2014 MHA Nomination for Patient Safety Award
Facility Name: University of Minnesota Medical Center, Fairview
Nomination Title: Daily Safety Calls; Debra Cathcart, MS, RN, NEA-BC
Nominator: Carolyn, Wilson, President, University of Minnesota Medical Center
Summary:
Daily Safety Calls at the University of Minnesota Medical Center were implemented in 2013. These daily calls involve 29 reporting units across the hospital and clinics, including both patient care and business units, and not only promote a greater awareness to safety issues across the hospital, but also allows a more rapid and complete response to critical issues as they arise. Pre and post-implementation safety metrics show a marked improvement, decreasing both the number of days to close occurrences and the volume of our most severe occurrences.
Narrative:
It is my pleasure to nominate the University of Minnesota Medical Center (UMMC) for the Patient Safety Improvement Award. In 2013, the leadership at UMMC implemented “Daily Safety Calls”, for the pediatric service (starting in May 2013) and the adult service (starting in September 2013). These safety calls have already made a tremendous positive impact for our patients: they have dramatically enhanced a culture of safety for staff and providers in all areas, at all levels of the hospital; reduced the risk of harm for patients, staff and visitors; enhanced awareness of safety events and risk, improved safety and clinical outcomes, and; reduced preventable adverse events.
These calls occur daily and include the participation of nearly 30 reporting units across the hospital, including clinical and ancillary units, such as environmental services, security, information services, supply chain, and transportation. The average attendance rate for this call is 98% (adult) to 99% (peds), and the average length of the call is 16 minutes. The calls follow a defined script, and accomplish three things: 1) look back at significant safety and quality issues from the last 24 hours; 2) look head at anticipated safety or quality issues in the next 24 hours, and; 3) follow-up on the status report on issues that have been identified. This broad participation by so many different constituent groups not only promotes a greater awareness to safety issues across the hospital, but also allows a more rapid and complete response to critical issues, in “real time”, as they arise. This also provides a great opportunity for collaborative problem-solving, creating a dynamic team-based environment that promotes input from many different areas of expertise to enrich the knowledge of the entire group.
Pre and post-call implementation safety metrics demonstrate the dramatic efficacy of this process and its impact on our patient care. Data has been collected during the first eight months of implementation, and measured against the baseline data prior to implementation. Highlights of this data include the following:
· Total weekly occurrences being reported into the electronic tracking system have increased
o Median Pre-Implementation: 34 pediatric occurrences and 60 adult occurrences; Median Post-Implementation: 43 pediatric occurrences and 77 adult occurrences)
· Total days to close occurrences has decreased
o Median Pre-Implementation: 13 days (peds); 7 days (adult)
o Median Post-Implementation: 6 days (peds); 6 days (adult)
· While pediatric volumes overall have increased (reporting is encouraged), pediatric cases of the most severe harm have decreased
These results are the first step towards a greater focus on safety throughout the hospital. As the team gains experience and new knowledge of safety concerns through this process, better preventative measures will be identified to eliminate many of these incidents moving forward. This will create lasting and sustainable results.
Plans have been made for best practices from this process to be shared and supported throughout additional adult services at UMMC, impacting how we care for every single patient. These practices, as they are refined, will be shared across the Fairview system, influencing how we care for patients throughout the metropolitan area and the State. The process and lessons learned are applicable across the region and State. Many healthcare entities across the Nation are watching our efforts closely and planning to implement this effective initiative.