build a team of dedicated innovators
start your journey of organizational learning
Healthcare is one of the most diverse institutions in the world with each hospital having its own structures, systems & processes. HBHS will work with facilities independently to best develop a unique training curriculum & will further help to set up case review teams & a project leadership structure based on your institution's size, organizational structure & culture.
HBHS offers role-based training for system administrators, project leadership & case reviewers. All staff will be trained in systems-thinking to recognize that the hospital is a system in which everyone is accountable for its failures. We are moving away from the shame-and-blame culture of personal fault to accountability & support for all colleagues.
Project leadership shepherds the process of improvement & project team members from implementation to the dissemination of findings.
System administrators are in charge of configuring the Healthcare Safeware® technology & managing hospital(s), users & cases.
Case reviewers are practicing nurses & physicians. Front line staff is needed to get the most accurate & up-to-date picture of hospital operations.
Coaching & Training Services
HBHS offers training & guidance throughout the improvement process. Training services may result in one of three options: online, on-site, or a hybrid of the two. The specifics will be determined during the on-boarding process.
HBHS will offer resources & guidance in the socialization of the Safety Learning System™ (SLS) to gain interest & buy-in.
The on-boarding process helps us to understand your organization so we can help you strategize the local implementation of SLS.
Healthcare Safeware® is built to be customized. Configuration must be done before information & cases are put into the system.
Most project team members are initially recruited, especially front-line staff who are required for case review work.
All project staff has role-based training available. Case reviewers must complete reviewer training before reviews begin.
The Safety Learning System™ (SLS) is not intended to be controlled by the leaders of your organization - it was designed to create new leaders from the trenches & quality offices of your hospital. New leaders have the opportunity to participate in our leadership development coaching to discover their potential.
Customize Your Findings
Healthcare Safeware® needs to be customized to your hospital beyond customized plans for communication, training, & change management. It can be a lengthy process but we can't stress the importance of this step enough. Actionable information could not be gained from findings & data would cease to be meaningful to your organization without this process of customization.
Recruiting the Eyes & Ears
of Your Organization
Reviewers are practicing nurses & physicians who serve as the eyes & ears of an organization - not the fixers. Every case is reviewed by a nurse and physician to increase findings, ensure inter-rater reliability, and foster deference to expertise. HBHS will be at your disposal to help throughout the reviewer recruitment & training processes.
Case Review Process
Nurse & physician reviewers must be initially recruited until MultiLens discussions can partially replace the recruitment process by inviting interested parties to the discussion.
Nurse & physician reviewers will be trained in our seven-step screening process for examining patient charts to understand the patient's hospital journey & experience as a whole.
Case reviews should never take more than an hour to complete. Nurse & physician reviewers are assigned to each case to align with our principle of deference to expertise.
Each case is presented during MultiLens discussion by the nurse & physician reviewers. If issues exist they will become Opportunities to Improve through consensus.
Opportunities for Improvement will be examined & analyzed by project leadership to carefully target findings for QI projects & strategize methods for the dissemination of learnings.
Participate in a
All cases found to have issues will be presented to a group of multi-disciplinary and -specialty providers during regular case discussion meetings. All audience members must come to 100% agreement on whether or not the issues identified by reviewers really exist. This consensus creates an Opportunity for Improvement (OFI). Our Collaborative members have found this step of the process to be one of the most rewarding as providers can find support & meaningful learning.
"Our current health care system is built on the belief that the physician is the captain of the ship and needs to be in charge in every setting and situation. However, given the complexity of health care today, that is impossible, may be dangerous - and is actually unnecessary. Rather, today we need inter professional teams of caregivers who can each contribute their own experience and perspectives."
~ Joanne Disch
What is an Opportunity
We define an Opportunity for Improvement (OFI) as any process or system failure that needs to be fixed but, what really is an OFI? We use this simple test to get at the heart of issues identified: if the care was not good enough for a loved one then it is not good enough for any other patient in your hospital and is therefore, an Opportunity for Improvement.
Cluster & common
Discover How to Help
the Greatest Number
Cluster & Common Thread (CCT) analysis allows your organization to discover meaningful ways to improve healthcare for the greatest number of patients & providers. Healthcare Safeware® paired with CCT analysis coaching can help your organization to identify the most pervasive issues in your organization to better develop lasting changes that support both patients & providers.
Learn to Share with the Greatest Number
We say 'intentional' knowledge dissemination because reports must be directed in a meaningful way so the greatest number of people can learn from your findings. HBHS will work with you to develop strategies in disseminating knowledge so that nearly everyone in your organization can learn from your findings yet not waste their time with unnecessary reports unrelated to them.
Knowledge Dissemination Outcomes
Lessons learned should be shared will all who cared for the patient even if they were not involved when an OFI occurred.
Anyone involved in the patient's journey should be informed of the patient's experience, outcomes, and OFIs.
Leadership should be informed of OFIs pertinent to their role through a combination of data & storytelling.
Actions taken by leadership to fix OFIs should be reported back to reviewers to provide meaning & closure to their hard work.
Quality staff should be informed of all OFIs to help reconcile their data, strategize improvements, & influence leadership.
The Ojibwe story of how the Beaver got its flat tail is one of humility. Like the Safety Learning System™, we work hard to achieve lasting results and do not concern ourselves with showmanship or quick fixes.
Interested? Keep exploring, follow us on social media, or contact us on how to get started!
HB Healthcare Safety® is a Social Benefit Corporation offering systems-improvement & technology resources to reduce the harm caused by care delivery. We believe that no one should ever suffer or die as as the result of system or process failures in care delivery.