SAFETY IN NUMBERS: S TRENGTHENING OUR CULTURE OF SAFETY
ST. JOHN MEDICAL CENTER, WESTLAKE, OHIO
Issue: Patient Safety has been a focus in healthcare organizations for over a decade.
Through the years, we have built organizational structures that evolved our safety culture.
To become a Highly Reliable Organization (HRO), we needed to strengthen our culture
by including patient safety in the organization’s strategic plan and goals.
Project Description: The first step in the project was to implement patient safety into
the organization’s strategic initiatives. Leaders were educated on what it takes to become
an HRO and identified the strategic initiatives. The AHRQ Culture of Safety Survey was
completed and assisted in the identification of opportunities. Based on the results the
Daily Safety Huddle was implemented in September 2013. The Huddle is facilitated by
Senior Leadership and is attended by all department leaders. The agenda requires each
department to look back 24 hours to address safety or quality issues that had an impact on
staff or patients; to look ahead to anticipate issues that may cause problems in the future
and to follow up on open issues that have been previously identified. This huddle
empowers caregivers to think safety at all times. Additionally, Leadership rounding was
implemented to identify patient safety opportunities and provide staff with a venue to
communicate their concerns. Staff hourly patient rounding was also initiated which has
helped to heighten awareness of safe and timely care. Transparency in reporting potential
or actual safety issues has been a byproduct of these initiatives, for not only hospital staff
but for hospital physicians as well. Success is measured by an increase in Patient Safety
Event Reporting, decrease in Serious Safety Events, decrease in events causing harm to a
patient and leadership’s awareness of safety issues identified by frontline staff on a daily
basis. This communication approach facilitates a strong safety attitude and just culture by
keeping the emphasis on safe work practices and behaviors.
Results: The safety huddle has greatly improved communication and greater
transparency in reporting of events. Frontline staff has been empowered to share
information with management who then brings the issues to the huddle. The time from
reporting to resolution in the safety huddler averages 24 hours. There was an increase in
the reporting of events following implementation of the safety huddle due to increased
awareness and accountability for reporting. Daily reporting of days since last serious
safety event and last fall has heightened awareness of these types of events and
contributed to a decrease in Serious Safety Events and falls.
Lessons Learned: Organizational leadership support and involvement in the growth of
the culture of safety have been the key component in strengthening our culture of safety.
The support and example of Senior Leadership trickles down to all in the organization
and is what we need to successfully become an HRO. There definitely is safety in
numbers.
Submitter: Kathleen M. Sweeny, RN, CPHRM, CPHQ