About five years ago, the quality department at Kittitas Valley Healthcare (KVH), took a hard look at the value they were providing to the organization. One of the things they immediately noticed was an extremely low usage of their incident reporting system due in part to a clunky electronic tool, lack of follow-up on reported incidents and punitive responses to errors. This analysis launched the 25-bed critical-access hospital with associated clinics in Ellensburg on a journey toward improved quality and safety by creating a framework of “just culture” and increasing accountability through improved incident reporting. KVH success is also due in part to the effective integration of quality and safety across multidisciplinary teams.
The system KVH created includes a reformed electronic incident reporting system with better follow-up for staff and a residency program with multidisciplinary case reviews, which encourage staff to report events of harm or near misses. Additionally, the just culture focus ensures that errors are addressed from a systemic level, with an emphasis on improvement rather than punishment. Events that are reported no longer go into a black hole; there is leadership effort to not only understand and address the problem, but also to frequently round back with staff about what action was taken. KVH acknowledges that people make errors and a great patient care system is obligated to collect and investigate data that can be analyzed and acted upon for improvement in patient safety. Therefore, increased reporting of errors, near-misses and concerns is welcomed because it provides an opportunity to learn from the events and make positive changes.
In addition to the electronic reporting system staff are given numerous other opportunities to provide feedback on quality and safety. One simple but innovative tool is departmental SAFE (Share Analyze Fix Empower) Boards, where staff add sticky notes with challenges (e.g. door not functioning properly, medication near-miss). Each new staff note is reviewed during the department daily huddle or, if an ongoing issue, tracked on a continued basis. Staff who are part of the near-miss identification process can be acknowledged with “Safe Catch” awards.
In a review of the most recent incident reports, KVH found that it averages 73 cases per month, which is on track for the target number of cases they think their hospital should have for its size. The staff are all involved in tracking the number of SAFE Board notes and the number of electronic incidents and welcome all types of feedback to make organization-wide improvements. The intention is that increased reporting will result in decreased harm.
In addition to hard work and leadership, which KVH staff will tell you is a must for just culture, they integrate multidisciplinary teams across the hospital and clinics to help with root cause analysis. Additionally, they include external partners as appropriate, including emergency medical services, mental health, local law enforcement and clinicians from other practices (providers, nutritionists, etc.). Through this effort, the leadership, quality and hospital staff have helped break down silos and encourage organization-wide engagement in incident reporting so lessons can be shared across KVH to create sustainable improvement. KVH exemplifies just culture by constantly improving with an orientation toward patient safety. The hospital’s approach to quality is proactive as opposed to reactive. KVH’s commitment to preventing harm is also evident with their involvement in WSHA’s Patient Safety Alert Huddles; they not only identify and share alerts to prevent harm in their own organization, but are actively spreading their learnings to others as well.