RWJBarnabas Health is on a transformational journey to become a high-reliability
organization. Beginning in 2018, every health care 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:
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Download the
Safety Together Toolkit and Cheat Sheet.
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Watch the presentation,
Physicians Leading Safety Together.
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Download the
Safety Together Pledge and commit to ZERO incidents of preventable harm.
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Submit an
evaluation. Score 100% to receive
AMA PRA Category 1 Credit(s)™. Score at least 80% to maintain medical staff privileges.
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:
- Explain how errors occur and lead to harm
- Identify their role in preventing human errors and detecting and correcting
system weaknesses
- 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).
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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.
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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.
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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 Health Care 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.
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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%.
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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.
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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.