Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we've crossed that mark for a couple of events in patient safety that merit both celebration and reflection. In January 2001, a series of lapses at Johns Hopkins led(...)
Organizational and Cultural Change
Turning Health Care Improvement Training into Results
Posted by | Organizational and Cultural ChangeMaybe you've had this experience: You attend a workshop or conference to build your skill set, you pick up new strategies and tools, and you leave energized and excited to put them to use in your hospital or clinic. Yet when you return to work, you find it hard to get the ball rolling. Colleagues(...)
To Engage Physicians in Cost Savings, Start with Quality
Posted by | Organizational and Cultural ChangeLike a pro golfer swears by a certain brand of clubs or a marathon runner has a chosen make of shoes, surgeons can form strong loyalties to the tools of their craft. Preferences for these items — such as artificial hips and knees, surgical screws, stents, pacemakers and other implants — develop over time, perhaps out of habit(...)
Walking in Another Caregiver’s Shoes
Posted by | Organizational and Cultural Change, Preventing Patient HarmHow many of our conflicts could be handled better or averted if we had the opportunity to spend some time in the shoes of the person on "the other side"? When we experience a situation through another's eyes, and when we understand their work and world, true empathy, understanding and trust can emerge. This is(...)
Learning from the Leaders in Patient Experience
Posted by | Organizational and Cultural Change, Patient-Centered CareHospitals across the country are searching for ways to create the "always positive" patient experience. For example, we want our patients to tell us that their pain was always addressed, that clinicians were always responsive to their needs and that our communications at discharge time always helped prepare them to take care of themselves once(...)
What Any Caregiver Can Do to Support a ‘Second Victim’
Posted by | Organizational and Cultural Change, Preventing Patient HarmLet's say that you're a nurse on a hospital unit, and a colleague has recently been involved in a medication error. It was a mistake that anyone might make — a tenfold overdose that occurred when she wrote down an order and accidentally moved a decimal point one space to the right. Luckily, it didn't lead(...)
Supporting ‘Second Victims’ with Emotional First Aid
Posted by | Organizational and Cultural Change, Preventing Patient HarmShe was a newly minted Johns Hopkins Hospital pediatric nurse — let's call her Mary — but she was already unsure if she had chosen the right career path. She had inserted an intravenous line into a young patient's arm, and there had been an infiltrate, a pooling of IV fluid under the child's skin that indicated(...)
Patient Safety and Quality Champions Grow into Leaders
Posted by | Organizational and Cultural Change, Preventing Patient HarmFor years, physician assistant Stephanie Figueroa has worked with our Emergency Department and the sickle cell care team to improve the treatment of patients with this disease who arrive with acute pain crisis. When beds were unavailable in the busy adult ED, these patients might spend hours in excruciating pain before our staff were able(...)
What’s Your Theory? Bringing Rigor to Local Quality Improvement Projects
Posted by | Measurement of Safety and Quality, Organizational and Cultural ChangeFor a moment, consider that you work at a primary care clinic, and your team needs to improve performance on annual foot exams on patients with diabetes — a critical step to prevent foot ulcers and amputations. At your monthly meeting, staff members enthusiastically suggest solutions, such as using robocalls to urge patients to schedule appointments(...)
To Make Hospital Quality a Priority, Take a Page from Finance
Posted by | Measurement of Safety and Quality, Organizational and Cultural ChangeWhen you are a patient at a hospital, you want to know that the executives who run that facility put the safety and quality of care above all other concerns. Encouragingly, more of them are saying that safety is indeed their number-one priority—a fitting answer given that preventable patient harm may claim more than 400,000(...)