October 18, 2016
Texas Children’s was recently named October 2016 Hospital of the Month by Solutions for Patient Safety (SPS) in recognition of our outstanding achievements in cultivating an environment of safe patient care.
The SPS is a network of more than 80 children’s hospitals across the U.S. that share a common vision that no child will ever experience serious harm while we are trying to heal them.
“At Texas Children’s, we care for some of the country’s most critically ill patients, and we understand safe, quality care for every patient is the most important responsibility of each staff member and employee here,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “Ensuring our staff and employees are equipped with the knowledge and tools to take preventive action are key to keeping our patients safe.”
Through our organization-wide error prevention training program implemented in 2014, employees and staff are now more comfortable in applying proven safety behaviors in their everyday work to ensure error prevention alertness and personal accountability are always top of mind. These safety behaviors include effectively communicating concerns requiring action, supporting a questioning attitude and using three-way communication to achieve greater clarity so that everyone speaks a common language in the delivery of patient care.
To propel error prevention training to the next level, Texas Children’s launched the Safety Coach Program which consists of clinical and nonclinical frontline staff and providers who are trained to observe employee interactions and provide feedback to reinforce safety behaviors and skills taught in error prevention training.
“Since the program’s launch in February of last year, we’ve had 16 classes and trained 334 coaches throughout the organization,” said Texas Children’s Patient Safety Specialist Tiffany Wrenn. “Our program has contributed to people’s’ increased comfort level in speaking up when there is a concern resulting in a 5.2 percent significant improvement in communication openness as reported in our latest AHRQ Hospital Patient Safety Culture Survey.”
The SPS also recognized Texas Children’s systemwide efforts in reducing hospital acquired conditions by reassessing current practices to identify areas of improvement.
When patients in the Epilepsy Monitoring Unit (EMU) developed a hospital acquired pressure ulcer (HAPU) due to skin breakdown from the electrodes affixed to their scalp and forehead during an electroencephalography (EEG) study, Texas Children’s Clinical Specialist Joellan Mullen and her EMU colleagues collaborated to develop techniques to enhance skin care management and HAPU prevention, which were later published in the 2014 Journal of Pediatric Nursing.
These best practices included using a less abrasive solution to remove oils from the skin before electrodes were placed on the forehead, wrapping a breathable fishnet dressing around the electrodes to prevent moisture and pressure buildup on the scalp and implementing wireless technology to allow greater mobility for EMU patients.
“Before revising our quality improvement practices for HAPU prevention, 10 percent of our EMU patients developed a HAPU, averaging three or four occurrences per month,” Mullen said. “Today, we have seen a reduction in HAPUs within our unit after implementing these changes.” The creation of the Skin Champions Program also helped staff reduce the number of pressure ulcers in the EMU and in high acuity areas of the hospital like the intensive care and cardiovascular units.
Other units experienced their share of collaborative successes. To reduce the occurrence of central line-associated blood stream infections (CLABSI) in the neonatal intensive care unit, clinical specialist teams collaborated with infection control partners to review current policies and practices against national standards which led to the creation of a massive educational initiative for nurses. More than 2,000 nurses across the organization were trained on several key skills in central line care.
“We went through hand hygiene, cap changes, dressing changes, just accessing the central line, since we are doing all of that differently than we used to,” said Nicole Sheets, a nurse in the Pulmonary Adolescent Unit. “No matter where you are in the hospital, the standard of care is now the same across the entire organization.”
To learn more about Solutions for Patient Safety, click here. To read more about our patient safety achievements, click here.
Chief Safety Officer Dr. Joan Shook received the 2016 Jim Seidel Distinguished Service Award from the American Academy of Pediatrics Section on Emergency Medicine at the AAP National Conference on October 22 in San Francisco. The award recognizes members who have provided exceptional service to the section and to the field of pediatric emergency care.
