Reporting Culture Vital to Improving Patient Safety
An enhanced focus on reporting potential harm and empowering employees to speak up about safety concerns continues to improve patient safety throughout Bellin Health.
These two critical elements are known as "Good Catches" and "Safety Stops," events that are recognized and corrected by staff before harm occurs to a patient.
- A Good Catch is recognition of an event or circumstance that had the potential to cause injury or illness but did not occur thanks to corrective action or timely intervention following the reporting.
- A Safety Stop is defined as a set of standardized behavioral tools that empower all employees and providers to bring immediate attention to any safety or quality concerns and reach resolution before harm or poor-quality impacts patients or teams. A Safety Stop has two primary elements—communicate clearly and speak up for safety. Bellin encourages all team members to use these tools to maintain a psychologically safe environment in which everyone is empowered to speak up and respectful response is the norm.
Each time an event is reported, it is an opportunity to identify and correct flaws in a process that could potentially jeopardize patient safety. The learnings from Good Catches and Safety Stops are spread throughout the health system to cast a widespread safety net around the patients we care for.
A Preventive Focus and "No Blame" Culture
According to the Institute of Medicine, 85% of safety events go unreported. Furthermore, staff members are 10 times more likely to report events that caused harm than events that were caught before harm occurred. There are several barriers to reporting Good Catches and Safety Stops, such as concern over punitive action, lack of confidence that positive change will result, and psychological barriers to admitting an error occurred. It is Bellin’s goal to foster transparent communication throughout the organization and support a “No Blame” culture while reinforcing accountability and learning. Daily huddles that involve all areas of the health system further underscore Bellin’s commitment to this approach.
"After implementing safety huddles, we were able to recognize safety concerns across the organization, not just at a unit level,” said Bellin Director of Nursing & Clinical Practice Ashley Lyman. “Often when looking at just one unit, you can't see a trend. However, when teams start sharing safety issues across the system, trends emerge more quickly and can be addressed in a timely manner. These shared learnings create a just culture, allowing teams to feel comfortable in raising other potential issues or good catches, which results in the ability to fix a problem before an event occurs.”
Surveys, Awards Bolster Safety Culture, Psychological Safety Focus
Ensuring staff members feel safe reporting patient events is vital for continuous improvement. Bellin encourages all staff to participate in safety culture and psychological safety surveys each year to receive feedback on the work environment. The Patient Safety team also presents a Good Catch and Safety Stop award program, which publicly highlights those who report such events on a weekly and monthly basis. Since its inception in late 2021, Bellin’s Good Catch program has celebrated 18 monthly winners. The recognition includes acknowledgment on daily huddles and a surprise ceremony with their peers, in which winners are presented with a certificate and gift card for their efforts to keep our patients safe.
Vice President of Bellin Psychiatric Center Debbie Patz has had success with frontline staff reporting good catches and safety stops.
“Patient and staff safety is our highest priority, and our unit staff members feel empowered to identify and share any potential safety issues in our event system,” Patz said. “This allows for leaders to review and refine our practices, such as our safety search process and how personal items are managed during a patient’s stay with us. We also share ‘good catches’ throughout the system, which is another great way to share learnings because we can learn to be proactive from others.”
Bellin Psychiatric Center also sees benefits of celebrating those who report, Patz said. “It’s wonderful when one of our staff members’ great catches is shared system wide, as it is positive encouragement for them on a job well done,” she said. “It creates a psychologically safe environment for staff to share and know that their concerns and ideas can make a difference.”