Morath drove and initiated the Patient Safety Initiative at Children’s Hospital and Clinics by transforming mindsets and culture within the hospital. Key initiatives implemented by her included (a) Introduction of a Blameless Patient Safety Reporting System (b) Conducting Focus Groups and (c) Setting up of Patient Safety Steering Committee.
Building Block 1: A supportive learning environment (key activities implemented, key challenges and effectiveness of endeavor)
1.1 Psychological Safety
Blameless Patient Safety Reporting System
Morath introduced a Blameless Patient Safety Reporting System for recording medical errors, where employees were allowed to communicate confidentially and anonymously about medical accidents without penalty. She added a category to the existing patient safety report to allow employees to describe and comment on the incidents.
To change people’s ingrained mindset towards a medical accident; from one that is penalty-centric to one that is a learning-centric. o
To convince employees that owning up to a mistake would not backfire.
The system indeed encouraged, the employees to be more forthcoming in sharing their mistakes. o
The system assumed that errors occurred due to drawbacks in processes rather than incompetence of staff. However, besides process drawbacks, human errors could also be the cause. As such, it was difficult to hold any employee accountable and responsible for his or her negligence. No consequences for poor performance might lead to mistakes being repeated.
She introduced a common language which fostered an environment where everyone could discuss the causes and sequence of accidents. She created a set of ‘Words to Work By’, wherein the use of positive words was encouraged so that negative feelings of patient safety would not be evoked.
Morath took almost two years to develop the new vocabulary. The employees might find it difficult to get used to a new set of words in a short period of time.
Incorporating the new vocabulary into their daily communication injected a positive attitude and culture among employees.
Appreciation of differences and openness to new ideas
Morath created several opportunities to involve as many people as possible from different job functions within the organization, so that creative initiatives and ideas for enhancing patient safety could be generated.
Because, healthcare issues are very complex in nature, it was inevitable that conflicting views from various parties would have to be resolved, before an effective solution could be formalized.
Her efforts created enthusiasm among employees towards working for patient safety initiatives.
Time for reflection
Morath scheduled meetings in such a way that there was reasonable time for post-session informal discussions, where participants could contribute and clarify their doubts in a relaxed environment.
Building Block 2: CONCRETE LEARNING PROCESSES AND PRACTICES (key activities implemented, key challenges and effectiveness of endeavor)
Within a year of joining the hospital, Morath changed the Disclosure Policy of the hospital by changing the way the hospital communicated with families when accidents occurred. A greater transparency of information was provided to patients’ next of kin when accidents occurred. It included the explanation of steps to be taken by the hospital when accidents happened within a reasonable time and a promise to keep them updated about new discoveries and findings. This experiment strived towards strengthening the hospital – patient relationship, and showed greater responsibility of matters, although this radical idea might result into law suits from the parents.
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