Kick-starting a culture of safety in a public hospital

Background: The 1999 IOM report and the IHI's 100,000 Lives campaign have dramatically raised awareness and commitment to reducing errors and preventable harm in US hospitals. For urban safety-net health systems such as ours, the relative lack of resources, an undertrained workforce, minimal quality department infrastructures, and a crisis-management focus of managers have all limited our ability to keep pace with improvement efforts, even where proven interventions exist. Previous efforts to improve were piecemeal and under-supported, driven by external grants, and often lost momentum and focus. In 2009, our organization developed and implemented an overarching strategy and framework to improve our performance, named the “Harm Reduction Initiative”. We applied it to ten different types of preventable harms across our organization: pressure ulcers, device-associated infections (CLABSI and VAP), sepsis mortality, assaults, medication administration error, falls, intubation complications, surgical site infections, code-blue outside the ICU, and preventable NICU admissions. Methods: Five elements were key to our success: 1) A clear and compelling goal: “Reduce preventable harm across the organization by 50% in 18 months”. 2) Leadership attention: the health system Board of Trustees, the senior executive team, and the Medical Executive Committee all equally owned and devoted their time and attention to the results. 3) Transparency of data: large efforts were required to gain consensus on the sources and validity of the data, and then to share it throughout the institution. 4) Interdisciplinary and vertical team composition: each effort was co-chaired by a physician and nursing leader, and teams were composed of both line staff and managers across 19 disciplines and four campuses, involving 160 individuals. 5) Process improvement expertise: meeting facilitation and coordination, project management skills, PDSA expertise, organizational communication, and team and morale management were all critical elements that needed to be brought in from outside the organization. By implementing these elements around the specific people, culture, and barriers of our institution, we were able to galvanize the organization around the common aim. Results: Over the 18 month project period, 9 out of 10 teams reached their goal of 50% reduction in harm, and a calculated 371 fewer people were harmed than would have been without the improvements that were made. Conclusions: Even in severely resource-constrained urban, safety-net hospitals, rapid and dramatic improvement in safety and quality can occur through organizational change strategies tailored to the circumstances and culture of the institution.