Failures in optimal healthcare delivery can happen to any one of us, on any given day. Many occur because of a

constellation of seemingly unrelated factors. Our Safety Learning System aims to identify the process of care and

system failures that get in the way of providers doing their best job every day.

The process is a cultural re-frame.



Learn more about a system's engineering, multidisciplinary, multispecialty approach with onsite or web sessions.


Diagnostic Case Reviews

Give us 100 cases to review and we will help you to identify Opportunities for Improvement within your healthcare system.



We will coach you to become a systems-thinker that supports transparency for system learning.

iceberg with above and underwater view taken in greenland

The Quality Improvement Iceberg

Traditional case review systems such as peer review, incident

reporting, and the global trigger tool are only at the top of the

quality improvement iceberg. HBHS has dived below the

water to discover why healthcare delivery is still the third

leading cause of death in America.


Our Solution?

Discover omissions of care through system case review.


Traditional Review Systems

More than 80% of the time, resource and energy is spent on counting, trending, and reporting traditionally defined adverse events (HACs and HAIs) and other regulatory requirements.


Safety Learning System

Our Collaborative findings suggest that more than 80% of the things we can do something about are acts of omission - delays and missed opportunities to improve outcomes of care. Less than 20% of the opportunities are traditional adverse events.


Why Systems Review?

Reviewing deaths does not save lives;

Reviewing readmission does not prevent readmission;

Reviewing high cost cases does not lead to cheaper care;

ONLY identifying common patterns of process failures and targeting/prioritizing those with an improvement initiative will make a meaningful and measurable difference.

The Goal of SLS is to:

Learn from a patient's journey from a system evaluation perspective; be used to discover both positive and negative trends over

time and empower institutions to make informed decisions or changes; and further be used to affirm new implemented

methodologies over time to improve overall quality of care for patients.


The Safety Learning System moves away from insular peer review

and is NOT about adverse events. SLS aims to pinpoint process of

care and system failures to identify Opportunities for Improvement

and create real quality improvement initiatives. Cultural change is

crucial to the successful implementation of SLS as it fosters a

cooperative multispecialty, multidisciplinary environment.

Tenants of SLS

Systems Review

Our process is NOT peer review nor is it about adverse events. System review identifies process of care and system failures. We foster accountability and innovation, not placing blame.

Deference to Expertise

Every case is reviewed by a practicing doctor and nurse to utilize optimal expertise already on hand, increase physician involvement, and foster communication across all levels of hospital hierarchies.

Multispecialty/Multidisciplinary Approach

Multiple specialty and discipline sessions are used to build consensus and increase findings. Nurses have an equal voice in our system.


Implementation is local using actionable information and influence. Teaching is based on case review and patient stories. Influencing change is a bottom-up process that is structures around Six Sigma architecture and analytics.

Learning Outcomes


Participants will become aware that the hospital is a system in which omissions of care need to be addressed.


Participants will recognize that the hospital is a system in which everyone is accountable for system failures.


Participants will perform case reviews to discover omissions of care and identify OFIs.


Participants will gather OFI data to develop and implement quality improvement initiatives.

Contact us today to discuss the impetus for the Safety Learning System and its multi-disciplinary, multi-specialty review process approach. Hear Dr. Huddleston share lessons learned through its development and evolution.


What's Next?

HBHS will coach your organization in putting our learning outcomes to practice.