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Raising Awareness About Patient Safety at ZSFG

Starting in August 2012, Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) worked with the former Essential Hospitals Engagement Network (EHEN), a federally funded patient safety initiative of America’s Essential Hospitals, to reduce hospital-acquired pressure ulcers (HAPUs) and falls with harm.

Our first site visit to ZSFG took place in January 2013 with our EHEN improvement coach, and what an eye opener it was. We had been working on improving transparency within our hospital for more than a year to show front-line staff our outcomes, good or bad. During the site visit, we scheduled two sessions to round on inpatient units, including med/surg, step down, and ICU. Our improvement coach talked with bedside nurses about how we worked to reduce HAPUs and falls.

While he conducted the interviews, I took the opportunity to walk around the units to see if the clinical outcome dashboards were posted anywhere. I was surprised to find that none of these dashboards — on which we worked so hard to improve transparency — had been posted on any of the units where we rounded. Immediately it became clear that we had to do something differently to better communicate our outcomes to front-line staff. At that point, they were not informed of our outcomes and had no idea where we stood.

Our chief quality officer challenged me to have a “data wall” placed on each unit “by next Tuesday,” with only one caveat: “It doesn’t have to be perfect.” Our patient safety team met to develop strategies to meet this deadline. We decided to concentrate on these dashboards: falls, central line infections, HAPUs, and sepsis mortality. Originally, we wanted to place each dashboard on poster-sized paper, but soon discovered that we would not make our deadline if we did. Not seeking perfection, we printed the dashboards on letter-sized paper and posted them side-by-side on each unit.

We also realized that it would not be enough to just post them and walk away, so we conducted our first “patient safety huddle.” We gathered a group of staff nurses, assistants, and physicians and spent five minutes in front of the data wall, reviewing each dashboard. We then asked for a volunteer to pass this information on to the next shift.

Right away we knew we were on to something fantastic. Everyone who participated was engaged, interested, and had no idea what our outcomes looked like. Most were very surprised, but they walked away knowing where we stood, and how they could contribute to fixing it. We also asked staff how we could improve the dashboards to make them easy to read and feature useful data. This first small test of change was completed in early February 2013, and we are did our second weekly “patient safety huddle” in March.


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