December Quality Corner

December 22, 2014 by

The Children’s Hospital and a Culture of Safety

As Be Safe continues to roll, we need to remind ourselves that in health care, there will always going to be errors and near misses. This does not mean we can become complacent or be “okay” when things do not go as planned. But expecting humans to be error-free 100% of the time is a recipe for failure as well.

The Children’s Hospital, through Be Safe and other quality and safety initiatives, needs to have a Culture of Safety. The Institute of Healthcare Improvement defines a Culture of Safety as having the following characteristics:

  • Psychological Safety: People know their concerns will be openly received and treated with respect.
  • Active Leadership: Leaders actively create an environment where all staff are comfortable expressing their concerns.
  • Transparency: Patient safety problems aren’t swept under the rug. Team members have a high degree of confidence that the organization will learn from problems and use them to improve the system.
  • Fairness: People know they will not be punished or blamed for system-based errors.

So what is the Children’s Hospital doing to develop and/or strengthen these characteristics?

  • Psychological Safety: Every day, all events reported through the Be Safe Event reporting system are viewed by local unit based leaders as well as Children’s Hospital senior leadership. If you feel you cannot openly share information, please find someone that you can speak to who can help find a solution. If team members feel that they cannot speak openly and freely, we will actively work to make that a reality.
  • Active Leadership: In 2013, we started having Quality & Safety Walk Rounds in the Primary Care Center and the 7th Floor inpatient units involving senior Pediatric leadership and local unit/clinic leadership. As Be Safe was initiated, these rounds became part of the Unit Based Leadership meetings. Look for increased visibility by senior leadership as part of these rounds after the New Year.
  • Transparency: All units have developed a process to share their information to both team members and patients/families. For example, as you enter into the NICU, many have noticed the TV screen sharing information. The NICU team shares on a daily basis how many days since their last central line infection, unplanned extubation and breast milk protocol errors.
  • Fairness: The Children’s Hospital leadership believes that “every system is perfectly designed to get the results it produces” and that only a very small number of errors are due to an individual.

Does the Children’s Hospital have a “Culture of Safety?” Send me your thoughts and ideas to improve our Culture and let’s see if we can become the “Safest Hospital in America.”


7 Acute surpasses 300 Central Line Associated Blood Stream Infection Days!

Congratulations to everyone on 7 Acute. This is a great milestone and one that everyone can be proud of across the Children’s Hospital. Keep up the great work! We will have more information on the entire Children’s Hospital rates for 2014 next month.


The Children’s Hospital Situation Room – Nearly Up and Running.

The Children’s Hospital has nearly completed the “remodel” of the Fishbowl on 7 West for our own “situation room.” Every weekday morning at 9:30 AM, unit and clinic leaders (although anyone is invited!) along with administration meet to discuss everyone’s M.E.S.S. (Methods, Equipment, Supplies, and Staffing) issues. If issues cannot be resolved, they are brought to the Medical Center’s Situation Room at 10:00 AM to pull on the Help Chain. Stop by the room soon to see what A3s are being developed and what issues are being solved. We hope to soon have the capability for off-site clinics to be able to join us via video-conference.


Filed Under: Features