Champions for Children’s Health
NACHRI 2008 Annual Meeting Session Presentation
Patient Safety Fridays: A Hospital-wide Initiative
Cynthia N. Sparer, MPH, Executive Director
Tony Dawson, RN, MSN, Vice President for Quality and Patient Safety
Morgan Stanley Children’s Hospital of NewYork-Presbyterian, New
York, NY
Learning objectives: Following this session attendees will be able to:
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Discuss common areas of non-compliance in most hospitals
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Discover how to organize your staff into tracers
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Learn how to develop tracer tools
Introduction/background:
Our large, urban hospital is extraordinarily sophisticated in handling
complex clinical problems. Yet, we found inconsistencies in how we were
meeting many basic requirements for the everyday care of our patients.
Therefore, the hospital recently introduced “Patient Safety
Fridays” to raise awareness and improve quality and safety
throughout the institution. This enormous undertaking requires the
commitment of our administration, medical and nursing staff and all
hospital services. It focuses on implementing clinical and environmental
improvements to ensure everyone and every area of the hospital are
always ready for the next patient, and consistent quality care is
rendered to every patient
Initiative or project description:
Patient Safety Fridays is creating a cultural shift so that every single
member of the hospital staff feels empowered to improve quality and
safety standards. Every Friday, tracer teams are sent to each unit and
the day is set aside to intensely focus on safety and quality (e.g., no
Friday meetings and we go “blackberry free” during
educational and tracing sessions). Twenty-six tracer teams –13
clinical and 13 environmental – totaling about 100 staff members
meet from 8 a.m. to 9 a.m. for an education session covering both an
environmental and clinical topic. The teams, consisting of physicians,
nurses, pharmacists, and many other clinical and non-clinical staff,
then spread out over the hospital to assess and reinforce patient safety
practices. Using a specially designed survey form, team members conduct
one-on-one interviews with staff, patients and families, review medical
records, and make observations in order to evaluate compliance with
established clinical and environmental standards. Later, the teams
review the gathered data and identify and discuss problems that were
uncovered. Next, team leaders prepare a report of the findings. During
the afternoon, patient care directors and managers share what they had
learned at the morning education session with their staff.
Results/Outcomes:
The non-punitive approach of Patient Safety Fridays to identify
and address clinical and environment opportunities has created a
paradigm shift in our culture. Staff throughout our hospital are fully
engaged in its mission and seem to be comfortable approaching anyone
– no matter his/her title – to point out deficits and to
educate. After just two months, results are encouraging. We will share
data demonstrating our ongoing improvement in both environment of care
measures (e.g. fire safety, equipment use/monitoring) as well as staff
adherence to safety practices and policies (adverse event management,
medication safety, communication, etc.).
Future of initiative:
Hospital administration is committed to continuing Patient Safety
Fridays, especially since the impact has been very positive. There will
be further refinements in the processes over time and changes will
inevitably occur. The tracer form, for example, began with 5 questions
and now has 30, and that number will expand.
Lessons learned:
The full participation and commitment of hospital leadership
– both administrative and medical – is critically important
for Patient Safety Fridays to overcome any resistance and to succeed.
While it is important to have a basic structure to follow, flexibility
in our approach has been and will likely be critical to enhancing the
effectiveness of this initiative. Hospitals can never assume that the
staff knows every relevant policy and procedure and, therefore, ongoing
education is invaluable. And, finally, given the opportunity, the staff
is enthusiastic to take steps to improve quality and safety for our
patients.