Hospital-wide safety program can lead to rapid improvement in safety
10 Dec 2010
Rapid improvements in the culture of safety, even in a large
complex hospital, can result from implementing a prescribed set of
hospital-wide patient-safety programs, according to a new study by Johns
Hopkins University. The programs included buy-in from senior management
and an electronic event-reporting system.
“It doesn’t take decades or tons of money to get from a culture
that says ‘mistakes are inevitable’ to a belief that harm is
entirely preventable,” says Peter Pronovost, MD PhD, a professor of
anesthesiology and critical care medicine at the Johns Hopkins
University School of Medicine and leader of the study.
Drilling that belief in prevention into dozens of disparate
hospital units can seem a daunting task, Pronovost acknowledges, but
he says he was pleasantly surprised by the results of his latest
study, which was conducted at the thousand-bed, 144-unit Johns
Hopkins Hospital in Baltimore. Establishing a sustained culture of
safety in health care has been associated with better outcomes for
patients in previous studies.
From 2006 to 2008, Pronovost’s team implemented a comprehensive,
unit-based safety program (CUSP) at the hospital, designed to make
mistakes more transparent and use that and other tools to improve
the culture of safety. CUSP relies heavily on local staff training
in the science of safety — how to identify problems, report them,
measure them, plan and implement corrections, and measure again. It
also embraces discussions about improving communication and
A novel layer of CUSP is buy-in from the senior management of the
hospital, with an executive meeting monthly with each unit’s patient
safety team and other staff to ensure that resources are made
available for quick, evidence-based interventions necessary to
reduce risks to patients.
Johns Hopkins also put in place an electronic event-reporting
system, which all staff members are encouraged to use. All reported
events are reviewed by the hospital’s patient safety office,
categorized and assigned to a designated and accountable improvement
team. The review helps to identify trends and give feedback to those
on the front lines.
In the new study, hospital staffers on each unit were surveyed
annually from 2006 to 2008 to assess safety attitudes and to
determine whether the CUSP program appeared to be working.
Researchers determined that a safety goal was achieved when a unit
met or exceeded a 60% positive score on a five-point Likert response
scale, from strongly disagree to strongly agree.
In 2006, the first year, 55% of the units achieved the safety
“culture” changes set for them. In 2008, 82% reached the goal. The
teamwork goal was met by 61% of units in 2006 and 83% of units two
years later. In both years, survey response rates hovered near 80%
of staff members.
“We want a culture where nurses aren’t afraid to raise concerns
with doctors, where problems are solved not by looking at who is
right but what is right for the patient, where staff believe that
hospital leaders are committed to make health care safe,” Pronovost
says. “We don’t want a place where the staff wouldn’t be comfortable
being treated as patients.”
Pronovost says his research shows that when a hospital makes a
commitment to safety interventions, improvements can be made. One
limitation of the study, he says, was that an improved safety
culture could not be tied to improved patient outcomes.
Meanwhile, Pronovost says that if a large institution such as
Johns Hopkins can achieve such gains in culture, smaller hospitals
may be able to achieve even more success.
“If we can do it in our organization, it’s much easier to do in
smaller institutions,” he says. “In this case, size is a