This equation is critical because the focus has to be primarily on delivering high–quality care. If high-quality care can be delivered, the next focus is to provide it at the lowest possible cost. Hence, delivering quality care at a responsible cost provides excellent value, and high value is what patients, families, and third-party payers, such as CMS, are seeking. Hospital-acquired conditions (HAC’s), such as blood stream infections and urinary tract infections associated with medical devices such as indwelling catheters, are now carefully monitored; and they are no longer part-and-parcel of hospitalization in an intensive care setting. Hospitals now must be accountable for their outcomes, although research results linking reimbursement to outcomes in a pay-for-performance model have been mixed [4, 5].
Evolution of a Safety Culture
Hospitals have begun learning how to improve safety and quality from industries such as aviation and nuclear power operations [6]. These complex organizations are mindful of failures, as well as of successes; and they focus on system solutions and standardization of processes as a means to improve safety. Preoccupation with failure and the relentless pursuit of improvement are ways that high-reliability organizations produce fewer than the expected number of problem events for a given high-risk situation [7, 8]. For hospitals to take on a likeness of a high reliability organization, they must focus on detecting errors and improving faulty processes with the goal of reducing the risk of recurring errors [9]. The mindset needed to drive change toward institutional improvement starts by a better understanding of how errors are committed. The epidemiology of errors in pediatric hospital care has been recently reviewed [8].
The Children’s Hospital of Michigan Safety Story
The commitment to patient safety needs to permeate throughout the hospital. This commitment must begin at the highest levels of the organization, including the Board of Trustees and the executive leadership team. Those at the patient-care level must also hold this same commitment-, including nursing, physicians, pharmacists, radiology technicians, transportation services, and environmental services.
Children’s Hospital of Michigan (CHM) is a 228-bed, freestanding pediatric hospital founded more than 125 years ago. This urban hospital is staffed by pediatric medical and surgical specialists who serve children in the local community, in addition to children across the region and state. The Hospital is the lone pediatric center in a larger, seven-hospital medical system. Like most pediatric hospitals, CHM offers comprehensive and specialized care, including programs for solid organ and bone marrow transplantation and burn and trauma care.
The hospital strives to be the best, but achieving quality requires establishing appropriate metrics, such rates of central-line associated bloodstream infections, and showing that data pertaining to these metrics have improved over baseline and benchmarked values.
When we decided we could do more to improve safety, we formed workgroups, such as our hospital safety event team (HSET), and implemented our daily “safety huddle” to begin changing our institutional culture. Importantly, we also engaged our board of trustees early on. These steps set the stage for several initiatives, especially in training our staff on error prevention techniques and on the importance of event reporting. Firmly engaging staff in this way has been critical to achieving and sustaining our success in quality and safety initiatives.
Staff Training in Safety Initiatives
Both our medical staff and other hospital personnel were trained in error-prevention techniques. Mandatory workshops and on-line tutorials were instituted to increase the skills and engagement of physicians, nurses, and support staff. Safety coaches were identified among hospital leaders in an effort to reinforce safety principles and to disseminate updates on new safety initiatives. This training in error recognition and prevention strategies created the necessary building blocks to drive event reporting, which is so critical to our improvement efforts. A key message to staff was that patient safety is everyone’s responsibility. A second key message was that anyone who witnesses an unsafe situation has the duty to speak up and change the situation in the interest of patient safety.
Reporting Safety Events
As earlier discussed, high reliability organizations have a high sensitivity to operations-the systems and processes that influence patient care, and are preoccupied with failure-looking at near misses as opportunities to improve these systems and processes to safeguard against recurrence [10]. The need to report errors is paramount to becoming a high reliability organization. Categorizing error reports by event type and responsible service allows us to develop or improve strategies to prevent recurrence. Creating a culture of expectation around event reporting is essential; event reporting must be seen by every employee as a responsibility needed to improve hospital safety.
Identifying barriers to reporting is also important because an arduous, time-consuming process discourages consistent reporting. An anonymous reporting process can reassure employees that reporting is safe if they fear retaliation for “whistle blowing”. These fears should subside as the safety culture becomes further embedded in the institution.
Creating a culture of increased reporting is necessary for success of a patient safety program. The result of an aggressive reporting environment, is a large number of reports that must be sorted through and organized in a meaningful way. Our quality team, which is comprised of the Director of Quality, the Chief Medical Officer, and other members of HSET, has developed a systematic way to organize these event reports, to direct them to the appropriate service for investigation, and to allow close out of these reports with action plans to enable improvements. Further review of high frequency events, (medication errors, for example), might trigger the development of a work group to focus on common underlying causes of these events. Thus, event reporting is essential to starting the process, but it is the analysis of the events by the quality team that allows a deeper understanding of the opportunities for improvement.
Classifying Safety Events
The Healthcare Performance Improvement system classifies an event as a near miss, a precursor event, or a serious safety event [11]. Near miss events do not reach the patient. Precursor events reach the patient but result in no or only minor, temporary harm, such as a wrong dose of medication that has no adverse effect. A serious safety event reaches the patient and causes moderate to severe temporary harm, permanent harm, or death. An example of a serious safety event would be a wrong dose of medication that leads to acute kidney injury requiring hemodialysis and placement of a hemodialysis catheter. Although this error caused only temporary harm, the need to subject the patient to additional procedures and their associated risks makes this error a serious safety event. This classification system allows us to report our near miss-to-safety-event percentage: the number of near-miss events divided by the total number of safety events. This percentage is reported on our hospital safety dashboard to increase the visibility of events and to reinforce the importance of protecting our patients against harm.
Celebrating and Rewarding Success
We acknowledge successes in error prevention. A medication error caught by a pharmacist or nurse can turn a potential serious safety event into a near miss error instead. These “Great Catches” occur throughout the institution: a transporter recognizes that two patients with the same last name are to be taken to radiology and takes the time to determine which patient is which, or a housekeeper calls attention to an unusual odor in a cleaning closet before a chemical spill worsens. We publicly celebrate and recognize these Great Catches in hospital town hall meetings-large employee forums led quarterly by the hospital president, which focuses on new activities and accomplishments of the hospital. We also acknowledge the individuals privately with a thank you note and a copy of the Great Catch announcement to the responsible individual(s). In general, the staff response to this approach has been to embrace our safety culture, which is paramount, because the staff will make or break the overall success of a quality improvement program.
Investigating Safety Events
Converting reported error events into quality improvement changes requires effort. We can inform leaders of safety concerns in several ways. We first describe these ways before describing our investigations.
Notification Mechanisms for Safety Concerns
The Safety Huddle
At CHM, we begin each weekday morning with a “safety huddle.” This 30-min meeting is attended by the hospital president, chief nursing officer, and chief operating officer, and is led by the chief medical officer. Other attendees include nurse leaders from various acute care units, including neonatal and pediatric intensive care, and clinical service areas, such as the emergency department, operating room, radiology, and pharmacy. Other attendees come from quality, risk management, transportation, facilities, environmental services, social work, and care management.
Each meeting is begun with the discussion of Great Catches in the past 24 h, followed by the reporting of serious safety events. The former sets the tone of the meeting by celebrating success and helping others feel empowered to share their successes and encourage their front-line staff to participate. The latter helps hospital leadership quickly identify problems. At huddle, we may learn of critical supply shortages with equipment, pharmacy, or staff. We may learn of a new safety event that occurred a few hours before huddle, which has not yet made it through our event-reporting pathway. Whenever safety events are discussed, those reporting are asked to be certain that an event report is also filed to assist with our follow-up investigation and accounting of event occurrences.
Daily Summary Reports and Hospital Safety Event Team
Our quality department sorts the event reports from the prior 24 h by location of occurrence and severity (near miss, precursor, or serious safety events) and records them in a spreadsheet. This daily report is circulated to quality and safety leaders 2 h before safety huddle. This spreadsheet helps bridge the gap between safety huddle meetings. The daily report includes relatively minor events (e.g., infiltrated intravenous catheters) as well as any major events that occurred after the previous day’s safety huddle, thereby giving leaders a preview of a safety huddle discussion for that morning.
The HSET consists of the directors of quality, risk management, and pharmacy; the chief and associate chief medical officers; and the chief nursing officer. At weekly meetings, the Team looks for trends in precursor events and identifies those that require more detailed investigation. Team members review non-physician event reports and the corresponding responses from the supervisors overseeing the front line staff involved. Hospital leaders are reminded to complete the investigation of events in a reasonable time and receive feedback about the event and its associated response. Providing feedback to hospital staff is important because it emphasizes that time spent entering event reports is valued by hospital leadership. Further, highlighting changes made in response to an event report helps validate the difference that event reporting can make in improving patient safety.
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