RWJBarnabas Health is on a transformational journey to become a high-reliability organization. Beginning in 2018, every healthcare employee and credentialed member of the medical staff will receive education and training about a selection of behaviors and evidence-based error prevention tools that we have adopted to keep our patients and each other safe. Please join us in delivering “Safety Together” and committing to ZERO incidents of preventable harm at RWJBarnabas Health.

Instructions:

  1. Download the Safety Together Toolkit and Cheat Sheet.
  2. Watch the presentation, Physicians Leading Safety Together.
  3. Download the Safety Together Pledge and commit to ZERO incidents of preventable harm.
  4. Submit an evaluation. Score 100% to receive AMA PRA Category 1 Credit(s)™. Score at least 80% to maintain medical staff privileges.
  5. Contact Emily Halu if you are interested in becoming a “Safety Together” trainer for other physicians at RWJBarnabas Health.
    Emily Halu, RN, MSN, Vice President - High Reliability
    Emily.Halu@rwjbh.org
    Cell: (334) 389 - 1996

Target audience: RWJBarnabas Health Physicians

Speakers: Steven Kreiser, Emily Halu

Disclosure statement: Steven Kreiser and Emily Halu are employees/consultants of Press Ganey Associates, Inc; Planners have declared nothing to disclose.

Objectives:

At the end of this activity participants will be able to:

  1. Explain how errors occur and lead to harm
  2. Identify their role in preventing human errors and detecting and correcting system weaknesses
  3. Use SAFETY behaviors and tools to prevent errors

Original release date: June 11, 2018

Review date: June 1, 2019 unless indicated by new scientific developments.

Termination date: June 1, 2021

Resources for further study:

Organization: Abington Memorial Hospital

Study: 2013 Delaware Valley Patient Safety and Quality Award, Delaware Valley Health Care Council.

Findings:

  • Utilized High Reliability principles to set training and accountability benchmarks throughout system.
  • Safety mission became part of the culture and everyday work.
  • 91% reduction in serious preventable harm.
  • 365 consecutive days without a serious safety event (SSE).

Organization: Advocate Health Care
Study: Weinstock, M. (2007). Can your nurses stop a surgeon? Hospitals and Health Networks, 81(9), 38-40, 42, 44-46.

Findings:

  • Leaders at Advocate Health Care created a culture of safety that permeates every level of the organization.
  • The initiative, inspired by work at Sentara Healthcare, gave all employees the power to stop any action they think might harm a patient or co-worker.

Organization: Ascension Health

Study: Pryor, D., Hendrich, A., Henkel, R. J., Beckmann, J. K., & Tersigni, A. R. (2011). The quality ‘journey’ at Ascension Health: How we've prevented at least 1,500 avoidable deaths a year--and aim to do even better. Health Affairs, 30(4), 604-611.

Findings:

  • Seven pilot sites with 50-90% reductions in serious harm.
  • Compared to the baseline year, more than 18,000 lives were saved.

Organization: Children’s National Medical Center

Study: Hilliard, M. A., Sczudlo, R., Scafidi, L., Cady, R., Villard, A., & Shah, R. (2012). Our journey to zero: Reducing serious safety events by over 70% through high-reliability techniques and workforce engagement. Journal of Healthcare Risk Management, 32(2), 4-18.

Findings:

  • The Safety Transformation Initiative at Children's National resulted in national and local recognition, a financial savings of $35 million, and a greater than 70% decrease in the SSE rate.
  • The results were achieved during a time of significant financial constraints and with limited resources.

Organization: Connecticut Hospital Association (CHA)

Study: Cooper, M. R., Hong, A., Beaudin, E., Dias, A., Kreiser, S., Ingersol, C. P., & Jackson, J. (2016). Implementing high reliability for patient safety. Journal of Nursing Regulation, 7(1), 46-52.

Findings:

  • 50% reduction in serious preventable harm.
  • 86.7% reduction in catheter-associated urinary tract infections.

Organization: Main Line Health System

Study: 2014 Delaware Valley Patient Safety and Quality Award, Delaware Valley Health Care Council.

Findings:

  • 88% reduction in serious preventable harm.
  • 39% reduction in overall mortality.
  • 55% reduction in sepsis-related deaths.

Organization: Nationwide Children’s Hospital

Study: Brilli, R. J., McClead, R. E., Jr., Crandall, W. V., Stoverock, L., Berry, J. C., Wheeler, T. A., & Davis, J. T. (2013). A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. Journal of Pediatrics, 163(6), 1638-1645.

Findings:

  • 83.3% reduction in SSE rates.
  • 25% reduction in observed hospital mortality.
  • 22% reduction in harm-related hospital costs.
  • Significant increase in hospital-wide safety culture scores.

Organization: ProMedica

Study: Ball, D., Kaminski, B., & Webb, K. (2016). First, do less harm: A health care cultural operating case study to improve safety. People + Strategy, 39(1), 29-33.

Findings:

  • 86% of staff and 87% of medical staff rate safety as a priority of the organization.
  • Key strategies included leader encouragement for goals setting, the transparency of performance on quality of service, and the link between safety efforts and core values of the organization such as compassion, teamwork, and excellence.

Organization: St. Vincent’s Medical Center

Study: The Joint Commission (2012). Improving patient and worker safety: Opportunities for synergy, collaboration and innovation. Oakbrook Terrace, IL: Author.

Findings:

  • Reduction in preventable deaths.
  • Significant improvements in associate health and safety, including OSHA reportable events, the DART (days away, restricted, or transferred) rate, SSE rate, and days between events.
  • Reduced malpractice costs

Organization: Sentara Healthcare

Study: 2005 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality, National Quality Forum and The Joint Commission.

2004 AHA-McKesson Quest for Quality Prize®, American Hospital Association.

Findings:

  • Used the principles and processes learned from High Reliability Organizations outside of health care to create a culture of safety throughout the system.
  • 50% harm reduction in 18 months.
  • 80% serious harm reduction overall.

Organization: VCU Medical Center

Study: 2014 AHA-McKesson Quest for Quality Prize®, American Hospital Association.

Findings:

  • Developed “Safety First, Every Day” mantra to support the goal of becoming America’s safest health system, through reaching zero events of preventable harm to patients, team members, and visitors.
  • 50% reduction in SSEs after implementing High Reliability practices.

Vidant Health

Study: 2013 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality, National Quality Forum and The Joint Commission.

Findings:

  • Vidant Health implemented a series of interventions to improve patient safety and quality that included board literacy in quality, an aggressive transparency policy, patient-family partnerships, and leader and physician engagement.
  • 83% reduction in SSEs.
  • 62% reduction in hospital-acquired infections.
  • 98% optimal care performance on CMS core measures.
  • HCAHPS performance in the top 20%.

Organization: WellStar Health System

Study: Johnson K., & Delk M. (2014, May). The high-reliability chassis: Improving patient and employee safety. Paper presented at the Annual NPSF Patient Safety Congress, Orlando, FL.

Findings:

  • 90% reduction in serious patient harm.
  • 84% reduction in worker injuries.
  • 50% reduction in workman’s compensation claims.

Accreditation Statement: The Monmouth Medical Center is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.

AMA Credit Designation Statement: The Monmouth Medical Center designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.