Building Change

Healthcare is one of the most diverse institutions in the world with every hospital having its own structure and procedures. HBHS will work with facilities independently to best develop a unique training curriculum and will help to set up case review teams determined by your institutions needs. HBHS will train all staff into becoming system-thinkers that recognize the hospital is a system in which everyone is accountable for its failures.

What is an Oppotunity for Improvement (OFI)?

The main purpose of system case review is to find what we call an Opportunity for Improvement (OFI). An OFI is any process of care or system fault that contributed to patient harm or death. A case can have multiple OFIs or none.

When reviewing a case, ask yourself, could I have stood by, watched and not intervened if this was my loved one? If the care was not good enough for your family it is therefore an Opportunity for Improvement for your hospital.

Coaching Proccess

Step 1


All hospital sites within healthcare systems will receive their own evaluation (Current State Assessment) to determine a Course of Action, Training Plan, and Change Management Plan. This aligns with out principle of local implementation. Each hospital is given a voice and a chance to succeed. The Current State Assessment will examine your hospitals needs based on existing resources and cultural atmosphere.

Step 2


A Course of Action will be determined for your hospital following the Current State Assessment. The Course of Action is used to inform the SLS™ project leadership team on who should contribute to the collaboration participation, where barriers might be, and the actions that need to be taken to successfully on-board and implement the Safety Learning System™ at your site(s).

Step 3


A customized Plan for Communication, Training, and Change Management will be created for your hospital based upon the determined Course of Action. Communication best practices will be deployed to raise awareness and understanding of the SLS™ Collaborative project through its development and in particular how key messages are to be communicated to identify stakeholders and target audiences. We will work with project leadership to ensure that appropriate best practices as well as custom site needs are met to train staff in SLS™ methodology and Healthcare Safeware®. The Training Plan may result in one of three options: onsite work, web-based training, or a hybrid of the two. The Change Management Plan will outline the most beneficial method for your team to move forward in creating meaningful change from the actionable insights discovered by case reviewers.

Case Reviewer Training

An effective case review team must be trained in systems-thinking. Recognizing that the hospital is a system in which everyone is accountable for its failures. An effective case review team  will be trained in and adhere to the principles of SLS™: deference to expertise, multidisciplinary/multispecialty consensus, local implementation, and systems review.

Coaching Outcomes

1. Trained Staff

Project leadership will be given the tools to effectively manage and maintain a case review team of practicing care providers trained in systems-thinking.

2. Safeware Use

System administrators and case reviewers will be trained on how to use our Healthcare Safeware® technology. Help information for users will be made available within the system after gaining access.

3. Independent Review

After training is completed, case review teams will perform independent reviews on 100 consecutive cases from a pre-selected cohort. Case reviewers will be able to identify OFIs which may be brought forth in the next committee meeting.

4. Culture Shift

Reviewer physicians and nurses will begin to practice differently. A dialogue will be established across specialties and disciplines leading to more open discussion ultimately improving quality of care.

5. Closing the Loop

Monthly multidisciplinary/multispecialty committee sessions will be held to build consensus and increase OFI findings. Higher authorities will be informed of committee findings and move forth with resolving process and system failures.

6. Shared Learning

Project leadership and case reviewers are not the fixers of healthcare but are essential in shifting through pools of information to find what is useful. Benchmarking reports should be distributed to case review teams showing the results of their findings to increase motivation and encourage a sense of pride in their work. SLS™ Collaborative members have the benefit of sharing lessons learned and results with other members and/or through our research program.

Chatham House Rules

Case Review Committees will run under Chatham House Rules. This rule originated at Chatham House with the aim of providing anonymity to speakers and encourage openness and the sharing of information. The Chatham House Rule reads as follows:

“when a meeting, or part thereof, is held under the Chatham House Rule, participants are free to use the information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participants, may be revealed.”

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Meaningful Learning


A Strong Team


Actionable Insights


Your Wisdom


Worldwide Change
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