Since Yale New Haven Hospital started its high reliability organization (HRO) journey in 2014, the goal has been to get to zero events of patient harm. It’s ambitious and will take time to achieve, but the hospital recently reached a major milestone: an 80 percent reduction in serious safety events (SSEs).
“This is a significant accomplishment, and it’s due to our employees’ and physicians’ dedication to creating a culture of safety,” said Thomas Balcezak, MD, chief medical officer, YNHH and Yale New Haven Health System. “This is a great opportunity to celebrate our success and renew our commitment to reaching zero events of harm.”
The hospital’s safety culture includes a number of key components. Since 2014, thousands of employees and physicians have undergone high reliability training to learn the CHAMP safety behaviors: communicate clearly, handoff effectively, attention to detail, mentor each other with 200% accountability and practice and accept a questioning attitude. More than 500 employees trained as safety coaches reinforce the behaviors through regular peer-to-peer coaching.
Another component, the Great Catch program, spotlights employees and physicians who have used specific CHAMP behaviors to prevent patient harm.
“The Great Catch program illustrates how the safety behaviors make a difference in real-life situations,” said Ellen Macone, RN, safety and quality specialist, Performance Improvement. “We’ve had many Great Catch winners who are in non-clinical positions, which shows how all employees can use these behaviors to prevent harm.”
“Situational awareness” is also an important component of a culture of safety, said Katie O’Leary, RN, executive director, Safety and Quality, YNHHS.
Situational awareness is demonstrated every morning during the hospital-wide safety huddle called Morning Safety Report (MSR), when representatives from various departments discuss recent or potential safety concerns. Many departments and service lines also have their own daily safety huddles.
Another important safety culture component, event reporting, continues to rise at YNHH, and is part of the hospital’s Performance Incentive Plan (PIP) goals. Reporting helps the hospital find and fix problems before harmful events reach patients. Events entered into the RL Solutions reporting system are reviewed and classified; anything deemed a serious safety event undergoes a rigorous investigation.
SSEs and recommendations for corrective actions are presented to the hospital’s Safety Event Review Committee. The hospital has worked hard to improve transparency around SSEs by regularly sharing lessons learned at Safety Event Debriefs. Employees who want to learn more about these events and the debriefs should check with their managers or contact Macone, [email protected].
