Quality Report Cultural Transformation
"Leaders, staff and physicians compare monthly outcomes to goals set at 100 percent for quality measure performance and 0 percent for preventable harm."
At Memorial Hermann, safety is everyone's responsibility. To recognize high-reliability behavior, we created the Memorial Hermann High Reliability Certified Zero Award for hospitals that go a year or longer without adverse events in federally defined categories. We call the award "certified" because these results are formally certified in monthly reports to the Centers for Medicare & Medicaid Services. Since the program started in 2011, Memorial Hermann hospitals have earned more than 100 Certified Zero Awards for avoiding hospital-acquired infections and other conditions causing patient harm for a year or more.
Heightened attention to detail means employees are more likely to detect subtle variances in complex situations. The cornerstone of our performance improvement efforts, Breakthroughs in Patient Safety (BIPS), encourages employees to think critically, communicate openly, ask questions and consider alternatives - behaviors that foster collaboration and reduce errors. To sustain our performance improvement gains, employees are reminded continuously of high-reliability techniques and nationally recognized actions that prevent patient harm and support quality care. Leaders, staff and physicians compare monthly outcomes to goals set at 100 percent for quality measure performance and 0 percent for preventable harm.
Three Red Rules - safety practices that must be observed regardless of how urgent or emergent a situation is - were developed as part of the BIPS program.
Employees are trained to take a one-second stop - called STAR for Stop, Think, Act and Review - before injecting a medication or taking another action that could affect patient safety. The one-second stop has proven to reduce errors by 90 percent, saving countless lives.
We implemented a comprehensive electronic health record (EHR) in all patient care areas, including computerized physician order entry (CPOE) or eOrdering in the majority of Memorial Hermann hospitals, automated computerized decision support and barcode bedside medication administration to ensure that the right patient receives the right medication.
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