Children's Hospital & Clinics

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(1) Comment on Patient Safety Initiative: To enhance patient safety is not a new idea in the hospital. However, it is difficult to implement it due to culture resistance. What Julie Morath has done differently in Children's Hospital was that she breaks the ABC (Accuse, Blame, Criticize) culture into an open, transparent system to the patient's family, to the hospital employees including the first line workers, the medical doctor and the management. She develops it into an organizational value to implement the Patient Safety Initiative. It helps to reform the hospital culture on medical accident, to improve the process on safety and financial outcome. The Patient Safety Initiative is of great value for Children's Hospital and is recommended to other hospitals. On the other hand, Patient Safety Initiative is revolutionary and would take some time to implement it with full support and resources in the hospital. Before it is well-implemented, the leadership is particularly critical for the success on the Initiative.

(2) Blameless reporting: Instead of ABC in old system, "Blameless reporting" focuses on the analysis of the fact and trace what really happened. It encourages the first line workers such as the nurse to provide the truth of the fact without burden to be blamed and helps the hospital to improve and prevent the recurring. On the other hand, it may be misleading that nobody would be punished for making mistakes. Subsequently, it may increase the overall risk. There should be other mechanism to manage those who have conducted significant medical errors.

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(1) Difficulty: The employees were reluctant to admit that medical error/accident was a significant problem in Children's and was not convinced that the National data can be applied to Children's. Being afraid to be punished, they were very defensive to discuss it openly.

(2) Why it was not easy for the employee to discuss medical error/accident openly: Because it may cause legal risk for the hospital and have negative impact on personal career.

(3) Morath's actions/strategy: She presented medical accident data by numerous presentations that such a complex health care system is risk prone and errors happen to any hospitals including Children's. A new safety approach may reduce the accident. Secondly, by the help of "key influencers" she conducted employee and patient parent focus groups to discuss safety issue. The employees feel safe to disclose any accident and enhance their enthusiasm on this Initiative. It provides a channel for the patient parents to provide their experience and suggestion. Thirdly, she formulated the strategic plan-SAFE (Safety, Access, Financial, Experience) to implement the Initiative by setting well-defined goals and tasks.

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(1) Steps/measures:

? Developed consensus and established new vision: Morath made the employees understand that medical accident is a significant problem but can be reduced by Patient Safety Initiative.

? Formulated the strategic plan: SAFE set clear goals and critical tasks to be accomplished and was a useful tool for aligning the organization.

? Established infrastructure: She organized the core team such as Patient Safety Steering Committee to oversee the safety initiative. In addition, the PSSC revised the hospital policy to conduct the problem-solving procedure "Focused Event Studies" more frequently.

? Obtained the top management support Morath gained the Board support to be able to fully implement the Patient Safety Initiative.

? Implementation: Morath created a culture of open and frank communication about safety issue by setting up the Blameless Reporting system; changed the Language when discussing safety issue; changed the Disclosure Policy