It always comes back to patient safety.
At the heart of every initiative that bore fruit in 2009 was the desire to always do the right thing. "It’s not important to focus on imperfection if you’re perfect," said Dr. Samuel Lehman, Children’s medical director of patient safety. "But if one of my three kids is being treated here, I want perfection for them. All of our patient families want perfect care, too. The goal of our improvement efforts is to come as close to perfect as possible."
Children’s Board of Trustees member Dr. Robert Kubo echoed the sentiment, "Quality and patient safety are top priority. We are committed to becoming the safest children’s hospital in the Western United States."
"There’s a tendency to think that patient harm is caused by one big mistake, but most patient harm is caused by a culmination of small things," said Dr. Lehman. "We are creating systems and developing a patient safety culture to prevent these small errors and keep them from turning into patient harm."
Children’s takes a number of steps to achieve safe, quality care and enhance communication. We comply with – and often exceed – patient safety recommendations from The Joint Commission and other regulatory agencies. We learn from evidence-based literature, and participate in multidisciplinary committees and collaboratives to share best practices and develop better methods to deliver care. We engage Hospital leadership in initiatives, and conduct frequent reviews and assessments. We encourage staff and patient families to report mistakes and promote a "just culture" in which errors are evaluated objectively.
We allot resources where we need to improve the most. "In addition to our success with the National Patient Safety Goals, we tailor our improvement program to focus on the areas that will prevent the most harm to our special type of patients – children," said Dr. Lehman.
In 2009, Children’s piloted a "global trigger tool" to measure and quantify levels of harm in our hospital. The tool uses "triggers," red flags in patient charts that could signal a harmful event. Children’s randomly selects several charts a month from various areas of the Hospital and conducts a systematic review to identify these harmful events. Our goal is to use this system to monitor ourselves and focus on outcomes to drive our patient safety program.
But none of these efforts are accomplished without the work of many. Organizations that demonstrate the most progress know that commitment to continuous improvement and patient safety is everyone’s responsibility, and everyone at Children’s Hospital embraces this concept.