Children's Hospitals Today - Spring 2018 - 25

QUALITY AND SAFETY / FEATURE

early in the project was the broken
windows theory, which says crime
emanates from disorder, and if disorder is eliminated, serious crimes
would not occur. Researchers in New
York found little things changed the
culture in communities, like arresting
subway turnstile jumpers and cleaning graffiti off trains, which decreased
subway crimes. "The idea of 'patching'
inspired me-handling the little things
that, if left unaddressed, could lead to
big things," Grossman says. "We were
trying to do the same thing. Four or five
little things could lead to an SSE."
Ciaburri says the root of these
events is tied to culture, infrastructure,
critical thinking and communication
failures. "Mistakes that lead to serious
events can happen when we're not communicating clearly, when there's a power distance between a doctor and nurse,
or when we're rushed or distracted."

The motivation to report
At Yale New Haven Children's, the
existing reporting system didn't address the issues that prevented staff
members from speaking up: there was
no follow-up after a report, and they
feared getting in trouble. The team
realized it was hard for employees to
see the motivation to report. "We had
to show that safety was everyone's
responsibility," Grossman says. "The
changes we made proved to employees
when they report an event that someone is focused on fixing it. We're not
looking to blame anyone when they're
doing the right thing."
Ciaburri says it was crucial to provide a safe venue to report any concern.
"The old culture of making excuses
for harm, like the 'don't ask, don't tell'
mentality, had to be eliminated. So
did the perception of a punitive culture." Recognizing the people making
the catches was key to improving the
reporting system. Prompt follow-up

encouraged the transparency and
continued diligence that would be the
hallmark of this work. Here's what Yale
New Haven Children's did:
 Acknowledged the people reporting. This reaffirmed someone cares
about these events, and they are
being fixed.
 Sent thank you emails. The quality
and safety team sent notes to anyone who reported a safety event.
 Committed to a consistent followup timeline. Follow-up occurred
within two days.
 Showed leadership supports the
reporters. Staff members who
make a great catch receive a
congratulatory letter from the
executive director.
 Developed a report with solutions.
Each unit received a monthly
report of all events and resolutions.
Marianne Hatfield, chief nursing
officer and project executive sponsor, says there's a tendency in health
care to second-guess decisions made
at the bedside when something goes
wrong. "It's important when you say
you have a non-punitive response to
errors, you mean it," she says. "Our job
at the leadership level is to examine
what in our processes allowed the
error to occur and try to fix that, not
the people involved."

The numbers had to
go up to go down
In the project's first three months, the
hospital went from one event reported
per month to 29 reported per month.
"The increase in reporting was not
because we were more unsafe; rather,
everyone's eyes and ears were open,"
says Ciaburri. "This gave us the opportunity to aggregate more data and
look for trends to head off things that

A CLOSER LOOK

Category winners

The 2017 Pediatric Quality
Award uncovered major
improvement work in
children's hospitals. Here's a
look at the category winners:
DELIVERY SYSTEM
TRANSFORMATION and
OVERALL WINNER
Yale New Haven
Children's Hospital
New Haven, Connecticut
Reducing serious safety events
in a children's hospital
CLINICAL CARE
Primary Care Award
Nationwide Children's Hospital
Columbus, Ohio
Reducing emergency department
visits in children with asthma
Specialty Care Award
Monroe Carell Jr.
Children's Hospital
Nashville, Tennessee
Code yellow
PATIENT SAFETY AND THE
REDUCTION OF HARM
Ochsner Hospital for Children
New Orleans
Getting to zero: Eliminating
unplanned extubations in
the PICU
WASTE REDUCTION/
IMPROVED EFFICIENCY
Children's Hospital
of Philadelphia
Reducing waste of isoproterenol,
a high-cost medication, across
multiple hospital settings
Read about the projects at
childrenshospitals.org/award.

CHILDREN'S HOSPITAL S TODAY Spring 2018

http://www.childrenshospitals.org/award

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