"Patient Safety: It's a Team Effort," Cohen Children's Medical Center
Maintaining a safe environment reflects a level of compassion and vigilance for patient welfare that is as important as any other aspect of quality health care, and is a continuous priority.
Cohen Children’s Medical Center (CCMC) has collaborated with other nationally recognized pediatric hospitals to move toward becoming a High Reliability Organization (HRO). HROs reduce risk by minimizing the likelihood of an error reaching patients. CCMC’s Patient Safety Team led the effort by phasing in Commit to Zero, a program to support a culture of patient safety.
Starting in May 2012, CCMC established a daily, multidisciplinary safety report. The brief improved situational awareness at all levels of the organization of potential safety risks, to prevent hazards from becoming accepted or routine.
The next phase focused on mandatory safety behavior education for all practitioners and staff who encounter children during the work day. Attendees learned to identify potential risks and were empowered to report them without fear of retribution. Subsequent weekly safety rounds identified concerns and escalated them to the appropriate level to identify and implement solutions. A Safety Coach Program started in September 2014 utilizes frontline staff to encourage peer checking and coaching and provides just-in-time intervention for team members who needed support.
The program resulted in a significant increase in the reporting of near-miss safety events that would have caused patient harm if left unaddressed. So far, 18 employees have been recognized for extraordinary efforts in identifying near-miss events and opportunities for improvement.
With a focus on reducing hospital-acquired conditions, CCMC health care professionals applied safety culture behaviors in daily practice and bedside care. More than 500 days passed without a CCMC patient’s experiencing a catheter-associated urinary tract infection.
A quantitative measure of the program’s progress is the Serious Safety Event Rate, a national benchmark for safety culture. Calculated at 1.22 before the program began, CCMC’s rate dropped to 0.59 in December 2014, indicating significant improvement.
Furthermore, the hospital’s employee engagement scores improved from 2012 to 2014. Employees indicated that they felt more comfortable raising concerns about potential risks to patient safety.
“The key components of a successful culture of safety include teamwork, open communication, a blameless environment, and transparency—all of which were addressed by this team’s program,” said Mr. Dowling.
The Patient Safety Team received a crystal award and a $10,000 bonus divided equally among team members.
Teamwork Award Finalists
- Leaders of the Future Team, Ambulatory Services
- Patient Safety: It’s a Team Effort Team, Cohen Children’s Medical Center
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