make better use of the recall management data that was available.

2. Systematizing processes—As its program matured, the St. Luke's team systematized actions taken through policy, procedures, and infrastructure. Examples include:

a) Producing a recall policy for the entire St. Luke's Health System

b) Creating standard operating procedures, sharing best practices, and addressing pain points to be avoided

c) Creating workflows for each Alerts Tracker account type, with step-by-step directions

d) Standardizing the new employee training system, and sharing the system with existing employees

e) Integrating with Environment of Care and with the Quality and Patient Safety Councils

3. Mobilizing people—The St. Luke's team recognized that successful change requires more than just technology and processes; it requires engaging both leadership and staff in the process. This involved:

a) Developing a clear shared vision

b) Communicating that vision throughout all departments

(1) Program goals are communicated so that staff understand the value of the changes.

(2) Additionally, effort is made to explain the "why," so that staff can put needed actions in context.

c) Empowering people to act on that vision

(1) Employee feedback is solicited and is used when developing best practices, to streamline processes, or to help improve training.

(2) Objective measures are provided in weekly reports, so that staff can view progress and push to attain improvements.

The Results

The success of the team's approach can be seen in the significant reductions in unresolved alerts that were achieved in the first six months.

1. More efficient handling of alerts allowed the health system to largely clear out its substantial backlog of unresolved alerts in just six months' time.

a) The backlog reached a peak during periods in June and July 2016:

(1) The baseline of unresolved alerts—that is, the total that remained unresolved from week to week—rested at approximately 2,000 alerts.

(2) When new assignments were added each week, the number of unresolved alerts spiked to more than 3,000 alerts.

b) By December 2016, the baseline of unresolved alerts that remained at the end of each week was reduced to about 200 to 300 alerts—a tenfold reduction.

2. St. Luke's also reports that, with the new system:

a) Alert resolution times have been reduced dramatically. For example, for alerts labeled High priority:

(1) The average resolution time was steadily reduced from 54 days (in April) to 5 days (in January).

(2) The percentage of assignments that were completed within the organization's reduced-time standard increased from 54% (in April) to 88% (in January).

b) Compliance rates—signifying that all assignments for a recall are completed throughout the health system—have continued to improve.

Key Takeaways

The success of St. Luke's transition to a more robust recall management program illustrates the value of several "best practices" that ECRI Institute recommends for such implementations. These include:

1. Having a policy

2. Gaining leadership and participant buy-in

a) Because of the potential consequences to patient care, recall management should be viewed as a patient safety goal, not a clerical task.

b) Leadership at St. Luke's decided on clear goals and ensured that the recall program received the appropriate support.

3. Setting reasonable and manageable goals

4. Providing feedback to leadership and participants, including recognizing high performers and identifying low performers

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[1] Kotter JP, Cohen DS. The heart of change: real-life stories of how people change their organizations. Boston (MA): Harvard Business School Press; 2002.