Reflecting on the Journey of Patient Safety Week

Happy Friday from UMass Memorial Medical Center, where we are wrapping up a successful 2023 Patient Safety Awareness Week! As some many know patient safety has been one of my greatest passions throughout my career because it is the foundation of our care and it is a core expectation of our patients and families. That’s why “world class, high-quality care and achieving our goal of zero harm for both patients and our caregivers” are the primary components of our Patient Care Vision at UMass Memorial Medical Center. 

This year’s theme for Patient Safety Week was the Journey to Safety! I love this theme because it acknowledges that we have made progress and celebrated milestones along the way, but we still have many more miles to go … AND our caregivers are travelling this road together. This week featured a variety of creative activities and the chance to win travel-themed prizes.

There are many notable landmarks on our Journey to Safety in the last few years, all of which have a direct impact on the safety of those who entrust us with their care.  

Together, through your daily commitment to our patients, we have:

• Sustained reduction in mortality rates for six straight years.
• Since FY20, reduced harm events such as falls and pressure injuries by 24%.
• Since FY19, reduced PSI-90 (a publicly reported index of key adverse safety events like DVT’s and infections) by 60%.
• Since FY19, achieved year-over-year reductions in 30-day hospital readmissions.

We’ve also continued to prevent caregiver harm through a robust portfolio of Workplace Violence prevention and mitigation strategies, which I wrote about a few weeks ago. These efforts include transparent tracking of incidents on a monthly Caregiver Harm grid, our recently launched Patient Visitor Code of Conduct, and our AVADE de-escalation training opportunities for all staff.

Like all adventures, our Journey to Safety at UMass Memorial Medical Center has had plenty of twists and turns, but we’ve overcome these challenges through transparency and your hard work:

• Our Daily Access and Safety Briefing has been in place since 2020 and has brought forward over 400 safety related issues for investigation and resolution. When caregivers escalate an issue, it gets discussed at the briefing and investigated.
• 4 focused SWAT teams have taken on complex but important work in the areas of Alarms Management, Patient Verification, Pedi Behavioral Health and Equipment & Supplies.
• Multiple workstreams to address the many challenges of capacity constraints have helped advance delivery of safe care to the patients in our community.

Our caregiver's commitment to improving safety is demonstrated in the 8,463 event reports submitted through the Safety Intelligence system in FY22. When we say we take this seriously, we mean it. Our leadership follows up on these items and interventions that are needed to prevent recurrence of harm events. That could not be accomplished without the trained eyes and ears and valuable input of our front line staff.

I'm grateful to Kimi Kobayashi, Lesley Hawes Fucci and their teams for all of their efforts this week, including the various virtual and in person games that were held. It was a lot of fun and giving out travel prizes, like a Hotels.com gift card or Southwest airlines voucher, doesn't hurt either!

Most importantly, though, we were reminded that we are traveling the Journey to Safety together, not just this week but every week.

If anyone else celebrated Patient Safety Week with new or different ideas, I'd love to hear about them so we can make next year even more successful!

Onward!

Sincerely,

Michael Gustafson, MD, MBA

President, UMass Memorial Medical Center