Morning Safety Report generates change, efficiently

Staff gather for Morning Safety Report on the fifth floor of Smilow. Here, Diana Ellison, executive director, Ambulatory, raises a question at the daily meeting.
Staff gather for Morning Safety Report on the fifth floor of Smilow. Here, Diana Ellison, executive director, Ambulatory, raises a question at the daily meeting.

On a Thursday morning in late June, one of Yale- New Haven's most efficient meetings began promptly at 8 a.m. It was over by 8:15. The meeting, called Morning Safety Report (MSR), has been repeated every day since September 12, 2012, when the Hospital of Saint Raphael integrated with Yale-New Haven.

Every morning, about 40 people gather in the Smilow fifth floor conference room and another 20 in the Selina Lewis conference room, both outfitted with videoconference equipment. There, led by the administrator on call for the week, administrative and clinical hospital leaders from both campuses discuss safety events that have occurred — or nearly occurred — over the past 24 hours.

Under the direction of Performance Management, Morning Safety Report follows an efficient, fourpoint agenda: 1) Review safety or quality issues from the last 24 hours; 2) Anticipate safety or quality issues in the next 24 hours; 3) Update status reports on previously identified issues; and 4) Present daily Great Catch awards.

Topics raised that particular day included an injury from a low-hanging pipe in the Air Rights Garage; a recliner safety problem; a radiology patient treated in the wrong location; and a patient elopement. A look ahead at the next 24 hours included potential for a patient misidentification: a mother and daughter who were going to have surgery at the same time, both with the same last name, the same first initial, and medical record numbers that were just two digits apart.

"Since we began Morning Safety Reports, on average about 600 safety events have surfaced each quarter," said Katie Testa, administrative manager, Quality Improvement Support Service. "Each issue is categorized and documented until resolution is complete."

About 50 percent of the issues are clinical; others relate to the physical plant, operations, safety and security or information.

"The clinical issues are obviously extremely important and include adverse events, near misses, volume and patient flow, as well as problems related to policies and procedures and escalation of care," explained Testa.

The top three clinical issues that have surfaced in MSR over the past nine months are patient identification, medication errors and falls. About half the issues have required follow-up, with the average time to resolve the issue ranging from seven to 11 days.

"Of the 600 patient safety issues that are discussed each quarter, only about six are classified as serious safety events," said Testa.

"Morning Safety Report helps identify and escalate safety and quality issues throughout the organization. It is an incredible tool that creates situational awareness among the leadership here, which leads to interventions and improvements," said MSR sponsor Thomas Balcezak, MD, senior vice president of Safety and Quality and associate chief of staff. "But our ultimate goal is to eliminate every possible fall, every wrong-site surgery, and pressure ulcer we can."

Morning Safety Reports have led to numerous process and equipment improvements — re-labeling emergency phones, concrete plans to decant the Emergency Departments' crisis intervention units, standardizing drug libraries across campuses, wheelchair safety education, re-timing Smilow's revolving doors for child safety, and new ways of preventing and managing disruptive behavior in the hospital.

In addition to MSR-driven operational changes that benefit patient safety, the daily meetings have led to several improvements in Epic, including changing the sequential medical record number system to decrease the chance of patient misidentification, and improvements in label printing, medication administration and the blood transfusion process.

"The Morning Safety Report program has been so successful that the methods we started at YNHH are being expanded throughout our health system," said Dr. Balcezak.