March 2-8, 2014 is National Patient Safety Awareness Week, an annual education and awareness campaign for health care safety. In 2013, the University of Vermont Medical Center earned #1 ranking in providing safe patient care in the national University HealthSystem Consortium (UHC) Quality and Accountability Study.
This week, we observe National Patient Safety Awareness Week. We have a lot to celebrate at the UVM Medical Center. In 2013, we earned a #1 ranking in Patient Safety in the University HealthSystem Consortium (UHC) Quality and Accountability Study, which includes more than 100 academic medical centers from all over the country.
Our Patient Safety ranking was the main reason we achieved #7 ranking overall for Quality in the UHC annual rankings. The truth is it took many years of hard work to achieve last year’s ranking. It required constant focus on providing the safest possible care everyday and during every patient encounter. As we celebrate Patient Safety Awareness Week, it is valuable to reflect on how we achieved this ranking. Highly safe and reliable organizations share a number of common features.
#1. Hyper-vigilance for potential problems. This has to be a central part of the culture of the organization. The entire organization needs to focus on getting it right every time – and everyone’s input must be valued. Patient safety requires every member of our staff to be constantly on the lookout for opportunities to improve. Safety, obviously, must be the focus of staff who have direct patient interactions, but to be truly safe it must not stop there. It also must be a focus of everyone else who supports our providers and patients. In the 2½ years I have been Chief Medical Officer, I have been proud to see employees from every area and job description bring forward issues that have helped us become a safer organization. Potential threats to our patient’s safety are everywhere: Icy walkways, supply stocking issues, and equipment problems are just a few of the potential safety issues that have been noticed by our staff and reported through our electronic event reporting system, known as the SAFE System. These reports allow us to address problems before they impact patient care.
#2. A blame-free culture. When errors occur, a vigorous and thorough analysis must be done to understand what happened and why. This is called Root Cause Analysis (RCA). RCAs are extremely important for continuous improvement and increasing the safety of our hospital. An RCA seeks to uncover the underlying issues that lead to errors and focus on ways to eliminate these problems in the future. It requires that team members come together after an event and – in a blame-free meeting – uncover what systems issues led to the error and how they can be prevented in the future. at the UVM Medical Center, we do more than 20 RCAs each year in an effort to provide the safest possible care. Our RCAs are instrumental in making us as safe as we can possibly be.
#3. A willingness to explore better ways of doing things. Organizations must be willing to grow and change. New ideas need to be carefully explored, but change can make us a more reliable and safer organization. Examples include OR checklists and radio frequency identification systems to detect sponges in the operating room. Other changes include improved methods to prevent infections and using our electronic medical record to its maximum potential to identify allergies, medication interactions, and other patient safety issues.
As we celebrate National Patient Safety Awareness Week, the UVM Medical Center has much to be proud of. We are a safe organization, and we have a culture that is continually striving to be better. We have the right people, tools, and culture to continue on our journey toward eliminating preventable patient safety events.
Stephen M. Leffler, MD, is the Chief Medical Officer at the UVM Medical Center, former Medical Director of the Emergency Department, and has been a practicing physician for 20 years. He grew up in Brandon, VT.