John's Story: Purpose in High-Reliability Story

John was the life of any party, he would light up a room and fill others with joy and laughter. He taught me how to tie my shoes when I was a little girl and taught me that life is what you make of it; yes, he was a cup-half-full person.

John was 34 years of age when he died. His death resulted from a hospital-acquired central line infection. The caregivers who placed his central line failed to clean his skin surface and introduced staphylococcus into his bloodstream. John was found three days later on the bathroom floor. He was taken to a hospital in Chicago and initially, his temperature dropped very low, and not surprisingly over ten years ago, everyone thought he was "getting better". We did not understand "cold sepsis" and the healthcare team failed to identify sepsis and intervene quickly enough.

ince John's death over fifteen years ago, significant strides have been made in adherence to line bundles, prevention of central lines, and early removal. Hand hygiene practices continue to improve and teams continue to work diligently in early identification and treatment of sepsis. We now have "bots" built into our EMRs to trigger an alert for sepsis, so that we can intervene quickly and hand hygiene electronic tracking fueled by regulatory mandates. Sepsis teams champion education, awareness, and quality improvement, and many organizations empower front-line caregivers in driving sepsis initiatives.

The journey to high reliability continues as a priority to keep the next "John" safe. I encourage you to consider adopting the following and ensure rigor in your approach and monitoring:

• Onboarding: include high reliability and Just Culture training
• Daily GEMBA walks; go to the GEMBA.
• Start every meeting with a patient safety story & end every meeting with a "making a difference moment". Show a picture of the patient, and share something personal about them.
• Dissect every potential or actual patient/staff safety event by starting with a picture or story about the person. Engage those closest to the event, and encourage active participation. Defer to front-line expertise.
• Critically evaluate people, processes, systems, and outcomes. Lean up the work and remove variation.
• Create transparency by posting quality outcome scores, and information and provide recognition.
• Hardwire communication tools such as handoffs, SBAR, and Timeouts for patient safety.
• Create a zero-harm mindset and commitment; do not oversimplify or make excuses, instead dig deep and learn from the event, then apply those learnings (STAR Method).

For more information on how to achieve high reliability in healthcare, connect at www.matchhealthcare.com