Simple but thoughtful interventions can change a hospital's culture and have a substantial effect on patient safety.
By Darcie Reeson
A child came to Yale New Haven Children's Hospital on 21 medications; she was inadvertently sent home on 20. The missing medication was aspirin, and she had a stroke. It's a story that has stayed with Matthew Grossman, M.D., quality and safety officer, and his team, for years.
Team members still tell it when talking about their work to prevent serious safety events (SSEs). "This oversight caused harm to one of our patients," Grossman says. "That sticks with you. It's the top line of our jobs to prevent these kinds of things from happening."
Grossman, along with Rebecca Ciaburri, B.S.N., RN, performance manager, developed Reducing Serious Safety Events in a Children's Hospital, a project that won Children's Hospital Association's 2017 Pediatric Quality Award. The four-year effort established a baseline rate of SSEs for the first time at the hospital and subsequently reduced that rate—through improved reporting—to zero.
SSEs, a deviation from a generally accepted practice that leads to moderate or severe patient harm, are the most fundamental way to determine how safe a hospital is. In 2012, Yale New Haven Children's set its sights on being among the safest children's hospitals in the country.
But the hospital had a cumbersome system that left many events unreported, according to Grossman. "We couldn't answer the question about how safe we were," he says. "And we knew events were being swept under the rug or just considered a complication. It was the place to start."
Anything can lead to a serious safety event
Events with the potential to cause harm can look different with every report. "What are the common mistakes that lead to a big safety event? They could be anything," Grossman says. "And that's the idea behind this project. We wanted to know about everything that happened and address issues that could lead to harm."
A concept that moved Grossman early in the project was the broken windows theory, which says crime emanates from disorder, and if disorder is eliminated, serious crimes would not occur. Researchers in New York found little things changed the culture in communities, like arresting subway turnstile jumpers and cleaning graffiti off trains, which decreased subway crimes.
"The idea of 'patching' inspired me—handling the little things that, if left unaddressed, could lead to big things," Grossman says. "We were trying to do the same thing. Four or five little things could lead to an SSE."
Ciaburri says the root of these events is tied to culture, infrastructure, critical thinking and communication failures. "Mistakes that lead to serious events can happen when we're not communicating clearly, when there's a power distance between a doctor and nurse, or when we're rushed or distracted."
The motivation to report
At Yale New Haven Children's, the existing reporting system didn't address the issues that prevented staff members from speaking up: there was no follow-up after a report, and they feared getting in trouble. The team realized it was hard for employees to see the motivation to report.
"We had to show that safety was everyone's responsibility," Grossman says. "The changes we made proved to employees when they report an event that someone is focused on fixing it. We're not looking to blame anyone when they're doing the right thing."
Ciaburri says it was crucial to provide a safe venue to report any concern. "The old culture of making excuses for harm, like the 'don't ask, don't tell' mentality, had to be eliminated. So did the perception of a punitive culture." Recognizing the people making the catches was key to improving the reporting system.
Prompt follow-up encouraged the transparency and continued diligence that would be the hallmark of this work. Here's what Yale New Haven Children's did:
- Acknowledged the people reporting. This reaffirmed someone cares about these events, and they are being fixed.
- Sent thank you emails. The quality and safety team sent notes to anyone who reported a safety event.
- Committed to a consistent follow-up timeline. Follow-up occurred within two days.
- Showed leadership supports the reporters. Staff members who make a great catch receive a congratulatory letter from the executive director.
- Developed a report with solutions. Each unit received a monthly report of all events and resolutions.
Marianne Hatfield, chief nursing officer and project executive sponsor, says there's a tendency in health care to second-guess decisions made at the bedside when something goes wrong.
"It's important when you say you have a non-punitive response to errors, you mean it," she says. "Our job at the leadership level is to examine what in our processes allowed the error to occur and try to fix that, not the people involved."
The numbers had to go up to go down
In the project's first three months, the hospital went from one event reported per month to 29 reported per month. "The increase in reporting was not because we were more unsafe; rather, everyone's eyes and ears were open," says Ciaburri. "This gave us the opportunity to aggregate more data and look for trends to head off things that could turn into serious events."
The team measured the reported events per month and categorized them as SSEs, precursor safety events, or near-miss events. "We've caught and corrected errors I'm certain would've led to serious events," Grossman says.
By June 2017, the hospital averaged 247 event reports per month, an increase of 852 percent, and went 526 days without a SSE. "The numbers reflect our employees' willingness to trust us and report things that, in the past, may have led to blame and shame," Hatfield says.
Rewiring the system
Better reporting was a big step forward, and it was necessary for the next step to occur within the organization: using the reports to detect safety events. To practice, teams began to provide input into simulations in high-risk patient care areas, like the PICU, NICU and emergency department.
Issues detected during simulations received the same follow-up as an actual safety event. Staff members in each unit were trained as safety coaches and tasked with developing a culture of safety by supporting harm prevention behaviors. All staff members were also trained in high reliability organization techniques.
Focused daily on safety
No single change can claim credit for reducing SSEs at Yale New Haven Children's. However, Grossman says one was the anchor of this work: the morning safety report (MSR). The hospital implemented the MSR and continues to hold them each day with unit leaders, medical directors and ancillary staff leaders. And because it's valuable to anyone involved in patient care, it's also open to front line staff.
The MSRs cover four topics: safety events that occurred in the last 24 hours; potential safety concerns in the next 24 hours; scheduled follow-ups of previously reported safety events; and great catches. The daily reports are recorded and categorized within a database for the record.
Finding the time for team members to discuss and follow-up on safety reports was essential. This 15-minute intervention was an improvement for employees who used to spend weeks finding the right person to help solve an issue. "MSR put everyone in the same place, every morning, to immediately address safety concerns," says Hatfield.
"Initially, we worried we wouldn't get consistent representation from everyone we needed. But people began to see the process was working. They voted with their feet and kept showing up."According to Ciaburri, if the team had done nothing else, implementing this intervention would be a measure of success. "The MSR puts safety at the forefront because we start each day talking about safety. It sets the tone."
Clinicians aren't the only ones changing culture
While clinicians have obvious interactions with patients, those behind the scenes play a role, too. One frequent reporter, dubbed an MVP, is a member of the facilities staff. The MVP program recognizes high achievers who make great catches. Staff members with more than five great catches in a year earn the MVP title.
"This is about watching for something that doesn't look right and inquiring if things are okay," Grossman says. "When I was in the cafeteria one day, I watched a colleague talking with a family. I realized she's hearing what they say and knows about their experience."
It's the staff members, and patients and families, who inspire the team to continue this work. "I know all the stories about harm," Grossman says. "These aren't numbers; they're kids. And these kids have families that trust us. Even with our results, this project doesn't end; the job will never be finished. We need to eliminate every error."
While the interventions are critical, so is building and maintaining trust among employees. "The heart of this work was changing the way we interacted with each other," Ciaburri says. "This was about creating engagement to foster transparency." By relying on its reporting system and supporting staff members, Yale New Haven Children's can remain vigilant into the future.
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