Children's Hospitals Today - Spring 2018 - 26

FEATURE / QUALITY AND SAFETY

BY THE NUMBERS

Improved
outcomes

After implementing
interventions, here's
what Yale New Haven
Children's achieved:

0

serious safety
events

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

26

CHILDREN'S HOSPITAL S TODAY Spring 2018

526

days without a
serious safety event

852%
increase in

event reporting

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."

$3 inmillion
annual
savings to hospital

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.
Send questions or comments to
magazine@childrenshospitals.org.



Table of Contents for the Digital Edition of Children's Hospitals Today - Spring 2018

Contents
Children's Hospitals Today - Spring 2018 - Intro
Children's Hospitals Today - Spring 2018 - Cover1
Children's Hospitals Today - Spring 2018 - Cover2
Children's Hospitals Today - Spring 2018 - Contents
Children's Hospitals Today - Spring 2018 - 2
Children's Hospitals Today - Spring 2018 - 3
Children's Hospitals Today - Spring 2018 - 4
Children's Hospitals Today - Spring 2018 - 5
Children's Hospitals Today - Spring 2018 - 6
Children's Hospitals Today - Spring 2018 - 7
Children's Hospitals Today - Spring 2018 - 8
Children's Hospitals Today - Spring 2018 - 9
Children's Hospitals Today - Spring 2018 - 10
Children's Hospitals Today - Spring 2018 - 11
Children's Hospitals Today - Spring 2018 - 12
Children's Hospitals Today - Spring 2018 - 13
Children's Hospitals Today - Spring 2018 - 14
Children's Hospitals Today - Spring 2018 - 15
Children's Hospitals Today - Spring 2018 - 16
Children's Hospitals Today - Spring 2018 - 17
Children's Hospitals Today - Spring 2018 - 18
Children's Hospitals Today - Spring 2018 - 19
Children's Hospitals Today - Spring 2018 - 20
Children's Hospitals Today - Spring 2018 - 21
Children's Hospitals Today - Spring 2018 - 22
Children's Hospitals Today - Spring 2018 - 23
Children's Hospitals Today - Spring 2018 - 24
Children's Hospitals Today - Spring 2018 - 25
Children's Hospitals Today - Spring 2018 - 26
Children's Hospitals Today - Spring 2018 - 27
Children's Hospitals Today - Spring 2018 - 28
Children's Hospitals Today - Spring 2018 - 29
Children's Hospitals Today - Spring 2018 - 30
Children's Hospitals Today - Spring 2018 - 31
Children's Hospitals Today - Spring 2018 - 32
Children's Hospitals Today - Spring 2018 - Cover3
Children's Hospitals Today - Spring 2018 - Cover4
https://www.nxtbook.com/nxtbooks/cha/cht_spring_2022
https://www.nxtbook.com/nxtbooks/cha/cht_winter_2022
https://www.nxtbook.com/nxtbooks/cha/cht_fall_2021
https://www.nxtbook.com/nxtbooks/cha/cht_2018spring
https://www.nxtbook.com/nxtbooks/cha/cht_2018winter
https://www.nxtbook.com/nxtbooks/cha/cht_2017fall
https://www.nxtbook.com/nxtbooks/cha/cht_2017summer
https://www.nxtbook.com/nxtbooks/cha/cht_2017spring
https://www.nxtbook.com/nxtbooks/cha/cht_2017winter
https://www.nxtbook.com/nxtbooks/cha/cht_2016fall
https://www.nxtbook.com/nxtbooks/cha/cht_2016summer
https://www.nxtbook.com/nxtbooks/cha/cht_2016spring
https://www.nxtbook.com/nxtbooks/cha/cht_2016winter
https://www.nxtbook.com/nxtbooks/cha/cht_2015fall
https://www.nxtbook.com/nxtbooks/cha/cht_2015summer
https://www.nxtbook.com/nxtbooks/cha/cht_2015spring
https://www.nxtbook.com/nxtbooks/cha/cht_2015winter
https://www.nxtbook.com/nxtbooks/cha/cht_2014fall
https://www.nxtbook.com/nxtbooks/cha/cht_2014summer
https://www.nxtbook.com/nxtbooks/cha/cht_2014spring
https://www.nxtbook.com/nxtbooks/cha/cht_2014winter
https://www.nxtbookmedia.com