Forever Changed: Shared Learning in Patient Safety
In an effort to promote patient safety, Baptist Health South Florida (Baptist Health) has instituted the Shared Learning process, the purpose of which is to educate and communicate with all stakeholders—our clinical staff, the Quality and Patient Safety Steering Council, and board members—in a proactive way. The Quality and Patient Safety Steering Council (QPSSC) is a corporate body that consists of organizational executives, physicians, clinical staff, and family advisors. Under the Patient Safety Partnership (our Patient Safety Organization), the QPSSC guides organizational improvement efforts. The Shared Learning strategy focuses on promoting transparency and providing tools to enhance a successful patient safety plan.
When a significant event that may have caused harm to a patient occurs, sharing the lessons learned across the health system provides an opportunity to improve processes, as well as educate all employees, leadership, and our boards to prevent similar incidents from reoccurring. The same is true for lessons we learn from near-miss reporting and follow-up changes that have taken place. Through Shared Learning, all of our entities have the benefit of the Root Cause Analysis (RCA) and Action Plan conducted following an incident. All aspects of the RCA and Action Plan are presented and discussed, including the changes that need to occur to best protect patients and their families. The executive leadership of the QPSSC recommends which events to highlight and focus on across the system. We have taken one event to the next level and created a video, Forever Changed: The Kaelyn Sosa Story, which highlights the lessons learned, actions taken, and relationships formed following an incident in 2004.
Baptist Health embarked on its journey to enhance its patient safety and quality efforts in 2003. Already a founding member of National Patient Safety Foundation’s (NPSF) Stand Up for Patient Safety campaign, the need to partner with our patients and families to create an additional safety net was clear. We realized that our approach to patient and family centeredness was inconsistent across our health system. Throughout our patient safety journey, it became evident that we needed to involve patients and families, so Baptist Health South Florida made a commitment to inculcate patient- and family-centered care throughout the organization.
With six hospitals (1,595 beds), 19 outpatient centers, more than 2,000 private-practice physicians, and approximately 14,000 employees, Baptist Health is the largest faith-based, not-for-profit healthcare organization in South Florida. In 2010, the hospitals (combined) had 71,239 inpatient admissions, 10,134 births, and 235,176 emergency room visits. Our urgent care centers had 144,256 visits, and the outpatient diagnostic centers had 130,108 visits. This demonstrates Baptist Health’s tremendous responsibility to our community, patients, families, employees, and medical staff.
The philosophy behind developing a Shared Learning program was to enhance our already strong patient safety program and implement a strategy to promote transparency and the tools needed to better protect patients and their families. The purpose of Shared Learning is to educate and communicate to all in a proactive way, preventing the need for each entity to learn solely from its own mistakes.
Each “Learning” is initially shared with the specific hospital’s executive leadership; then with our system-wide Quality & Patient Safety Steering Council (members include corporate chief quality officer, corporate assistant vice president risk/patient safety, entity chief nursing officers, performance improvement directors, patient safety officers, director of patient safety partnership and marketing); and finally with the Baptist Health Board Committee on Quality & Patient Safety.
A Shared Learning presentation follows a template:
- Event Summary
- Disclosure Process
- Root Cause Team Members
- Key Issues and Timeline
- Education Action Items
- Lessons Learned
All presentations are written without personal health, physician, or specific employee information. Any details that would identify the specific entity or incident are omitted. Team members for the RCA are listed by role in the organization, not by name. The disclosure policy of Baptist Health is to openly and honestly take responsibility when things don’t go correctly and provide the patient and/or family members with an explanation, apology, and assurance that everything possible is being done to make sure problems are addressed. If media attention was involved, there is discussion of how this was managed.
Key issues are drawn from detailed results from the root cause analysis. These include any problems that are identified as risk points in the processes surrounding the event. Education action items include root cause and anything done following the event to prevent a similar incident from recurring, such as physician/staff education and communication, policy and procedure changes, documentation tools, equipment repair or substitutions, or any other performance improvement actions.
Finally, the lessons learned by Baptist Health are presented. These include what each of our entities can do to assess their processes and make changes to prevent this same type of incident from happening again. The ultimate goal is to evaluate current practice and proactively implement process changes when needed. Examples of processes we have covered in Shared Learning include pediatric airway, transfusion safety, medication adverse event, CT contrast reactions, fire in the OR, and wrong-site surgery.
While Shared Learning originally began with adverse events, in 2010 we expanded it to include system performance improvement work conducted by our Accelerated Change Teams (ACTs), TRIM (Lean) projects, and other performance improvement (PI) activities. ACTs are Baptist Health’s systematic, structured process for planned/continuous focus on improving quality, clinical performance, and patient safety issues, and for rapidly deploying initiatives across the system.
Baptist Health has accepted invitations to showcase many of our patient safety efforts at a variety of professional meetings nationwide. For example, our Patient Safety Champion program has been showcased by National Patient Safety Foundation, the American Society of Healthcare Risk Management, the Florida Society of Healthcare Risk Management and Patient Safety, Healthcare Education Association, and Versant Residency conferences. We also measure the success of our patient safety efforts by looking at several outcomes, including:
- A 51% decrease in active medical malpractice cases (2003 to 2010).
- A drop in Code 15 reports (mandatory reportable events in Florida): 10 in 2010 compared with 41 in 2003.
- Fifty-three percent of Baptist Health’s quality measures (compiled by U.S. Department of Health and Human Services and the Hospital Quality Alliance) are in the top 10% of all hospitals nationally—better than all of the U.S. News and World Report’s Honor Roll.
- All Baptist Health hospitals meet or exceed the 90th percentile for inpatient as well as outpatient satisfaction, based on Press Ganey’s national database of nearly 1,800 hospitals.
- Our patients consistently rate our hospitals at 9 or 10 when asked the HCAHP question, “Would you recommend the hospital to friends or family?”
- Physician satisfaction in benchmark surveys has steadily gone up at all Baptist Health hospitals, with scores now in the 97th percentile.
- A repeat of a baseline patient safety climate survey showed improvements in nearly every area. Employee responses of “strongly agree” regarding hospital management providing a climate that promotes patient safety went from 27.5 to 47%; for hospital management showing that patient safety is a top priority, “strongly agree” went from 41.3 to 55.3%.
- In 2010, mean scores went up considerably in all inpatient, outpatient, and ambulatory surgery areas for a patient satisfaction survey question that checks whether patients feel adequate precautions were “taken by the staff to protect your safety, such as hand washing, checking identification bands, etc.”
- Our falls prevention program continues to see a 50% decline in patient falls in all categories since the program began in 2001.
- Scorecards have been developed to track our performance on the Joint Commission’s National Patient Safety Goals (2009 to 2010).
- Accelerated Change Teams (ACTs) have measures and are working on return on investment.
- Each Code Help is evaluated, and random rounds are conducted to audit the effectiveness of patient teaching.
Our Shared Learning process was the springboard for developing a teaching tool, which we have shared with healthcare organizations worldwide. Our 15-minute video, Forever Changed: The Kaelyn Sosa Story, highlights the lessons learned from an adverse event involving a toddler; the actions taken following the event; the impact on the patient, her family, and our employees; and ultimately, the bonds that were formed. Both results and actions that have been taken to improve our patient safety efforts are showcased.
This video was produced in-house collaboratively with Kaelyn Sosa’s parents. From this, we built a framework to become more family-centered in our patient safety journey. We began by adding community members to our individual hospital patient safety committees and to our system’s Patient Safety Leadership Group (PSLG) in 2003. We established a Patient Safety Champion program for front-line staff and leadership. In 2005, we began the Shared Learning program that has grown to now include our Forever Changed video. In 2007, the PSLG became the Quality and Patient Safety Steering Council (QPSSC) that sponsors our ACTs. Patient/family advisors sit on the QPSSC as well as on the ACTs.
In 2008, our Baptist Children’s Hospital formed a steering council from the original ACT. Called “Harmony in Pediatrics,” the steering council has sponsored the elimination of visiting hours in pediatric areas, bedside report with families, and Code Help. Code Help is Baptist Health’s patient/family-initiated rapid response team code, which is now used system-wide in the pediatric and adult wards.
The involvement of patients and families in previous initiatives led to the creation of Baptist Health’s Family Advisory Council in 2010. This Council is comprised of patients and families who will establish similar committees in each of Baptist Health’s hospitals. They also serve with staff and leadership on the Baptist Health Patient- and Family-Centered Care Steering Council, which is co-chaired by a family advisor. The lead advisors also sit on the Baptist Health Board Committee on Quality and Patient Safety chaired by our chief quality officer and the assistant vice president for patient safety/risk management. We have already implemented the Council’s recommendation to change visitor badges to read “Family & Friends.”
Since 2003, Baptist Health has sponsored annual educational events featuring nationally recognized speakers in patient safety and patient/family-centered care. In January 2010, in an effort to take patient safety and patient/family-centered care to the next level, Baptist Health became certified by AHRQ as a Patient Safety Organization, called the Baptist Health Patient Safety Partnership. We look forward to sustaining our efforts to protect our patients, families, and community and to contributing nationally to improve the quality of healthcare.
Yvonne D’Angelo Zawodny is corporate assistant vice president of risk management/patient safety for Baptist Health South Florida. Zawodny has been with Baptist Health South Florida since 1976, beginning her career as a registered nurse. In 1987 she became risk manager. She received her degree in nursing from Miami Dade College and a bachelor’s degree from Barry University. She is a member of FSHRMPS, ASHRM, AHA, RIMS, and SFHA. She volunteers as a mentor in the Women of Tomorrow program and is a frequent guest speaker at symposiums and seminars regarding risk management, claims management, and patient safety. Zawodny may be contacted at