Multi-Center Collaboratives Create the Next Generation Safety Learning System

Our approaches for fostering healthcare free from harm leverages “systems thinking”—recognizing that the hospital is a system, and that the system can and must be designed to compensate for the errors that are likely to be made by any of its components. We were pleased to collaborate with hospitals that span across the United States in Multi-Center Collaborative studies. Through a combination of data gathering, analytics, interpretation and data visualization, we have been able to provide meaningful insights and knowledge for these participating sites to prioritize their healthcare quality improvement initiatives to make a significant difference in lives of patients.

2016 Collaborative

Preliminary data from the collaborative illustrates that of the patient journeys studied, 80% of the Opportunities for Improvement (OFIs) are all “acts of omission” as opposed to the commissions considered to be a more traditional definition of adverse events traditionally reported by healthcare systems. While most think of medical errors as something a care provider did to a patient that caused harm; however, as our data shows, a more common type of medical harm is the error of omission.

Why have these errors been overlooked for so long? With traditional quality monitoring, they are often invisible and hard to recognize, but more important is the culture shift required to no longer view these omissions as just inherent characteristics of our systems of care.

2016_SummaryStats
  • Beaumont Health, Royal Oak, MI
  • Mayo Clinic, Methodist Campus, Rochester, MN
  • Mayo Clinic, St Marys Campus, Rochester, MN
  • MedStar Franklin Square Medical Center, Baltimore, MD
  • MedStar Georgetown University Hospital, Washington, DC
  • MedStar Good Samaritan Hospital, Baltimore, MD
  • MedStar Harbor Hospital, Baltimore, MD
  • MedStar Montgomery Medical Center, Olney, MD
  • MedStar Southern Maryland Hospital Center, Clinton, MD
  • MedStar St. Mary's Hospital, Leonardtown, MD
  • MedStar Union Memorial Hospital, Baltimore, MD
  • MedStar Washington Hospital Center, Washington, DC
  • Penn State Hershey Medical Center, Hershey, PA
  • Regions Hospital Health Partners, St Paul, MN
  • Sharp Chula Vista Medical Center, Chula Vista, CA
  • Sharp Coronado Hospital & Healthcare Center, Coronado, CA
  • Sharp Grossmont Hospital, La Mesa, CA
  • Sharp Memorial Hospital, San Diego, CA
  • University of Mississippi Medical Center, Jackson, MS
  • University of Washington Medical Center, Seattle , WA

Study Aims

For participating medical centers, this collaborative will:

1) Elucidate and categorize types of process of care failures

2) Quantify the prevalence of process of care failures

3) Define the common causes of process of care failures

4) Quantify and describe the differences in findings aims between institutions

Methods

After on-site training, each participating hospital will review processes of care for 100 consecutive patients from a priori specified cohort (e.g. sepsis, readmissions, MET/RRT calls, mortalities, surgical events). These mixed method (qualitative & quantitative) reviews will be entered into the web-based safety learning system. Monthly multidisciplinary case discussions will be held locally for those cases with any findings. De-identified data will be aggregated at the end of the review period. Descriptive statistics and Pareto charts will illustrate process of care issues identified along with their common cause failures. Benchmarking reports between participating sites will be distributed.

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2017 Collaborative

Welcome back 2016 Members! Welcome:

  • Aurora West Allis Medical Center, West Allis, WI
  • Beaumont Health
    • Beaumont Hospital Grosse Pointe, MI
    • Beaumont Hospital Dearborn, MI
    • Beaumont Hospital Taylor MI
  • Eastern Maine Healthcare Systems
    • Eastern Main Medical Center, Bangor, ME
    • Inland Hospital, Waterville, ME
    • Mercy Hospital, Portland, ME
  • HealthPartners
    • Regions Hospital, St. Paul, MN
  • Hoag Memorial Hospital Presbyterian, Newport Beach, CA
  • Mayo Clinic Health System
    • MCHS - Immanuel St. Josephs, Mankato, MN
    • MCHS - Eau Claire, Eau Claire, WI
  • Methodist Health System
    • Methodist Dallas Medical Center, Dallas TX
    • Methodist Mansfield Medical Center, Mansfield TX
    • Methodist Charlton Medical Center, Dallas, TX
    • Methodist Richardson Medical Center, Richardson, TX
  • Parkview Health, Fort Wayne, IN
  • Tasmanian Health Service, Tasmania, Australia
    • Launceston General Hospital
    • Mersey Community Hospital
    • North West Regional Hospital
    • Royal Hobart Hospital
  • University of Colorado Health
    • Memorial Hospital North, Colorado Springs, CO
    • University of Colorado Hospital, Aurora, CO
  • UT Southwestern Medical Center, Dallas, TX
  • Wake Forest Baptist Health, Winston-Salem, NC