Press Ganey reports that 251,000 Americans die each year from preventable hospital errors. As part of our commitment to patient safety, Kettering Health has joined Press Ganey’s “Safety 2025” initiative.
The goal of Safety 2025 is to reduce serious reportable events (SRE) by 80% by 2025. When an SRE occurs, Kettering Health must conduct a Root Cause Analysis (RCA). Last year, Press Ganey trained Kettering Health leaders from Quality, Risk, and Patient Safety on best practices for conducting an RCA. Best practice includes the below 3-meeting model.
The 3-meeting model includes assigning a campus executive sponsor; doing one-to-one interviews with staff involved in the event; and creating a sequence of events to aid in identifying gaps between our practice and best practice. It is important to note the Press Ganey 3-meeting model also follows Just Culture, which centers on identifying and improving issues with our process and systems—not assigning blame to the employee.
The goal of the Press Ganey model is also to reduce déjà vu events. Déjà vu events occur because
- Real root causes were not identified.
- Action plans did not effectively address the root causes.
- There was a failure to implement items for the action plan.
- Corrective actions were not effective or sustained.
- There was a failure to share lessons learned.
The Press Ganey 3-meeting model is being used at Kettering Health Miamisburg and Hamilton, and at Kettering Health in Dayton in August. We hope to see it used throughout the system by the end of 2022.
Great catches
A great catch is when someone proactively prevents harm from reaching a patient. Kettering Health uses safety events reported through Great Catches and SAFE-Midas to make positive changes and improvements across the system.
Great Catches are celebrated each day at the respective campus Daily Safety Briefing. Please share your Great Catches with your leader so your commitment to patient safety can be celebrated.
- Thank you, Jan Murphy, from the Surgery department at Soin Medical Center. While opening sterile instruments, Jan paid attention to detail, noticing that the indicators on the sterile wrap were not the usual color. Jan stopped and prevented possible contamination to the sterile field.
- Thank you, Terri Brewster, from Kettering Health Troy. Terri noticed that a provider put in a progress note stating that a patient was being discharged with an antibiotic. However, a prescription was not entered. Terri contacted the provider to correct it. Thank you, Terri, for speaking up for safety.
- Thank you, Jessica Smith, from Kettering Health Miamisburg’s EVS team. Jessica went into a patient’s room and noticed the patient was bleeding. Jessica immediately escalated this to the nurse, who intervened. Thank you, Jessica, for operating as a team and speaking up for safety.
- Thank you, Nancy Strope, from Kettering Health Washington Township’s Patient Access department. Nancy prevented patient harm when she intervened and reported a “wrong arrival” in the emergency center.