Is It Possible to Fix Broken Systems and Processes?

Virginia Mason Institute

For health care organizations everywhere, patient safety is a top concern. But how can an organization go from being vigilant about safety to actually fixing the broken systems and processes that lead to patient harm? Improving overall patient safety and care has become even more important in the modern day, making an improvement system necessary.

At Virginia Mason, sustaining a safety culture—in which every employee is empowered to be a safety inspector—is not a pipe dream. More than ten years ago, leaders worked with providers throughout the organization to create the Patient Safety Alert SystemTM. Since then, Virginia Mason has experienced not only dramatic increases in safety reporting and staff engagement, but also decreases in professional liability claims. All employees, from human resources professionals to cafeteria workers to medical assistants to executives, are encouraged to report events that they believe might contribute to patient harm. Safety permeates the culture, and employees encourage each other to report. The organization also encourages reporting by recognizing team members who speak up to identify patient safety concerns.

Through this system, reporting is distributed through the staff to encourage honest and open communication. By every team member participating and upholding accountability, overall patient care continues to improve. 

Getting there, though, didn’t involve a simple solution or result in overnight success. It took leadership planning, transparent communications to staff, creative thinking, testing and refining. Even today, Virginia Mason solicits feedback from all employees to make the system easier, faster and better. Both Virginia Mason and Virginia Mason Institute continue to focus on efficiency and process improvement in healthcare. Because the patient is the primary focus of everything the organization does, leaders know they can never take their eyes off patient safety.

“The aha moment for us,” says Cathie Furman, RN, MHA, who led the creation of the Patient Safety Alert System and now teaches at Virginia Mason Institute, “is that once employees started reporting threats to patient safety, we could actually fix problems before they became something bigger and hurt patients.” Being aware of the problem enables healthcare organizations to address and solve the risk before it becomes a prominent issue.

“We know that all clinicians make errors,” says Furman. “Learning how to mistake-proof health care processes can help prevent those errors from happening in the first place.”

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