At Missouri Baptist Medical Center in St. Louis, Missouri, they call it “putting it all together,” the ability to take the kind of multi-faceted approach to improving safety that results in reduced mortality rates.
“From the board of trustees to the front line we recognize that in order to affect mortality, we have to do multiple things on multiple fronts,” says John Krettek, MD, PhD, Vice President of Medical Affairs and Chief Medical Officer. Every month the board reviews not only financial measures, but also data on patient satisfaction and all-cause mortality.
“The culture of safety is infused in every staff member,” says Krettek. “Error identification is critical, and every employee knows that he or she has the responsibility to report potential sources of error or injury. Management is responsible for addressing and removing those risks.”
Hospital staff use IHI’s Global Trigger Tool to help identify sources of adverse events, and take steps to and mitigate the effect. Where possible, a focused intervention is implemented to prevent a recurrence.
Krettek underscores the importance of keeping an eye on the big picture. “A physician sees one patient at a time. We look at populations of 300 patients at a time, and we are able to pick out subtle trends before they become patient injuries.” In addition to the right improvement tools, Krettek names three qualities necessary to build safety into the system: “Vigilance, diligence, and a naked awareness that things can go wrong.”
06/01/2008
