Critical Care Patient Case Study

During the past five years, Sentara has intensified and expanded the program by engaging the health system’s physician group and other operating units in efforts to: 1) encourage employees to be mindful of the signals of inadequate care and act on those signals; 2) provide leaders with concrete methods of reinforcing employee behaviors that enhance patient safety; 3) reinforce bulwarks against medical error by instituting processes for learning from mistakes; and 4) reward the attainment of high standards of performance.

The initiative has helped to reduce the measured rate of serious safety events at Sentara hospitals by 80 percent over seven years.

Safety principles have been spread outside the hospital setting to the systemâs home care group.

Success factors include setting ambitious goals, empowering frontline staff to make improvements, involving executives and the board in change, and rigorously measuring and holding units accountable for results.

This private hospital found that engaging frontline staff was more effective than top-down directives for adopting and maintaining new practices.

Also, the hospital relies on a small number of critical care intensivists to conduct or oversee central line insertions, including those performed by residents.

The model has been spread to hospitals nationwide and was associated with reductions in central lineâassociated bloodstream infections in intensive care units.

Through its safety efforts, Hopkins has achieved improvements in safety practices such as increased hand-washing, in patient outcomes such as fewer pressure ulcers among patients, and in the hospital staffâs perceptions of the organizational safety culture.

Four case studies--of the Department of Veterans Affairs, Sentara Healthcare, OSF Health Care, and Johns Hopkins Medicine--document the progress achieved in the past five years by health care organizations that were early leaders in patient safety improvement.

Their experience reflects an expansion of interventions from individual hospital units to whole facilities and delivery systems, including new settings such as home health care.