The Safe Day Call: Reducing Silos in Health Care Through Frontline Risk Assessment

The Child Health PSO at 10 Years: An Emerging Learning Network

INTRODUCTION

The 2005 Patient Safety and Quality Improvement Act, actualized as a Learning Network (LN), has enabled the Child Health Patient Safety Organization (PSO) to play a vital and novel role in improving the quality and safety of care. This article describes the Child Health PSO and proposes PSOs as a new construct for LNs.

METHODS

A PSOs ability to affect patient care depends on member organizations' integration of PSO output into their individual Learning Healthcare Systems. Therefore, the Child Health PSO developed tenets of an LN to improve member engagement in PSO outputs.

RESULTS

All Child Health PSO members participate in case-based learning, requiring ongoing and robust participation by all members. The engagement has been strong, with 86% of children's hospitals achieving a case learning activity metric and 60% of children's hospitals submitting cases. From this LNs perspective, 53% of children's hospitals are considered highly engaged.

CONCLUSIONS

In the last 10 years, the Child Health PSO has evolved as a viable LN and, to sustain this, has set a target of 100% of participating children's hospitals being highly engaged. The previously inconceivable notion of sharing information to improve patient safety among hospitals is now an expected result of the formation of trusting relationships under a federally certified PSO. According to participants, collaboration is an essential element that empowers individual children's hospitals to eliminate preventable harm.

Using the Patient Safety Huddle as a Tool for High Reliability

A Patient Safety Huddle was developed at a community hospital (Providence Little Company of Mary Medical Center, San Pedro, California) through consultation with key stakeholders. The goal was to become a high reliability organization by improving communication across different departments, troubleshooting operational problems, focusing on safety and quality metrics, and reporting unusual occurrences. The Patient Safety Huddle involved executives in development and implementation, respect for employee time, ensuring accountability, and empowering frontline staff to foresee and deal with safety issues. The current template of the Patient Safety Huddle agenda and the Documentation Tools used to address patient safety issues are provided.