April 9, 2019

At Texas Children’s, we care for some of the country’s most critically ill patients, and delivering safe, quality care for our patients is the most important responsibility of each staff member and employee.

As part of Texas Children’s continuing efforts to enhance patient safety across the system, employees and medical staff are encouraged to complete the Hospital Survey on Patient Safety Culture by April 22. The survey will be sent via email and will measure Texas Children’s overall patient safety performance.

“Our clinical and non-clinical staff play an important role in patient safety at Texas Children’s and their input matters,” said Katie Basta, assistant director of Quality and Patient Safety. “The more feedback we have, the better we can plan for the future by identifying gaps and taking action. The survey also tells us what areas we’re doing well in – which is equally important – so that we can hardwire good practices.”

The survey assesses 13 dimensions of patient safety including communication openness, teamwork within and across individual work areas, overall perceptions of patient safety, frequency of safety events reported, and implementation of solutions to cultivate a work environment that promotes patient safety.

“Texas Children’s employees and medical staff – regardless of their job title or position – are crucial in helping us cultivate a harm-free environment for our patients,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “The survey takes only a few minutes to complete and is one important way we can assess how well Texas Children’s is performing. The feedback received will guide our strategies for continual improvement.”

The survey is administered every18- 24 months per regulatory requirement by Joint Commission. The survey takes about 10 minutes or less to complete. All responses will remain anonymous.

If you have any questions, please contact Sharon Jacobson with Patient Safety at 832-824-1310.

March 12, 2019

As patient care manager in the Emergency Center (EC) at Texas Children’s Medical Center Campus, Tashia Bush oversees a dedicated team of nurses that treat more than 75,000 children every year.

Given the fast-paced, high-stress nature of an emergency care setting, there is one common goal that Bush and her team focus on daily – cultivating a safer environment for patients and staff in the EC.

“Every day is patient safety day in the EC,” Bush said. “The key to creating an environment of safe patient care is ensuring our staff is equipped with the knowledge and tools they need to take preventive action.”

Bush recently was recognized for her patient safety efforts in the EC when she became the January 2019 recipient of the Shamrock Award, which is awarded every month to a patient safety champion.

Texas Children’s Safety and Quality Leadership Group presents this award to a person or group who has done something extraordinary to enhance patient safety across the organization like taking immediate action to avert a potential safety concern, spearheading improvements to enhance patient safety and other above and beyond actions that make a positive impact on the safety of Texas Children’s patients.

Last year, Bush created the Safety Promotion Team comprised of EC staff, a quality improvement specialist and 10 safety coaches that meet every month to review current trends in the EC, identify opportunities for improvement, and develop action plans to address potential patient safety concerns.

To promote transparency, safety scoop report cards are sent to staff each month to keep them abreast of the number of serious safety events reported in the EC. By comparing data trends on a monthly basis, staff can see what areas they have improved upon and what areas need additional reinforcement. Staff members can then share their ideas for improvement with the Safety Promotion Team for consideration.

“Through our educational efforts, our EC staff has made great strides in patient safety,” Bush said. “We have seen a decrease in the number of falls and central line infections, and we have implemented new processes to improve positive patient identification and reduce the potential for medication errors.”

Similar to the Shamrock Award, Bush also created a new program in her unit called “Catch of the Month,” that recognizes staff for making “great catches” that averted potential safety concerns in the EC.

“There is no question our employees are making Texas Children’s safer,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “Since we launched the Shamrock program more than a year ago, there has been tremendous enthusiasm and the number of nominees has grown dramatically every month.”

The Shamrock Program is open to both clinical and non-clinical employees since everyone at Texas Children’s – regardless of their job title or position – plays an important role in cultivating a harm-free environment for our patients. Click here for a list of previous Shamrock Award winners.

For Bush, she says programs like this are a great morale booster and keeps patient safety top of mind.

“It is so important that we acknowledge our patient safety champions who play a critical role in the care of our patients,” Bush said. “Every time we let somebody know that they’ve done a great job, they are more apt to do more and become an inspiration for others to go the extra mile to keep our patients safe.”

Do you know someone who is deserving of the Shamrock Award? Click here to access the nomination form.

May 3, 2017

As a health care system, Texas Children’s believes that a critical component to offering outstanding clinical care is measuring the results of the care we deliver and doing our best to provide our patients and families with the safest environment possible.

“By tracking what we do, we learn about what happens to our patients, and we also learn about our performance as a health care delivery organization,” said Chief Safety Officer Dr. Joan Shook. “We know we can always do better and must continue to strive toward excellence in health care delivery.”

With that in mind, Texas Children’s has created a dedicated safety and outcomes website that parents can access directly from the Texas Children’s main landing page. The information on this page is organized into the following nationally recognized categories of quality measures:

  • Safe: Avoiding harm to patients from the care that is intended to help them.
  • Effective: Providing services based on scientific knowledge. This category also measures the outcomes of the care we provide.
  • Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.
  • Timely: Reducing wait times and harmful delays for both those who receive and those who give care.
  • Efficient: Avoiding waste, including waste of equipment, supplies, ideas and energy.

When possible, the website shows how Texas Children’s compares to other children’s hospitals in the United States in these categories. Where no good comparisons are available, the website illustrates how Texas Children’s compares to our own performance in the past, and how we measure up to our own goals.

Some of the topics and data reported include: hand-hygiene compliance, catheter associated blood stream infections, surgical site infections, death and complications within 30 days of surgery, patient experience, third next available appointment, patients leaving emergency care and transfer denials. Additional measures will be added over time.

For each measure, information is provided that lays out what parents can do to help Texas Children’s deliver the highest quality pediatric care. The website also includes links to our health system’s evidence-based guidelines. A distinctive feature of the website is an email address for readers who want to provide input on what additional information they would like to know and ways we can improve our website.

“We invite you to check out how we are doing and to share our outcomes with patients and their families,” Shook said. “We believe our patients and families deserve the most complete and accurate information possible about how we are doing as a health care system.”

Texas Children’s Pavilion for Women also has launched a safety and outcomes website. Click here for more information.

March 21, 2017

Imagine spending several months trying to find the pathogen responsible for a cluster of Burkholderia cepacia infections among critically ill, hospitalized patients. For infection preventionists, solving this mystery can be a daunting task but not impossible if you have the epidemiology skills and collaborative resources in your investigative toolbox.

When Texas Children’s had a small outbreak of B. cepacia infection last year, Texas Children’s Quality and Safety Director Elaine Whaley immediately sprang into action to identify the cause of the outbreak. Her extensive experience in infection prevention and control coupled with her professional networking skills helped her locate an infection preventionist at another pediatric hospital one-thousand miles away who had experienced a similar outbreak. Together, they identified the pathogen responsible for the B. cepacia outbreak in their respective hospitals.

Partnering with Infection Preventionist Angela Rupp of Lurie Children’s Hospital of Chicago, their collaborative investigation expedited the nationwide recall of liquid docusate, a medication used to treat constipation. This product was later found to be contaminated with the bacterium B. cepacia, which was directly responsible for the sudden outbreak of infection at both hospitals.

As a result of their work and commitment to promoting a culture of safe patient care, Whaley and Rupp will be recognized with the Heroes of Infection Prevention Award during a special ceremony in Portland by the Association for Professionals in Infection Control and Epidemiology (APIC).

“It is a great honor to have one of our own be nationally recognized for this heroic award in patient safety,” said Trudy Leidich, Texas Children’s assistant vice president of Quality and Safety. “We are grateful to Elaine and our Infection Control team for identifying the direct source of contamination in order to keep our patients safe and free from preventable harm.”

B. cepacia is the name for a group of bacteria that can be found in soil and water and are often resistant to antibiotics. The bacterium can cause life-threatening infection in high-risk, medically complex children, such as children with cystic fibrosis and immunocompromising conditions.

In February 2016, when a small cluster of patients at Texas Children’s and Lurie Children’s Hospital came down with B. cepacia infection, Whaley and Rupp initiated separate outbreak investigations. But once the two hospitals’ clusters were confirmed to be identical, the patients were combined to facilitate the investigation.

After thorough analyses, their investigation found that the ducosate product at each hospital came from the same manufacturer. After reporting these findings to the Centers for Disease Control, the Food and Drug Administration was called into the investigation which subsequently resulted in a national product recall. This recall protected patients at Texas Children’s and patients at other pediatric hospitals across the nation from this serious pathogen.

The nursing team on 14 West Tower (WT) has reached an impressive milestone – 500 days and counting without a Central Line Associated Blood Stream Infection (CLABSI). Training, practice, diligence, team work and a collaborative focus on safety contributed to this team accomplishment.

Several new patient safety procedures were implemented to achieve this goal. Twice a year, each nurse on the unit completed return demonstration on a sterile dressing change and a sterile cap change during Critical Competency sessions, and thereafter got checked off on these skills at least once per quarter.

The unit recently started a new system in which all nurses are divided into three groups. Each group is assigned to a specific time of the year. During their assigned time, they work with central line champions to verify their central line maintenance techniques are up to par and are given real time live feedback. These observations ensure that each nurse performs these specialized skills in the safest and most evidence-based manner.

“We care for many patients on 14 WT who have central lines,” said Karen Santos, nightshift patient care manager on 14 WT. “Our team has been greatly involved and highly motivated to learn and diligently follow all of the correct steps and processes it takes to care for central lines.”

The Unit Quality Practice Council members also have been involved in these efforts to prevent CLABSIs by engaging all staff members on the importance of proper care of central lines. The unit has six nurses who volunteered to become central line champions. They attend monthly meetings to learn more about central line care, share any new knowledge and information with the rest of the team, complete monthly observations of central line care and access, help with annual check-offs, and act as safety advocates for our patients with central lines.

The 14 WT team takes pride in keeping our patients healthy, safe, and free of central line infections. The unit’s leadership team recognized this 500-day milestone with an early morning breakfast celebration to show how proud and appreciative they are of each and every nurse who helped bring this goal to fruition.

The countdown of success is constantly on display to remind 14 WT team members to keep patient safety on the forefront of their minds. Safety is our priority!

March 14, 2017

This week — March 12 through March 18 — is National Patient Safety Week. It also is that time of year when college basketball teams give it their all for the ultimate title. With a little imagination, this is what it might look like if we combined Patient Safety at Texas Children’s and March Madness.

To win at patient safety and basketball, a team of dedicated coaches and players is needed! At Texas Children’s, we have hundreds of great Safety Coaches, 372 recruited and trained to be exact, much more than any basketball team.

Team Texas Children’s is comprised of multiple devoted and enthusiastic players and they are: Texas Children’s Hospital West Campus, Texas Children’s Pavilion for Women, Texas Children’s Medical Center Campus, Outpatient Clinics & Health Centers, and Texas Children’s The Woodlands, our newest member to the team. Each player performs a vital role in Texas Children’s pursuit of the ultimate goal, Zero Patient Harm.

The scoreboard shows that West Campus is scoring big for Patient Safety with day and night executive safety walk rounds, monthly microsystem Safety Coach meetings, daily campus safety briefings, and multidisciplinary case conferences to learn from precursor and/or near miss safety events.

The Pavilion for Women is a proven player. They hit the target of 100 percent compliance with antenatal steroids administration; reduced obstetric adverse events by almost 50 percent; saw a significant reduction in post cesarean surgical site infections; and are implementing the use of a Fetal-Maternal Early Warning System for early recognition of a patient who may need a higher level of care.

Main Campus is a versatile player. When playing as a point guard, they lead the team in assists and aid in directing plays to improve patient safety. Main Campus has been working hard at implementing new practices to prevent intraventricular hemorrhages in newborn patients, enhancing staff knowledge about alarm management, and establishing new processes to care for aggressive behavioral health patients, which help keep patients and staff free from harm. They also provide leadership to the Safety Coach Program.

Outpatient Clinics and Health Centers have exceptional moves aimed at fall reduction, critical lab reporting, recognizing and responding to medical emergencies, and the identification of potential safety issues with the help of a Safety Coach.

New to the team this year is The Woodlands. The Woodlands ballers have been busy perfecting their game. They participated in three days of “live action” simulation activities prior to the opening of the ambulatory clinics, where they identified possible threats to patient safety that could be eliminated before seeing their first patient! All of the Woodlands team leaders completed “QI Boot Camp” (a review of quality improvement principles) and all staff and leaders completed Error Prevention Training to further emphasize the importance of building a culture of patient safety. Patient safety is being especially highlighted at the Woodlands through more simulation training and testing throughout the month of March as they prepare for their April 11 inpatient opening.

The Team’s playbook is full of special moves to eliminate harm. It includes the use of error prevention tools and techniques, compliance with steps to prevent CLABSIs, CAUTIs, VAPs, SSIs, PIVIEs, ADEs, pressure injuries, unplanned extubations, falls, readmissions, and more. Team Texas Children’s outperforms any college basketball team when it comes to key plays.

Whether your role is on the court, providing patient care, or off the court like keeping things clean, repaired, and ready to go, you are part of Team Texas Children’s. You are instrumental to Team Texas Children’s ultimate goal! Zero Patient Harm is within our reach!

To assist Team Texas Children’s in Scoring Points for Patient Safety (and have a little fun too), click on the links below.

January 10, 2017

11117clabsi640Texas Children’s neonatal intensive care unit (NICU) 2 nursing team has a big reason to celebrate – they reached 365 days and counting with zero central line-associated bloodstream infections (CLABSI), which demonstrates the value of team work and our hospital’s commitment to cultivating an environment for safe patient care.

In November 2015, NICU 2 reported three CLABSI infections. Since then, the rate of CLABSI occurrences has dropped to zero.

“Last fall, we were concerned about the number of CLABSIs we were having not only in the NICU but across the organization,” said NICU Clinical Nurse Specialist Alex Luton. “Together, with our infection control counterparts in education and vascular access, we implemented a massive educational initiative that trained more than 2,000 nurses across the organization on several key skills in central line care.”

Besides opening dialogue with the bedside nurses and care providers to identify and close any gaps observed around central line care, current hospital policies and practices were reviewed against national standards to identify areas of care that could be standardized to reduce CLABSI occurrences.

“Prior to this initiative, units had their own way of accessing and maintaining the central line,” said NICU Education Coordinator Rachel Leva. “Now, all nurses follow the same standard procedure for central line maintenance across the hospital system which has significantly helped us reduce our CLABSI rates in NICU 2.”

Creating the new role of central line resource nurses (CLRNs) has also provided an added layer of support for CLABSI prevention. To help bedside staff focus on other important patient care responsibilities, the CLRNs round on all patients with central lines during every shift.

“By providing central line care support and education, we’ve been able to address concerns early before they potentially manifest into a bloodstream infection,” said Ivy Lynn Ersan, a CLRN in NICU 2. “For instance, if a patient sweats a lot or has a lot of secretions, we may need to check on the patient more frequently per shift and change the dressing sooner than later to ward off an infection.”

Other strategies implemented in NICU 2 to reduce CLABSI include:

  • Central Line Champions Program – Specially trained to observe and audit central line care practices, these champions serve as coaches to ensure compliance with proven CLABSI prevention strategies. While all NICU staff are trained in CLABSI prevention, central line champions undergo more intensive training and must attend monthly educational sessions.
  • Hand Hygiene – NICU 2 nurses participated in a house-wide hand hygiene competition and posted signs in the unit as a visual cue to keep hand hygiene top of mind. NICU 2 leadership worked closely with Facilities to ensure ample supply of free standing hand sanitizer in the unit.
  • Weekly CLABSI meetings – Meetings are held every Tuesday to review and share information on CLABSI occurrence and identify any gaps in practice that need to be addressed. Attendees at these meetings include members from the vascular access, infection control and CLRN teams. A representative from Facilities also attends to ensure the working environment is conducive to safe patient care.

NICU 2 Assistant Clinical Director Tanya Williams says one important aspect that helped NICU 2 nurses achieve this milestone was their questioning attitude.

“Our nurses are not afraid to ask questions when something doesn’t seem right,” Williams said. “I think fostering this culture of a questioning attitude is how we were able to get this far. I am so incredibly proud of our nurses and our CLABSI partners for helping us achieve this patient safety milestone.”