the training. Only 10 percent should
come from formal teaching, such as
through classroom lectures, grand
rounds, and webinars. This approach
is very different from traditional
medical teaching.
If we're going to teach leadership
in patient safety the right way, it will
not come from a traditional classroom. Instead, our institutions must
have the foundation in place to create
and sustain hands-on learning
experiences for our clinical staff.
Laying a foundation
Our ambitious safety culture
transformation began with the creation of new safety leadership structures. Physicians stepped forward to
participate in and lead many of the
following initiatives:
•;A multidisciplinary safety leadership team, with staff from many
departments.
•;A physician safety leadership
committee.
•;An executive safety council to
classify serious events, create
accountability and “close the loop”
on root cause analysis cases.
•;Designated unit-based safety
coaches with specialized training
in essential safety behaviors.
•;A "Top 10" team to address
high priority needs and sustain
improvements.
•;Unit-based incident reporting
teams.
•;Cause analysis expertise and
trainings.
•;Executive safety rounding.
•;Daily check-ins involving 30
departments to report safety
issues or concerns.
•;High reliability units, or
microsystem development.
At Helen DeVos Children’s Hospital safety check-in meetings have gotten clinical staff
and residents across many departments to regularly communicate with one another
about potential safety concerns on a daily basis.
•;An integrated team of risk management and safety specialists.
•;Safety specialist "on call" all day,
every day, to assist all staff and
physicians.
Quality and safety metrics
reporting has become a routine part
of all meetings. The first item on
every agenda is safety. The serious
safety event rate (SSER) is calculated
and reported monthly. We track days
since our last safety event and review
bi-weekly unit-based incident reports.
