Bellin Health System, Green Bay
Reports
2023
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.
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.”
Members of the System Quality Team, along with CEO Dr. Rathgaber, pose for a picture with February Good Catch winner, Nicole Belter, RN. Care for the Caregiver – Bellin Health’s Peer Support Initiative
Every day, health care professionals face the risk of traumatic events—such as an unexpected death, a medical error or an unplanned transfer to the ICU. Estimates indicate that approximately 50% of clinicians are involved in an adverse event each year, and too often, these employees experience self-doubt, burnout and other problems that cause personal anguish and hinder their ability to deliver safe, compassionate care.
In response to this data, Bellin Health created and implemented a peer support group, Care for the Caregiver, made up of passionate, dedicated volunteers. This important task was headed up by Bellin’s Quality and Patient Safety department and officially launched at the beginning of 2023.
In order to build awareness and recruit staff and providers to be part of the Care for the Caregiver program, a comprehensive communication plan was rolled out including branding of the program, updates at monthly leadership meetings, articles on Bellin’s intranet site, flyers and announcements at department huddles and branded jackets featuring the Care for the Caregiver logo for all peer supporters. No peer support program can be a success without the commitment of staff and providers, making it all the more critical to spread the word surrounding the importance of this program and how to get involved. To date, Bellin has had over 90 colleagues in various roles from across Bellin Health step up to be peer supporters.
These volunteer-trained care team members are available to lend a friendly ear and provide support during difficult times. The goal of these connections is for Bellin’s peer supporters to provide quick support and guidance to impacted individuals, address their concerns or worries, and help them cope with any physical and emotional symptoms. This is accomplished by listening, emphasizing self-care and providing resources and referrals to other support organizations within Bellin. All these conversations are completely confidential and legally protected unless there is an issue of personal safety.
Although the Care for the Caregiver program at Bellin is in its infancy, it is a mechanism being embraced and utilized throughout the health system. As the program continues to grow and expand, Bellin’s Quality and Patient Safety Department aims to have a representative from each department serving as a peer supporter for the program.
In response to this data, Bellin Health created and implemented a peer support group, Care for the Caregiver, made up of passionate, dedicated volunteers. This important task was headed up by Bellin’s Quality and Patient Safety department and officially launched at the beginning of 2023.
In order to build awareness and recruit staff and providers to be part of the Care for the Caregiver program, a comprehensive communication plan was rolled out including branding of the program, updates at monthly leadership meetings, articles on Bellin’s intranet site, flyers and announcements at department huddles and branded jackets featuring the Care for the Caregiver logo for all peer supporters. No peer support program can be a success without the commitment of staff and providers, making it all the more critical to spread the word surrounding the importance of this program and how to get involved. To date, Bellin has had over 90 colleagues in various roles from across Bellin Health step up to be peer supporters.
These volunteer-trained care team members are available to lend a friendly ear and provide support during difficult times. The goal of these connections is for Bellin’s peer supporters to provide quick support and guidance to impacted individuals, address their concerns or worries, and help them cope with any physical and emotional symptoms. This is accomplished by listening, emphasizing self-care and providing resources and referrals to other support organizations within Bellin. All these conversations are completely confidential and legally protected unless there is an issue of personal safety.
Although the Care for the Caregiver program at Bellin is in its infancy, it is a mechanism being embraced and utilized throughout the health system. As the program continues to grow and expand, Bellin’s Quality and Patient Safety Department aims to have a representative from each department serving as a peer supporter for the program.
Social Determinants of Health
Beginning in 2018, Bellin developed and implemented a workflow to screen for and address the Social Determinants of Health (SDOH) for all patients across the organization. This workflow started in primary care, screening patients on an annual basis prior to their wellness visits. SDOH questions are tailored for three age groups: child (0-12 year olds), adolescent (13-17), and adult (18+). To date, 90,000 patients, just over half of the entire patient population, have completed an SDOH screening within the past year.
Recently, Bellin implemented an SDOH screening workflow in the hospital when patients are admitted. Nurses and case managers are asking these questions upon admission to better understand their patients’ needs and provide assistance both during their stay and after discharge.
In addition to screening, the staff are equipped with the resources they need to address any risks related to SDOH. For each SDOH domain, a list of resources was gathered and categorized by patient education, system resources within Bellin, and community resources outside of Bellin. Based on the presence and severity of the risk(s), staff will work with the patient to identify which resource will best meet their needs.
Recently, Bellin implemented an SDOH screening workflow in the hospital when patients are admitted. Nurses and case managers are asking these questions upon admission to better understand their patients’ needs and provide assistance both during their stay and after discharge.
In addition to screening, the staff are equipped with the resources they need to address any risks related to SDOH. For each SDOH domain, a list of resources was gathered and categorized by patient education, system resources within Bellin, and community resources outside of Bellin. Based on the presence and severity of the risk(s), staff will work with the patient to identify which resource will best meet their needs.
Decreasing Equity Gaps Related to Cancer Screenings
A multi-disciplinary team was established to identify mammography screening barriers at point of care through a three-part data review process. Data shows a disproportionate mammogram screening disparity for people of color in the service region. The goal was to decrease the disparity gap by the end of FY2022. Collaboration with employers and Bellin Health’s multidisciplinary team resulted in a personalized, comprehensive service designed to address equity gaps. The next step in the project is to strengthen partnerships and explore the expansion of current mobile mammography services.
