Document Type

A3

Publication Date

9-5-2019

Institution/Department

MaineHealth Performance Improvement, Maine Medical Center

MeSH Headings

Root cause, patient, safety, staff, tertiary teaching hospital, quality improvement, goals, learn, leadership

Abstract

There is abundant evidence that links a strong culture of safety with improved patient and staff experience. However, there has been no clear avenue identified as to how to achieve this metric.

A team in a large academic tertiary teaching hospital set about leveraging their daily managing system (DMS) to attain improvement in their institution’s safety. The goals of this quality improvement project were to use DMS to identify and report safety concerns and increase frontline team knowledge and comfort with reporting safety concerns during Gemba walks.

A root cause analysis identified 5 areas for improvement and several countermeasures were established to address these areas. Post inception of the countermeasures, several positive outcomes were identified to include 12% increase in safety reports per month and growing comfort with transparently sharing safety concerns.

A series of next steps were generated. Amongst them were continued improvement in real time responses to safety concerns and strengthening executive and middle management adoption of “listening to learn” approach to leadership.

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