Improving the Patient Experience With Quality and Safety

Baptist Health continues to design various initiatives under the High Reliability Organization (HRO) implementation plan –– all in an effort to provide a safer environment for patients, visitors, and employees.

IN 2023, Baptist Health’s HRO efforts focused significantly on developing a more robust Root Cause Analysis (RCA) process that provided a framework for Baptist Health staff to investigate safety events in further detail.

By doing so, Baptist Health identified deeper root causes to these safety events, which allowed us to generate more effective action plans to help prevent the same event from occurring again. Action items are now rated by their strength of action, which is based on how effective certain types of actions are at reducing the chance of an error in a sustainable way with less chance of relapse.

Training sessions were held with outside experts in the Root Cause Analysis process that was adopted along with side-by-side guidance during events as competency with the RCA model was built. After initial training and implementation, executive sponsors were identified, trained, and began supporting the new process and pushing for actions that were strong and meaningful to reduce the likelihood of events.

As a result of this more robust process, Baptist Health has seen a reduction of “deja vu” events, or events that look very similar if not exactly like those that have occurred in the past.

A large part of building an HRO team and competency within Baptist Health is culture change, which addresses system failures and the unwavering expectation of achieving zero harm. In 2023, Baptist Health began deploying leadership safety skills, universal safety skills, and universal relationship skills to build and shape the culture at all levels.

By the end of the year, these skills began appearing widely in employee communications across the system.

Baptist Health’s HRO initiative started in 2021 as the next iteration of continual improvement of quality outcomes and safety events. The initiative provides evidence-based practices around leadership and individual skills that promote these outcomes and encourages continued excellence in patient care delivery.

Two additional items that began in 2023 will have a significant impact on safety within Baptist Health. The first, Epic’s Beaker module, will affect safety and efficiency of lab-based safety events. The second involves installing a new policy management software that will allow Baptist Health to better access policies, protocols, and procedures that guide the standard of care and the culture of the organization.

As part of Baptist Health’s commitment to excellent patient care, the system began self-reporting quality and safety data to Leapfrog in the fall of 2021. Leapfrog is a nonprofit organization that collects publicly reported and self-reported quality data from health care organizations and uses the data to evaluate performance around quality and safety.

Once Leapfrog completes an evaluation, letter grades are released to represent an organization’s overall performance. These letter grades range from an “A” to an “F” and consider measures that pertain to clinical outcomes, patient experience, and structures that promote safety and quality. Baptist Health is committed to achieving an “A” rating with Leapfrog for all of its participating hospitals.