Toward Zero Harm: Mackenzie Health’s Journey Toward Becoming a High Reliability Organization and Eliminating Avoidable Harm

Abstract

Objectives:In response to an organizational survey revealing low safety culture scores, we implemented a "zero harm" approach to eliminate preventable harm across a wide variety of clinical areas. We aimed to achieve this objective within 3 years. Methods:We developed a 5-part strategy for cultural and process redesign that included (1) engaging leadership; (2) developing an organizationspecific patient safety framework; (3) monitoring specific quality aims based on high-risk, high-volume, high-cost, and problem-prone areas; (4) standardizing a 3-part review process that includes a root cause analysis for moderate and critical patient safety incidents; and (5) communicating progress to staff in real time via unit-specific electronic dashboards. Results:In less than 1 year, we increased patient safety incident reporting by 37% while simultaneously decreasing falls with injury by 39%, pressure injury rates by 37%, and central line-associated blood stream infections by 34%. We also improved medication reconciliation rate by 3.3% and decreased our irretrievable specimen rate to 0. Finally, we noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care. Conclusions:This study describes an initiative that sought to introduce system-wide changes to practice and patient safety culture in a rapid time frame. Results suggest that our 5-step approach to transformation may confer substantial gains in patient safety for peer institutions. Next steps include continuing to expand and monitor quality aims as we progress through our journey to eliminating preventable patient harm in our healthcare system.

A Quality Improvement Initiative to Decrease Central Line–Associated Bloodstream Infections During the COVID-19 Pandemic: A “Zero Harm” Approach

“…First, a health system-wide promotional campaign outlining the institution’s commitment to zero harm with regular messaging across multiple platforms including posters, screens, and videos was initiated. 14 Second, we introduced electronic dashboards to share real-time progress across units. Third, routine review and solicitation of staff feedback during the intervention periods during huddles and meeting was completed.…”

“…Similar challenges were faced locally, and we sought to mitigate them using several strategies. First, a health system-wide promotional campaign outlining the institution’s commitment to zero harm with regular messaging across multiple platforms including posters, screens, and videos was initiated 14 . Second, we introduced electronic dashboards to share real-time progress across units.…”

“…In 2019, Mackenzie Health noted an elevated CLABSI rate, also exacerbated by the COVID-19 pandemic. In January 2020, as part of a hospital wide journey to eliminate preventable harm, Mackenzie Health aimed for zero hospital-acquired CLABSIs among several other quality aims 14 . This article reports the quality improvement (QI) initiative to reduce CLABSIs by 25% by 2023.…”

The last resort: reducing avoidable employee harm by improving the application of the disciplinary policy and process

“…Methodologies to support change were developed and a commitment to measurement and continuous improvement to ensure changes made were held and embedded in healthcare systems ( Health Foundation, 2021 ). For example, the implementation of risk assessments and checklists, improved education and training and the simplification and standardization of processes within healthcare have been found to reduce the harm experienced by patients ( Wilson et al, 2022 ; O’Connor et al, 2023 ).…”