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• W2771657246 abstract "With a focus on the elimination of all preventable harm, Ascension has been on a journey of continuous improvement in quality and patient safety since 2002. Our bold national system goals have been aligned to form core components of transformative initiatives such as the Journey to Zero and Healing Without Harm, as well as programs conducted in partnership with the Centers for Medicare & Medicaid Services (CMS), such as the Partnership for Patients and Leading Edge Advanced Practice Topics.Improving patient safety is a continuous process at Ascension, the nation's largest nonprofit healthcare system, with sites of care in 24 states and the District of Columbia. Central to this process is the universal adoption of the principles of high reliability (HR). The goal in adopting these principles is to foster a behavior-based model and evolve into a high-reliability organization (HRO). An HRO is defined by Weick and Sutcliffe (2007) as an entity that avoids catastrophes in an environment where accidents are normally expected as a result of risk factors and complexity.In 2011, Ascension committed to becoming an HRO system-wide and has trained more than 100,000 associates and providers, board members, and all senior leaders on the principles of HR. During this journey, we have had 19,000 fewer mortalities than would have occurred at our historic maximum rate, and we have identified significant reductions in the rates of serious safety events and associated severity of harm. Areas with the greatest gains, as measured by our work as a Hospital Engagement Network with the CMS Partnership for Patients, include reductions in injurious falls, surgical site infections for abdominal hysterectomies and colon surgeries, early elective deliveries, catheter-associated urinary tract infections, and venous thromboembolism.INSIGHTS FROM OUR H I G H - R E LI AB I LI T Y JOURNEYWhile Ascension cannot yet claim full achievement of our Journey to Zero, we continue to advance our safety principles at all points of care. Along the way, we have learned significant lessons. One central lesson is the understanding that healthcare leaders at all levels must be adamant in creating a safe environment for care delivery. Four other key insights from our journey to HR are shared here.Insight 1: Complacency Lurks Around Every CornerCountermeasure: Provide every executive, leader, provider, and associate with basic knowledge and set expectations to ensure continued organizational commitment and knowledge.Organizations pursuing HR often show an initial increase in adverse event reporting following HR training, but sustained behavior change is far more challenging to achieve. At Ascension, we saw an increase in reporting of serious safety events and near misses, suggesting adherence to the HR principle of preoccupation with failure.Nevertheless, we still find evidence of underreporting. Stabilization in the rate of reported safety events may reflect the emergence of a safer care environment-or it may be a sign of complacency in event reporting and a loosening of the safety culture. Complacency may lurk in seemingly minor choices. For example, is a wrongsite surgery a permanent or a temporary harm? A temporary harm may go unreported or uninvestigated. If a nurse administers a reversal agent to counteract respiratory depression due to oversedation, is it reported as an event, or and not reported because no harm resulted? Each of these events is preventable, and in an HRO, neither event should be normalized but, rather, fully investigated, with the learning harvested and disseminated for behavior and practice changes. Discussing such situations can help leaders and providers understand how well HR principles have been inculcated into the culture-or where complacency is lurking. When complacency is found, a process should be defined to determine what countermeasures can help sensitize providers to potential patient harm and identify learning opportunities. …" @default.
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• W2771657246 date "2017-01-01" @default.
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• W2771657246 title "Building a High-Reliability Organization: One Systemʼs Patient Safety Journey" @default.
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• W2771657246 doi "https://doi.org/10.1097/00115514-201701000-00004" @default.
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